He prefers instead to apply topical treatments first, opting for Cosmelan 2 by mesoestetic and Lytera by SkinMedica. “Cosmelan 2 is an at-home treatment patients can use; it’s primarily arbutin, which is a hydroquinone precursor, and it also has phytic acid and azelaic acid,” he says. “I recommend Lytera for patients who can’t tolerate Cosmelan (because it’s a bit strong). It’s a combination of vitamin C, niacinamide, tetrahexyldecyl ascorbate, retinol, squalane—a number of agents that help lighten the skin.”
Both products will cause some peeling, which is why Dr. Nikolaidis favors them over hydroquinone and retinol alone, though he stresses that his choice of treatment depends on the severity of the hyperpigmentation.
In cases where melasma or hyperpigmentation is severe, he graduates to a stronger in-office Cosmelan treatment. “I apply a Cosmelan mask in the office that the patient washes off eight to ten hours later, and then I have them use a Cosmelan 2 product once or twice daily for the next three months at home,” says Dr. Nikolaidis. “It’s generally going to be topical creams first, the next thing would be Cosmelan masks. After that, I would consider light chemical peels and then potentially either a light Fraxel or PicoSure treatment.”
For his patients, results with the mask are visible within a couple of weeks, while the topicals alone will yield a better complexion after six to eight weeks. After the melasma is cleared, results will last as long as the patient wears sunscreen and maintains a continuous lightening skincare regimen. “Once you’ve gotten patients where they want to be with the stronger treatments, then you can maintain results with something like the SkinMedica TNS Essential Serum, which is a 2% arbutin product and an all-in-one growth factor, antioxidant and lightening serum,” says. Dr. Nikolaidis.
He warns that the melasma will come back after even one day in the sun without protection. “I counsel my patients with melasma that there is no cure; it’s an ongoing maintenance of sun avoidance and protection, and some type of lightening agent,” he says.
The best way to get around post-inflammatory hyperpigmentation (PIH) is to preemptively avoid it, particularly in patients with darker skin types. “The pigmentation process is the same for all skin types and colors. What differs is the likelihood to express hyperpigmentation as a primary skin concern,” says Green, noting that Fitzpatrick types IV–VI and often type III are more likely to develop irregular pigmentation. “From a formulation perspective, when treating skin of color, it is very important to avoid overly aggressive formulations that can lead to post-inflammatory hyperpigmentation as a side effect,” she says.
Dr. Dover agrees that, in general, the darker the skin type, the higher the risk of pigmentation problems. “With all of these conditions, light skin types are easier to treat than darker skin types. Skin types I to II do best, III is slightly more difficult and IV is a challenge,” he says.
With that in mind, selecting a modality to treat PIH depends on what caused it in the first place. “It’s not uncommon to develop hemosiderin deposition after a lower lid blepharoplasty or even a liposuction. Those can be treated with a Q-switched or PicoSure tattoo removal laser because the hemosiderin essentially acts like tattoo pigment would within the skin,” says Dr. Nikolaidis. “On the other hand, with post-inflammatory laser or chemical peel hyperpigmentation I’m going with topical cream—again, Cosmelan and/or Lytera.”
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