In medical aesthetics, there are a wide variety of treatments geared toward reducing wrinkles and replacing lost volume. But what we have learned over the years is that pigmentation problems are, in fact, one of the most noticeable signs of aging.
Whether your patient suffers from melasma, UV-related hyperpigmentation or post-inflammatory hyperpigmentation, the key to offering relief is to help them understand that treatment will require both in-office procedures and consistent home care, and that results will be gradual. Adding to the challenge of patient satisfaction is the fact that pigmentation problems are often chronic and recurring.
“One can think of melanocytes in the areas of hyperpigmentation or melasma as being preprogrammed to produce extra pigment/melanin,” says Anetta Reszko, MD, PhD, assistant professor of dermatology at Weill Cornell Medical College and owner of New York Skin Institute in New York City. “Most of the treatment modalities remove extra pigment, but since the cells are preprogrammed to make increased amounts, the pigment frequently comes back.”
Reversing Sun Damage
The most common cause of hyperpigmentation is sun damage. For patients with UV-related dark spots, Gregory Nikolaidis, MD, of Westlake Dermatology in Austin, Texas, recommends laser resurfacing or chemical peels. “My most popular treatment for lentigines is the Fraxel DUAL combination 1550nm/1927nm erbium fractionated laser,” he says. “I also like chemical peels—anything from a modified Jessner’s, like the SkinMedica Vitalize Peel, to a TCA peel.”
For scattered lentigines on patients with fair skin he applies spot treatments using chemical peels or laser. “With skin types IV or darker, I’m less apt to do a spot treatment because it tends to show up more, and if I do a peel treatment then I counsel those patients that there is a high likelihood that they’re going to have some temporary post-inflammatory hyperpigmentation,” says Dr. Nikolaidis.
Improvement can be seen after the first session, but most patients will see results after two to three treatments. While the longevity of the results will depend on patients’ age and how much time they spend outdoors, Dr. Nikolaidis finds that results of in-office treatments typically last one to three years when combined with proper home care.
He counsels patients to avoid excessive sun exposure and use sun protection when outdoors to prevent recurrence. “Some patients like to come in once a year for ‘refresher’ laser treatments or chemical peels,” he says.
Jeffrey S. Dover, MD, of SkinCare Physicians in Boston also finds laser treatments most effective for lentigines, noting that success often depends on the area of the body being treated. “Q-switched lasers, intense pulsed light and fractional nonablative Thulium lasers as well as other superficial fractional nonablative devices are highly effective treatments,” he says. “Facial lesions respond best, and results are less impressive the further you move from the face. The neck and chest do fairly well, arms slightly less well and the legs are somewhat more stubborn.”
His patients typically achieve optimal results after three treatments and are counseled to return for in-office maintenance treatments as well. “We suggest that the patient come back 6 to 12 months after the final treatment to consider a polish-up treatment and to set up a maintenance program,” says Dr. Dover. Maintenance treatments are typically performed once or twice a year depending on the particular patient.
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