Efficacy and Safety of Intense Pulsed Light in Treatment of

Melasma in Chinese Patients

YUAN-HONG LI, MD, JOHN Z.S. CHEN, MD,y HUA-CHEN WEI, MD,z YAN WU, MD,
MEI LIU, MD, YUAN-YUAN XU, MD, GUANG-HUI DONG, PHD,y AND HONG-DUO CHEN, MD

BACKGROUND Melasma is commonly seen in the Asian population. Traditional therapies are less
effective and may cause adverse effects.
OBJECTIVE The objective was to study the efficacy and safety of a new intense pulsed light (IPL) device
in the treatment of melasma in Chinese patients.
METHODS Eighty-nine women with melasma were enrolled in this open-labeled study. Subjects re-
ceived a total of four IPL treatments at 3-week intervals. Changes in facial hyperpigmentation and tel-
angiectasis were evaluated using an objective, skin colorimeter (Mexameter, Courage & Khazaka),
the melasma area and severity index (MASI), and a global evaluation by the patients and blind
investigators.
RESULTS Sixty-nine of 89 patients (77.5%) obtained 51% to 100% improvement, according to the over-
all evaluation by dermatologists. Self-assessment by the patients indicated that 63 of 89 patients (70.8)
considered more than 50% or more improvement. Mean MASI scores decreased substantially from 15.2
to 4.5. Mexameter results demonstrated a significant decrease in the degree of pigmentation and ery-
thema beneath the melasma lesions. Patients with the epidermal-type melasma responded better to
treatment than the mixed type. Adverse actions were minimal.
CONCLUSION IPL treatment is a good option for patients with melasma. Adverse actions of IPL were
minimal and acceptable.
The authors have indicated no significant interest with commercial supporters.

M elasma is acquired hyperpigmented

macules or patches, occurring symmetrically
on sun-exposed areas of the body. Lesions are
associated with melasma, genetic predisposition, sun-
light exposure, pregnancy, oral contraceptives, and
stress appear to be the most significant risk factors.
ill-defined brown macules, usually involving the
centrofacial region, including the forehead, cheeks, Traditional therapies, including depigmenting agents
upper lip, nose, and chin. African Americans, Asians, (e.g., hydroquinone, azelaic acid), chemical
and Hispanics are the most susceptible populations. peels (e.g., glycolic acid, b-hydroxyl acid, trichloro-
Melasma skin contains increased amount of melanin, acetic acid), topical hormones, and sunscreens have
melanosomes, and melanocytes. Melasma is classified some therapeutic effects but are often unsuccessful
histologically into three patterns: an epidermal type, for refractory melasma. The use of laser in the
in which melanin is deposited solely in the epidermis; treatment of melasma is controversial. The 510-nm
a dermal type, in which melanin-laden macrophages dye laser and the 694-nm Q-switched ruby laser have
are primarily located in the dermis; and the mixed proved to be ineffective and could cause postin-
type, in which melanin deposition is found in both flammatory hyperpigmentation (PIH).2–4 Facial re-
epidermis and dermis.1 Of the many etiologic factors surfacing with erbium laser, pulsed CO2 laser, and

Department of Dermatology, No. 1 Hospital of China Medical University, Shenyang, China; ySheftel Associates Der-
matology, Tucson, Arizona; zDepartment of Dermatology, Dermatology Research Laboratories, The Mount Sinai
Medical Center, New York, New York; yDepartment of Biostatistics, China Medical University, Shenyang, China
[Correction added after online publication 03-Mar-2008: All author names have been transposed; Dr. Chen’s name
updated as John Z.S. Chen, MD.]

& 2008 by the American Society for Dermatologic Surgery, Inc.
Published by Blackwell Publishing

ISSN: 1076-0512
Dermatol Surg 2008;34:693–701
DOI: 10.1111/j.1524-4725.2008.34130.x

693
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ultrapulsed CO2 laser, alone or in conjunction with bleaching creams, chemical peels, or traditional
Q-switched alexandrite laser, has been reported suc- Chinese medicine for at least 3 months, were en-
cessful but gives significant downtime, and there is a rolled from the outpatient clinic in Department of
risk of adverse sequelae.5–7 Fractional laser therapy Dermatology, No. 1 Hospital of China Medical
with the 1,550-nm erbium fiber laser has recently been University, from July 2005 to October 2006. Patients
studied in a pilot study. Six of 10 female patients who could not avoid overexposure to sunlight were
(60%) with melasma showed more than 75% im- excluded. The study was approved by the Medical
provements. Yet one patient (20%) developed PIH.8 Ethic and Human Research Committee of China
Medical University. Before enrollment into the study,
Intense pulsed light (IPL), a broadband light source all patients were informed of the risks, benefits, and
that emits a continuous spectrum in the range of 515 possible complications of the treatment and in-
to 1,200 nm with low-end cutoff filters, was also formed consent was obtained from each patient.
studied in the treatment of melasma. Wang and col-
leagues reported that 6 of 17 patients (35%) obtained All 89 patients completed the full course of study.
more than 50% improvement in the treatment group Enrolled patients were all females with Chinese
(Vasculight, ESC, Santa Clara, CA; four sessions at heritage, with a mean age of 32.7 years (range, 26–
an interval of 4 weeks with topical hydroquinone) 56 years). The duration of melasma ranged from
compared with 2 patients (14%) in the control group 6 months to 30 years (mean, 9.4 years). According to
(topical hydroquinone only) at Week 16.9 Wood’s lamp assessment, 80.9% of patients (72/89)
had a mixed-type melasma and 19.1% (17/89) had
Traditional IPL sources have some shortcomings: the an epidermal-type melasma. Among the 89 patients
energy peak of ‘‘V-shaped’’ pulses could possibly investigated in this study, none of them have dermal-
cause overload burning and PIH; the energy slope type melasma. Under Wood’s light examination,
below the therapeutic threshold is not sufficient to there is always some part of the pigmented macules
produce photothermolysis on the targeted chro- being more prominent than under regular light.
mophores. A new IPL source (Lumenis One, Lu- Some believe that there is no real dermal-type
menis Co., Santa Clara, CA), incorporates a genuine melasma at all (Dr. Henry Chan, personal commu-
breakthrough in the form of optimal pulse technol- nication, February 2007). In addition, 37 patients
ogy (OPT). The essence of OPT is the system’s ability had Fitzpatrick Skin Type III, and 52 patients, Skin
to control the pulse shape and to deliver homoge- Type IV.
nous ‘‘squared-off’’ pulses, resulting in more even
distribution of the energy within each individual Before treatment, patients were asked to wash their
pulse and between subpulses. This novel pulse shape faces with a neutral lotion thoroughly and rest in
control mechanism enables use of lower fluency lev- the temperature-controlled (201C) and humidity-
els and can result in safer, more effective, and more controlled (40%) room for at least 30 minutes.
reproducible treatments. In this study we investigat- Photos prior to each session were taken under
ed the use of this new IPL device in the treatment of normal light and Wood’s lamp (courtesy
melasma in Chinese female patients. of Vichy, L’Oreal, China), to determine whether
the melasma was an epidermal, dermal, or
mixed type.
Patients and Methods

Enrollment and Preparation of the Patients Equipment

Eighty-nine female subjects (Fitzpatrick III and IV), A new IPL device (Lumenis One) was used
who had been unresponsive to previous therapy of throughout the study.

694 D E R M AT O L O G I C S U R G E RY
 LI ET AL

Treatment Protocols also rated their overall level of satisfaction with the
IPL treatment according to the following scale: sig-
Patients received four IPL sessions at 3-week inter-
nificant improvement, moderate improvement, mild
vals. No topical anesthesia was required prior to the
improvement, no change, and worsening. They were
treatment. Before the IPL irradiation, water-based
also requested to report a mean pain score from a
gel (coupling gel, Lumenis Co.) of a temperature of
scale of 1 to 10, with 1 as a mild pain and 10 as
41C (stored in a refrigerator) was applied in a 5- to 8-
severe bee sting–like pain.
mm thin layer onto the target areas. The energy
density for treatment ranged from 13 to 17 J/cm2,
For database management and statistical analysis,
depending on the patients’ skin type, melasma se-
we used computer software (SAS, Version 6.12, SAS
verity, and pain tolerability. Test spots were per-
Institute Inc., Cary, NC). Continuous variables and
formed on each patient 30 minutes before the first
categorical variables were presented as mean values
session. Usually, we utilized 560-/590-nm filters,
and frequencies, respectively. Continuous data from
double pulse for patients with epidermal type, and
different groups were evaluated using analysis of
590-/615-/640-nm filters, triple pulse for patients
variance. In the presence of significant F values, in-
with mixed type (3- to 4-ms pulse, 25- to 40-ms
dividual comparisons between means were made
pulse delay). Further adjustments were made
using the Student-Newman-Keuls test. All statistical
according to the patients’ skin complexion, age,
tests were two-tailed and p values r.05 were con-
melasma severity and location, Fitzpatrick skin
sidered statistically significant.
phototypes, histologic types under Wood’s lamp, and
their responses to the treatment. Patients were in-
structed to apply cold wet compress immediately Results
after treatment followed by a few days of the appli- Therapeutic Efficacy of IPL evaluated with MASI
cation of a bland moisturizer. Patients were in-
Mean MASI score decreased dramatically from 15.2
structed to avoid the use of any bleaching and
before the treatment to 8.1 after one session, 8.6
antiwrinkle agents during the course of treatment.
after two sessions, 6.4 after three sessions, 5.2 after
They were also instructed to avoid sun exposure and
four sessions, and 4.5 at the 3-month follow-up visit
wear a broad-spectrum sunscreen during and after
(F = 20.77, po.001). Figure 1 shows the representa-
the treatment.
tive photos of a patient with melasma before and
after IPL treatment. Table 1 summarizes the changes
Evaluation Criteria
in the mean MASI scores by two investigators based
Before each session and 3 months after the last ses- on the patients’ Fitzpatrick skin type, histologic type
sion, an objective, skin color-measuring device and age (Figure 1, Table 1).
(Mexameter, MX18, Courage & Khazaka, Elec-
tronic GmbH, Cologne, Germany) was used to The trend analyses were further performed based on
measure the melanin index (MI) and erythema index the histologic type (Figure 2) and age (Figure 3). As
(EI) on the highest point on cheekbones. Melasma shown in Figure 2, both types of melasma responded
area and severity index (MASI) scores were evalu- well to IPL treatments. Epidermal-type melasma
ated by two investigators independently before each exhibited a better response than the mixed type, but
session and 3 months after the last session.10 in a similar fashion. We further analyzed the impact
of stratified age groups on the outcome of IPL
At the 3-month follow-up visit, both the investiga- treatments. As shown in Figure 3, all three age
tors and the patients rated the level of improvement groups displayed a paralleled response with the in-
according to four categories: 0% to 25%, 26% to creasing number of treatment sessions, though
50%, 51% to 75%, and 76% to 100%. The patients the melasma patient at the age of 35 to 45 years old

3 4 : 5 : M AY 2 0 0 8 695
 I P L T R E AT M E N T O F M E L A S M A

A B C
Left side of face

A B C
Right side of face
Figure 1. A representative photograph of a melasma patient before and after IPL treatments: (Top row) Left side of face;
(bottom row) right side of face. (A) Pretreatment; (B) after 4 sessions; (C) at 3-month follow-up visit.

had relatively higher MASI scores at the baseline level of female hormones, use of contraceptives,
and the end of treatment. We speculate that and excessive outdoor activities in this age
these variations probably result from the high group.

TABLE 1. MASI Score Changes with IPL Treatment in Women with Melasma

Mean MASI Scores Evaluated by Two Investigators

3-Month
Type Subtype No. Before T  1 T2 T3 T4 Follow-upy

Fitzpatrick type III 37 14.13 8.07 8.41 6.23 5.12 4.38

IV 52 16.01 8.16 8.65 6.42 5.30 4.60
Histologic type Epidermal 17 15.26 7.01 7.32 5.24 4.11 3.31
Mixed 72 15.22 8.39 8.85 6.61 5.50 4.79
Age (years) o35 38 14.81 7.31 8.29 6.01 4.85 4.13
35–45 23 17.04 12.61 11.14 8.16 7.02 6.64
445 28 14.32 5.53 6.81 5.32 4.28 3.27
Total 89 15.23 8.12 8.56 6.35 5.23 4.51
MASI scores measured 3 weeks after one session of treatment.
y
MASI scores measured at 3-month follow-up visit.

696 D E R M AT O L O G I C S U R G E RY
 LI ET AL

20 judgments of the overall improvements of melasma

15 based on the lesion color, size, telangiectasis, and
10 skin texture (Figure 5). After one session, 56.2% of
the patients (50/89) showed more than 50% im-
5
provement, according to the investigators’ evalua-
0 tion. The percentage of improvement reached 75.3%
0 T×1 T×2 T×3 T×4 3m fu
(67/89) after four sessions and 77.5% (69/89) at the
Epidermal-type Mixed-type
3-month follow-up visit, respectively.
Figure 2. Effect of IPL on epidermal-type and mixed-
type melasma: The mean MASI scores of both types
decreased significantly with the number of IPL treatments Self-Assessment of Improvement by
(po.001), with the epidermal-type melasma even better in
Patients
effectiveness.
Before each session and at the 3-month follow-up
visit, the patients were asked to assess their treat-
Effect of IPL Treatment on MI and EI ment results according to a five-point scale (wors-
At the highest point of cheekbone, MI decreased ening, no change, mild, moderate, or significant
from 140.8 before the treatment to 133.0 after one improvement). After one session, 49.4% (44/89) of
session, increased a little to 136.1 after two sessions, patients rated themselves to have significant or
dropped down to 129.4 after three sessions, 121.1 moderate improvements. This percentage increased
after four sessions, and 119.7 at the 3-month follow- to 73.0% (65/89) after four sessions of IPL
up visit (F = 38.67, po.001; Figure 4A). In addition, treatments and remained at 70.8% (63/89) at the
quantification of EI at the highest point of cheek- 3-month follow-up visit, respectively (Figure 6).
bone indicated a substantial decrease from 390.4
before the treatment to 338.2 after one session,
Adverse Effects
310.4 after two sessions, 279.4 after three sessions,
213.2 after four sessions, and 201.9 at the 3-month Side effects were very limited with IPL treatment.
follow-up visit (F = 58.73, po.005; Figure 4B). The transient erythema and slight edema were ob-
served and usually resolved 0.5 to 12 hours after
procedure on the cold wet compress. Temporary
Global Evaluation by Blind Investigators
desquamating microcrusts lasting 7 to 10 days were
Two independent dermatologists not involved in the observed on the cheekbone regions in 72 patients.
study examined the serial photos and gave their Three patients with mixed-type melasma had obvi-
ous PIH after one or two sessions of treatment. They
were instructed to wait 1 to 3 months until the PIH
20
resolved before the next session. Topical hydrocor-
MASI scores

15
tisone cream (Class VII) was given 3 days before and
10
7 days after the treatment for the 3 patients with
5
obvious PIH. In addition, patients reported an av-
0
0 T×1 T×2 T×3 T×4 3m fu erage pain score of 3.7 (1–6) on a scale of 1 to 10.
However, all patients tolerated the discomfort well
<35 yrs. 35−45 yrs. >45 yrs.
throughout the full course of treatment. No scarring
Figure 3. Effect of age on MASI scores by IPL treatment. In all or hypopigmentation occurred during and after the
the three age groups, the mean MASI score significantly treatment. All patients could return to work and
decreased with the number of IPL treatment (po.005),
especially in those younger than 35 years or older than
resume normal daily activity without downtime im-
45 years. mediately after the treatment.

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 I P L T R E AT M E N T O F M E L A S M A

A 145 B 450

140 400
350
135

Erythema index (EI)

Melanin index (MI) 130
300
250
125
200
120
150
115 100
110 50
105 0
0 T×1 T×2 T×3 T×4 3m 0 T×1 T×2 T×3 T×4 3m
fu fu
MI EI

Figure 4. Effect of IPL on MI and EI in women with melasma. (A) MI at the highest point of cheekbone decreased gradually
with the IPL treatment, with a little rebound after the second session. At the 3-month follow-up visit, MI remained at a low
level. (B) EI at the highest point of cheekbone decreased gradually with each session of treatment. At the 3-month follow-up
visit, EI remained at a low level.

Discussion related with the location of the melanin. In the

epidermal-type melasma, the melanosomes in the
This study is the first report of the treatment of
epidermis rapidly migrate to the skin surface and
melasma in Chinese women with the new IPL device.
shed off with the microcrusts.11 This process occurs
By delivering an evenly distributed pulsed light with
rapidly and the whitening effect is observed even
lower fluency levels, this modality provides a safer
after one session of treatment. In mixed-type me-
and more effective treatment of melasma in Asian
lasma, the melanin-laden macrophages in the dermis
populations.
could barely be damaged. Thus the therapeutic
effects are attributed mainly to the photothermolysis
With the serial IPL treatments, MASI scores de-
of the melanosomes in the epidermis. In our clinical
creased gradually from 15.23 to 4.51 (po.005). The
experience, a laser source targeted at dermal mela-
therapeutic efficacy is relatively higher in patients
nin-laden macrophages could be more appropriate
with epidermal-type melasma than those in the
for the treatment of its dermal part, unless PIH is a
mixed type. This phenomenon could possibly be
major concern.

100 significant
100 improvement
16 20
80 24 29 32 76%−100%
80 moderate
51%−75% improvement
60 34
35 60
39 26%−50% mild
38 37 improvement
40 0%−25% 40
25 22 no change
20 19 18 16 20
14 12 worsening
7 4 4
0 0
T×1 T×2 T×3 T×4 3m fu T×1 T×2 T×3 T×4 3m fu

Figure 5. Overall evaluation of the efficacy of IPL treatments Figure 6. The patient subjective self-assessments of IPL
by two nonparticipating physicians. The Z-axis represents treatments. The Z-axis represents the number of patients.
the number of patients. Legends for therapeutic efficacy of Legends for therapeutic efficacy of IPL are expressed by
IPL are expressed by percentage of improvement. Purple percentage of improvement. Purple bar = worsening; pink
bar = 0% to 25%; pink bar = 26% to 50%; yellow = 51% to bar = no change; yellow bar = mild improvement; blue =
75%; blue = 76% to 100%. moderate improvement; green = strong improvement.

698 D E R M AT O L O G I C S U R G E RY
 LI ET AL

It is noteworthy to mention that the patients’ ages In addition, we observed that most melasma patients
seemed to be another important factor to affect the suffered from the coexisting erythema and tel-
therapeutic effect of IPL on melasma. The patients angiectasis. EI, which represented the extent of ery-
younger than 35 years or older than 45 years re- thema and telangiectasis, decreased substantially
sponded much better to the treatment, especially from 390.4 at the baseline to 213.2 after four ses-
after one session (po.005). For the elderly patients, sions of IPL treatments and continued to decrease at
especially those in postmenopausal stages, the epi- 3-month follow-up visit. The trend analysis was
dermal melanocytes are not as active as before, statistically significant (po.005). Up to now, there is
partly because of the low hormone level (both es- no evidence to support that melasma is correlated
trogen and progestogen). Once the residual melano- with the facial erythema and telangiectasis in Chi-
somes are evacuated, no new ones are replenished. nese women. It is hypothesized that since hydroqui-
This can explain the reason why melasma sponta- none is forbidden as bleaching agent and steroids are
neously resolves in aged skin. For those young pa- available over the counter (OTC) and at beauty sa-
tients, accumulation of melanosomes and melanin in lons, the facial erythema and telangiectasis are
epidermis is relatively low and shallow due to the probably caused by long-term use of topical steroids,
short course of disease. Thus the newly formed either from OTC medications or illegally added in
melanosomes in the epidermis are much easier to be cosmetic products sold by the beauty parlors.
targeted and shed off. Besides, the epidermal turn-
over in young patients is higher than in old patients. According to the patient self-assessment, 73.0% (65/
89) of patients in this study claimed that their me-
In this study, hyperpigmented macules were observed lasma improved by more than 50% after four ses-
on cheekbone areas of all patients. Thus we com- sions of IPL treatments. The patients’ self-
pared the MI and EI on the highest point of cheek- assessments are well in agreement with the global
bone with each session. With the broken-up evaluation by blind investigators, in which more
pigmented particles shed off from the skin, the mean than 50% improvement of melasma was observed in
MI decreased dramatically from 140.8 before the 75.3% (67/89) of patients. At the 3-month follow-up
treatment to 121.1 after four sessions and continued visit, the patient self-assessment and the investigator
to decline even at 3-month follow-up visit (po.005). global evaluation maintain the similar level of effi-
Interestingly, MI rebound slightly after the second cacy of 74.2% (66/89) and 77.5% (69/89), respec-
session (Figure 4A) and this can be explained as the tively. One-year follow-up is still required to
triggering of inflammation and PIH by IPL, which determine its long-term efficacy and safety.
was commonly observed 3 days after each session.
With the accelerated turnover of melanosomes, the Our results are far better than what Wang and oth-
PIH resolved spontaneously in 7 to 10 days. After the ers9 have reported with the use of a nonchilled, peak-
second session, the newly synthesized melanosomes shaped IPL device. Melasma lesion is easily aggra-
overwhelmed those removed from skin. This phe- vated by any stimulation, including sunshine, irritant
nomenon is consistent with our following clinical chemicals, etc. Without efficient cooling and other
observations. After the first session, the patients protection modalities, IPL may induce subtle me-
observed obvious depigmentation after the shed off lasma itself.12
of the microcrusts. They were satisfied and expected
more. However, in the following sessions, no mi- The traditional IPL devices (e.g., Vasculight used by
crocrusts occurred and the patients observed no ob- Dr. Wang) do not have the cooling system, while the
vious changes until after the fourth session. The new device incorporates a cooling mechanism that
exact mechanism of this phenomenon remains un- provides continuous contact cooling to the treatment
clear and needs further investigation in the future. area. Instant cooling could minimize thermal injury,

3 4 : 5 : M AY 2 0 0 8 699
 I P L T R E AT M E N T O F M E L A S M A

thus reducing possible complications, such as ther- pulse and 510-nm wavelength. J Dermatol Surg Oncol
1993;18:341–7.
mal necrosis, induced erythema, and hyperpigmen-
tation. Besides, traditional IPL devices produce peak- 3. Kopera D, Hohenleutner U. Ruby laser treatment of melasma and
postinflammatory hyperpigmentation. Dermatol Surg
shaped fluency. The peak fluency may cause over- 1995;21:994.
dose damage, which limits its application in a more 4. Taylor CR, Anderson RR. Ineffective treatment of refractory
or less extent. After the peak, the fluency gradually post inflammatory hyperpigmentation by Q switched ruby laser.
J Dermatol Surg Oncol 1994;20:592–7.
decreased in a slope. If the fluency dropped below
5. Manaloto RM, Alster T. Erbium:YAG laser resurfacing for re-
the effective threshold, the energy could not produce
fractory melasma. Dermatol Surg 1999;25:121–3.
photothermolysis to the melanosomes. However, the
6. Nouri K, Bowes L, Chartier T, et al. Combination treatment of
new IPL device produces even distributed energy. All melasma with pulse CO2 laser followed by Q-switched alexand-
the fluency is restricted between the effective rite laser: a pilot study. Dermatol Surg 1999;25:494–7.

threshold and dangerous threshold. Thus it provides 7. Angsuwarangsee S, Polnikorn N. Combined ultrapulse CO2 laser
and Q-switched alexandrite laser compared with Q-switched
a safer and more effective treatment than before. alexandrite laser alone for refractory melasma: split face design.
Dermatol Surg 2003;29:59–64.
Our clinic is located in North China, with a Sibe- 8. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with
rianlike climate. The summer season lasts only fractional photothermolysis: a pilot study. Dermatol Surg
2005;31:1645–50.
3 months. Thus, we suggest that the patients undergo
9. Wang CC, Hui C, Sue Y, et al. Intense pulse light for the treatment
this treatment in other seasons. of refractory melasma in Asian patients. Dermatol Surg
2004;30:1196–2000.

10. Balkrishnan R, McMichael AJ, Camacho FT, et al. Development

Conclusion and validation of a health-related quality of life instrument for
women with melasma. Br J Dermatol 2003;149:572–7.
Our study demonstrated that OPT-IPL is a safe and
11. Yamashita T, Negishi K, Hariya T, et al. Intense pulsed light
effective treatment of melasma in Chinese female therapy for superficial pigmented lesions evaluated by reflectance-
patients. There is no rebounding of melasma at a mode confocal microscopy and optical coherence tomography.
J Invest Dermatol 2006;126:2281–6.
3-month follow-up visit. The therapeutic efficacy is
12. Negishi K, Kushikata N, Tezuka Y, et al. Study of the incidence
related to the histologic typing of melasma and age
and nature of ‘‘very subtle epidermal melasma’’ in relation to in-
of the patients. tense pulsed light treatment. Dermatol Surg 2004;30:881–6.

References
Address correspondence and reprint requests to: Hong-
1. Grimes PE. Melasma: etiologic and therapeutic considerations. Duo Chen, MD, Department of Dermatology, No. 1
Arch Dermatol 1995;131:1457–6. Hospital of China Medical University. 155N. Nanjing
2. Fitzpatrick RE, Goldman MP, Ruiz-Espraza J. Laser treatment Street, Shenyang 110001, China, or e-mail: chenhd@
of benign pigmented epidermal lesions using a 300 nanosecond cae.cn

COMMENTARY
Melasma is one of the most common acquired pigmentary conditions in Asians and is also one of the most
challenging conditions to be treated. Previous studies indicated that lasers or intense pulsed light sources,
although they can be effective in some cases, can lead to deterioration in others.1–4 One of the main
reasons for melasma to be so difficult to tackle is due to the etiology of this condition. It has been
suggested that in epidermal and mixed type of melasma, characterized by epidermal hyperpigmentation,
the pathogenesis involves an increased number of melanocytes and increased activity of melanogenic
enzymes overlying dermal changes caused by solar radiation.5 This recent observation may explain the

700 D E R M AT O L O G I C S U R G E RY
 LI ET AL

development of hyperpigmentation after the use of pigment laser. An increase in melanogenic enzyme
activity suggests that melanocytes are hyperactive. Sublethal laser/light source damage to these diseased
melanocytes can increase the production of melanin and result in hyperpigmentation.
In this study, the investigators demonstrated that the use of an intense pulse light source device with a
uniform pulse profile for the treatment of epidermal and mixed melasma and were able to achieve
excellent results (77.5% of treated subjects had over 50% improvement 3 months after treatment)
with low risk of increase in pigmentation (3%). This was despite the lack of topical bleaching agents
during the study period. Their findings differ significantly from previous data. Wang and coworkers4 used
IPL for the treatment of melasma in patients that were already treated with topical bleaching agents.
There was a 39.8% improvement of the relative melanin index in the treatment groups compared to
11.6% improvement in the control group at Week 16. However, 2 of 17 patients (11.7%) developed
increase in pigmentation.

Although the uniform profile of this IPL device may be the main reason for such observation as suggested
by the investigators. In my opinion, other factors are likely to contribute to the differences in clinical
outcome. Beijing is situated in the northern part of China and beside summer months, ultraviolet light
exposure is not a major issue. This differs significantly from places such as Hong Kong, Singapore, or
California. Another issue is the recruitment criteria. In this study, subjects that were resistant to 3 months
of topical bleaching agents, traditional Chinese medicine (TCM), or chemical peels were recruited. While
the safely and efficacy of topical bleaching agents and chemical peels were well established, the effec-
tiveness of TCM is not known. Some of these patients that were previously on TCM may represent a less
severe subtype and were therefore more susceptible to IPL treatment.
Nonetheless, the findings of this study are significant. However, before IPL or other flat-beam profile
lasers can be considered as the standard of care for the treatment of epidermal and mixed type of
melasma, further studies are necessary. Until then, a laser/intense pulsed light source should be used as an
adjunctive and second-line therapy to topical bleaching agents for the treatment of epidermal and mixed
type of melasma.

DR. HENRY HL CHAN, MBBS, MD, FRCP

Hong Kong, China
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