Behind the Scenes: Cosmetic Consultation for Melasma

This article was inspired by a patient who presented to my office seeking options for improving her melasma. The patient is a 46-year-old woman with skin type IV. She had been to several offices and undergone several treatments, including laser therapy, chemical peels, and various topical treatments.

The Consultation

During our in-office consultation, I realized that the patient was ready to try another mode of treatment, but she was also very guarded and somewhat apprehensive about the treatments we were discussing. During the consultation, I explained to her that melasma is a difficult type of hypermelanosis, and multiple factors play a role in the etiopathogenesis of the condition.¹
Historically some of the causes are hereditary predisposition, pregnancy, oral contraception, hormone replacement therapy, cosmetics, and medications.¹ A combination of preventive measures and various treatment options is the best way to achieve and maintain the dyspigmentation.

The Treatment Options

I offered treatment with the PicoSure laser, which is a picosecond-aesthetic laser that has been studied and proven to be effective for improving dyspigmentation.² It is also safe for all skin types if certain precautions are in place.³ I explained the adverse effects, risks, and benefits to the patient in detail. She mentioned that she owns a boat and is on the water at least 5 months of the year; however, she only occasionally wears sunscreen. Regardless of previous treatments, protecting the skin from any controllable factors is key. For this patient, she can have better and sustainable improvement with proper sun protection and by taking preventive measures.

Toward the latter part of the consultation, she asked about products that can be used in between cosmetic treatments. Some of the common topical treatments are hydroquinone, retinoids, azelaic acid, and antioxidants such as vitamin C.¹ Vitamin C is one of the most common antioxidants and can protect the skin cells from UV light–induced damage and delayed tumor formation, reduce transepidermal water loss, and promote collagen production.¹ Of course, we cannot leave out sunscreen, which should be an SPF 50 or higher and reapplied every 90 minutes. For individuals who prefer hydroquinone-free options, several topical agents can be incorporated into the skin regimen individually or in combination, such as kojic acid, arbutin, glycolic acid, licorice extract, mequinol, paper mulberry, soy, melatonin, aloesin, deoxyarbutin, and niacinamide-acetyl-4-5-cystalminylphenol.¹

Several cosmetic treatments have been investigated to improve melasma, although some have achieved suboptimal results.¹ It can be difficult to attain the results some patients are seeking. Setting realistic expectations is the key to success. Aggressive therapy can result in inflammation, and the treatment outcome may be worse than the actual disease.¹ In the past, I have achieved great results with laser treatments and various types of chemical peels.

Nonablative light sources, such as intense pulsed light therapy, have been safely used.¹ Q-Switched lasers, such as the nanosecond aesthetic laser, 532 nanometer (nm) neodymium (Nd) yttrium
aluminum garnet (YAG), 694 nm ruby, 755 nm alexandrite, and 1064 nm Nd YAG, can also be used.¹ In my clinical experience, the PicoSure laser has yielded great results. New laser devices offering fractional photothermolysis use microthermal damage and fractionalized resurfacing to achieve promising results.¹ Laser treatments can be costly, which is why patients are hesitant to start therapy; they do not want to feel like they are wasting their money. I inform my patients that the mechanism of laser therapy is so precise, and scientifically proven, that it is worth it.

Tips for Managing Expectations

The first thing I do is gain the patient’s trust by letting them know I am here to help and that I am on the journey with them. It is best to undersell and overdeliver when it comes to cosmetic procedures. After a 58-minute, in-office consultation, I had answered all of the patient’s questions and she was comfortable with her decision to purchase a laser package consisting of 4 treatments scheduled 6 weeks apart. I even offered to try 1 treatment before committing to a package to make sure she did not experience any adverse effects.

The day before her scheduled 45-minute treatment, the patient emailed me with further questions about the treatment plan we agreed upon. Of course, I am happy to answer any and all questions. I want my patients to feel comfortable when coming to the office, which decreases the possibility for regret and improves the overall patient experience. Below are my answers to the patient’s questions.

Patient: How much experience do you have with providing PicoSure treatments?

Tracee: I have been using the PicoSure laser since April 2021. However, I have used multiple lasers since 2005.

Patient: Have you treated people of color or those with olive skin tones for melasma?

Tracee: Yes, I have years of experience in treating people of color and all skin tones. There is no cure for melasma, but it can be minimized with several treatment modalities. Results vary from person to person. I personally have not seen any adverse reactions with the treatment options that I have recommended for my patients.

Patient: Did their condition improve substantially or did the treatment aggravate the melasma, making it darker?

Tracee: Evidence of improvement varies from person to person. Patients who have more melanin in the skin require a lower energy level to start, but it is increased based on how the skin responds. I have not seen 100% clearance. Treatment for melasma is ongoing. Once you find something that works, it can keep the condition stable. However, it is very important to use the proper skin care in between visits and keep the skin protected from the sun.

Patient: What has been the effect(s) on people of color or those with olive skin tones?

Tracee: I have seen great results with PicoSure. Immediately after the treatment, the pigmented spots will darken but “flake off” within 1 week after the treatment. Aftercare is very important. I recommend hydroquinone or a hydroquinone-free topical treatment after the procedure to aid in healing and recovery.² I would also encourage you to have a consultation for the Clear + Brilliant laser, which is another laser that I have extensive experience with and has shown great results. We do not offer that laser treatment here, but I can refer you.

Patient: Were there any other skin conditions that developed because of the treatment?

Tracee: Not that I am aware of.

Patient: Does this treatment have better success on younger skin vs older skin?

Tracee: I do not have any concerns regarding the age of the patient. However, if the skin has extensive sun damage or increased laxity, more treatments may be needed to see optimal results. The PicoSure laser is recommended for 7 to 10 treatments.² We definitely see improvement between 2 and 4 treatments, but maintenance
is key.

Patient: In addition to having successful results, hydroquinone treatment is known to have several negative effects on the skin. One being that it can aggravate the melasma and cause it to turn bluish or greyish. Is this risk increased when combined with the PicoSure treatment?

Tracee: You are referring to a condition called exogenous ochronosis. After discontinuing the application of hydroquinone, the next step in treatment would be to treat with a laser like the Q-Switched laser or PicoSure.

Patient: Other than hydroquinone, are there additional ingredients in the products you recommend for use after treatment? If so, what are the adverse effects of those ingredients?

Tracee: One of the hydroquinone-free products that I would recommend is SkinCeuticals Discoloration Defense, as well as using a topical vitamin C in the morning before applying sunscreen. Some of the ingredients that aid in pigment alteration are licorice root, arbutin, kojic acid, glycolic acid, and tranexamic acid.¹ These products can sometimes cause dryness, so I would recommend using them as tolerated and monitoring how the skin responds.

Conclusion

I have not seen the patient again but welcome her if she chooses to reschedule in the future. Many of us have these types of consultations. Our goal is to get the results our patients desire, but every case is different. My motto is: “The more you know, the more you glow.” Maybe this patient is doing well with her at-home regimen for now.

References

1. Grimes PE. Aesthetics and Cosmetic Surgery for Darker Skin Types. Lippincott Williams & Wilkins; 2008:50-51, 73-123.

2. Wong CSM, Chan MWM, Shek SYN, Yeung CK, Chan HHL. Fractional 1064 nm picosecond laser in treatment of melasma and skin rejuvenation in Asians: a prospective study. Lasers Surg Med. 2021;53(8):1032-1042. doi: 10.1002/lsm.23382

3. Cynosure. PicoSure Clinical Reference Guide Rev 7. Cynosure; 2013–2015:19,44.

Note: The brand names mentioned above are personal recommendations. There are many more products and modalities that may be used.

Disclosure: The author has been a consultant or paid advisory board member for Lilly, Incyte, and Abbvie.