Patients who do not want to undergo laser or chemical peel treatments and those for whom these treatments are contraindicated can use a topical-only regimen, though Dr. Dover notes that it takes longer to lighten lentigines this way. “Topical treatment is highly effective, but it takes one to two years to achieve the best possible result,” he says. “Hydroquinone is effective, either alone or in combination with tretinoin, and triamcinolone—Kligman’s Formula—is also effective.”
When treating lentigines with skin-brightening topicals only, Dr. Nikolaidis finds that they rarely get rid of sun damage entirely. “Lentigines can be lightened to a certain extent with different topical agents, such as tretinoin and retinol, and hydroquinone or hydroquinone precursors like arbutin. You can even use topical vitamin C or azelaic acid,” he says. “But if you’re going for complete removal, you’re not going to get that with topical agents—you’re just going to get some degree of lightening.”
It is a challenge that formulators are looking to overcome. “Melanin production is mediated via the enzyme tyrosinase in a multi-step pathway, producing melanin that is packaged and exported out of the melanocyte cell to neighboring keratinocytes. The collections of darkened keratinocytes are seen as areas of hyperpigmentation,” says Barbara Green, vice president of clinical research for skincare company NeoStrata. “Each step in the pathway represents a potential target for brightening formulations.”
To increase the efficacy of topicals, NeoStrata and others are formulating lines with multiple skin lightening ingredients, each designed to affect a different step in the melanin production process. Ingredients in NeoStrata’s Enlighten line include patented NeoGlucosamine, a tyrosinase inhibitor and non-acid exfoliant, and SabiWhite, a brightening/antioxidant ingredient found naturally in the spice turmeric. “With continued use, we have seen in multiple clinical studies that obvious brightening starts to occur at six weeks and is much stronger by 12 weeks and 16 weeks,” says Green.
Though there are several effective skin lightening ingredients on the market, one of the most effective topicals to reduce hyperpigmentation remains sunscreen. “Diligent use of sunscreen and avoidance of sun exposure is essential for maintaining an even complexion,” says Green. “Clinical studies of up to six months have shown that with continued use, there is continued benefit. Additionally, an occasional professional peel can significantly boost brightening effects.”
Melasma—a chronic, ongoing disorder—is notoriously difficult to treat. Success varies widely and continuous maintenance is essential.
Dr. Reszko uses Clear + Brilliant Perméa (Valeant) 1927nm laser treatments in combination with a topical blend of retinoids, hydroquinone and a mild steroid for her melasma patients. “I usually recommend pretreatment with topicals—including retinoids and bleaching agents like hydroquinone, kojic acid and/or arbutin—for about a month prior to laser treatments. Patients typically require a series of two to five treatments, usually a month apart,” she says. “The Clear + Brilliant Perméa is my favorite because there is minimal downtime—patients experience one day of redness and a burning sensation, and dryness and peeling for about five to seven days post-treatment.”
Additionally, Dr. Reszko finds superficial microneedling to be effective for treating melasma. “Microneedling up to 2mm causes superficial injury to the skin, and healing mechanisms remove pigment as skin heals,” she says. “Several treatments are required for optimal benefits in this case as well.”
At Westlake Dermatology, Dr. Nikolaidis and colleagues use PicoSure (Cynosure) or Fraxel (Valeant) treatments, but only in cases with very resistant melasma. “I tend to stay away from laser treatments to treat melasma. The issue is that although some lasers are FDA approved to treat melasma, it’s not uncommon for them to make it worse,” says Dr. Nikolaidis. “They are my last line of treatments for melasma. If I do use lasers, I tend to use them at lower energies and densities than I would to treat actinic damage.”
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