Med Lasers 2022; 11(3): 159-165  https://doi.org/10.25289/ML.2022.11.3.159
Treatment of melasma using a combination of CO2 laser and Q-switched ruby laser
Jeong Do Park, Se Young Kim, Hyun Gyo Jeong, Syeo Young Wee
Department of Plastic and Reconstructive Surgery, Soonchunhyang University Gumi Hospital, Gumi, Republic of Korea
Correspondence to: Syeo Young Wee
E-mail: 94061@schmc.ac.kr
ORCID: https://orcid.org/0000-0002-1787-9715
Received: May 11, 2022; Accepted: June 28, 2022; Published online: September 30, 2022.
© Korean Society for Laser Medicine and Surgery. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background and Objectives
The CO2 laser is a tissue-selective laser that removes superficial lesions by vaporization and ablation. The Q-switched ruby laser (QSRL) is a pigment-selective laser that induces the disruption of melanosomes. This study aimed to evaluate the effects of a combination treatment of the CO2 laser and QSRL on melasma.
Materials and Methods
Fifteen patients with melasma were initially treated with a CO2 laser, followed by multiple QSRL toning. Photographs were taken on the first visit, on completion of the prescribed regimen, and 6 months after the treatment. The melasma area and severity index (MASI) and melasma severity scale (MSS) were evaluated through clinical photographs. Patients subjectively evaluated their improvement on a 5-point scale.
Results
There was a significant change in both mean MASI and MSS scores after the combination treatment with the CO2 laser and QSRL. The MASI score decreased from 5.82 ± 2.6393 to 2.607 ± 1.6973 (p = 0.001). The MSS score significantly decreased from 2.67 ± 0.488 to 1.20 ± 0.561 (p < 0.001). There were no statistically significant differences in the MASI (p = 0.891) and MSS scores (p = 0.046) between post-procedure and 6-month follow-up.
Conclusion
The combination of a CO2 laser and QSRL appears to be effective in the treatment of melasma.
Keywords: Melasma; Lasers
INTRODUCTION

Melasma can cause cosmetic problems for patients. So many patients hope for treatment to remove these lesions. Melasma can occur on any part of the face and manifests in variety of types ranging from superficial to deep lesions or combination of both. Various laser treatments are available for each type, but the standard treatment that is universally effective has yet to be established.

Laser treatment consists of light energy emitted by a laser medium.1 The carbon dioxide (CO2) laser uses CO2 gas as its medium to emit light energy at 10,600 nm to its main biological target, the fluid component of tissues. However, water is also present in the surrounding soft tissue beyond the target zone. CO2 laser is tissue-selective but not pigment-selective. Both pigmented and non-pigmented skin lesions are instantly removed by vaporization and ablation. Hence, it is important for physicians to treat the lesion with minimal damage to surrounding tissue.2 Generally CO2 laser is mainly used for the treatment of superficial skin lesions, such as nevus, xanthelasma, warts, and seborrheic keratosis.2

On the other hand, Q-switched ruby laser (QSRL) uses ruby crystal as its medium. This laser selectively disrupts melanosome through emission of 694 nm wavelength and is pigment-selective.3,4 So QSRL is effective in pigmented facial lesions, such as melasma, nevus, and lentigines, etc.5

If only one type of laser is used to treat mixed type melasma, the results may be unsatisfactory due to incomplete disruption of melanosome and may require prolonged treatment if the lesion recurs.

This study aimed to introduce a combined regimen using CO2 laser and a QSRL which showed favorable outcomes for patients with mixed type of melasma.

MATERIALS AND METHODS

A prospective study was performed on Fitzpatrick skin type III or IV patients who visited our hospital for treatment of melasma between March of 2018 and June of 2021. Patients who had been pregnant at the time of study, those with a history of keloid scar, photosensitivity, those who received other types of laser treatment within the last 6 months, and those who received oral or topical medication for the lesions had been excluded.

The study was approved by the Institutional Review Board of the Soonchunhyang Medical Center Office of Human Research Protection Program (IRB No. 2021-15) and performed in accordance with the principles of the Declaration of Helsinki. All patients provided written informed consent for the publication and the use of their photographs.

Procedural technique

All patients had been initially treated with CO2 laser (Lasun25-Dentalas; MEDSUN, Republic of Korea) followed by multiple QSRL (Quantel Medical, France) toning.

The whole face was washed with soap, and 5% lidocaine topical anesthetic ointment (Emla®; Recipharm, Sweden) was applied on the pigmented facial lesions 30 minutes prior to the procedure laser treatment.

CO2 laser was set at a pulse rate of 90 Hz and a spot size 4 mm remove melasma lesion superficially. Additional QSRL toning was done a month after. QSRL was set at a wavelength of 1,064 nm, a spot size of 5 mm, and a fluence of 1.0-1.2 J/cm2. The level of laser fluence was determined by the coloration of the lesion. Patients received 3 to 5 treatment sessions, at intervals of 3 to 4 weeks. Approximately 4,000 shots were delivered on the entire face, including the area previously treated with CO2 laser.

After the CO2 laser, the lesions were treated using hydrocolloid dressing (Comfeel® Thin; Coloplast, USA) with daily changes for a week followed by topical ofloxacin (Tarivid®; PT. Ferron Par Pharmaceuticals, Indonesia) for another week. After the toning procedure, ice packs were applied for 10 minutes for cooling and EFI ointment (JM BIOTECH, Republic of Korea) was applied on the lesions. After each laser treatment, avoidance of sun exposure was recommended, along with use of sunblock.

Measured outcomes

The results had been evaluated by digital photographs. The photographs were taken on the first visit (baseline), on completion of the prescribed regimen, and 6 months after the final treatment session. The equipment used (i.e., camera [EOS 80D DSLR; Canon, Japan]) and room conditions had been kept constant.

Melasma area and severity index (MASI) score was evaluated before the treatment, on completion, and 6 months after through photographic images by three physicians. The area (A) 0-6, where 0 = 0%, 1 = 1%-9%, 2 = 10%-29%, 3 = 30%-49%, 4 = 50%-69%, 5 = 70%-89%, 6 = 90%-100% subcomponent of MASI was graded by percentage of involved skin. The darkness (D) 0-4, where 0 = absent, 1 = slight, 2 = mild, 3 = marked, 4 = severe and homogeneity (H) 0-4, where 0 = minimal, 1 = slight, 2 = mild, 3 = marked, 4 = severe subcomponent was graded subjectively.6

Melasma severity was also documented alongside MASI using the melasma severity scale (MSS), a simple, easy-to-use categorical scale.7 The scores are as follows: 0 (clear: color of melasma lesions approximately equivalent to surrounding normal skin or with minimal residual hyperpigmentation); 1 (mild: color is slightly darker than the surrounding normal skin); 2 (moderate: color is moderately darker than the surrounding normal skin); and 3 (severe: color markedly darker than the surrounding normal skin).

All patients were asked to subjectively evaluate their improvement on completion of their regiments, and 6 months after. A 5-point scale by Noh et al.8 was used to investigate patient satisfaction as follows: (a) very dissatisfied (or 0%-10% improvement), (b) dissatisfied (or 11%-24% improvement), (c) fair (or 25%-50% improvement), (d) satisfied (or 51%-74% improvement), and (e) very satisfied (or 75%-100% improvement).

Statistical analysis

Statistical analyses were performed using SPSS software (SPSS 27.0; IBM Co., USA). Wilcoxon signed-rank test was used to analyze the results of the MASI score and MSS score. All p-values were two-sided and statistically significant was defined as p < 0.05.

RESULTS

A total of 15 patients participated in the study. There were 5 male (33%) and 10 female (66%) patients, with a mean age of 53 years (age range, 38-74 years). Table 1 shows demographic findings of patients.

Table 1 . Demographic findings of patients

Patient no.SexAgeForeheadRight malarLeft malarChinTreatmentComplication
1M52A : 2
D : 3
H : 1
A : 1
D : 3
H : 1
A : 1
D : 3
H : 1
CO2 laser 1 session
QSRL 5 sessions
None
2F74A : 1
D : 1
H : 1
A : 5
D : 2
H : 1
A : 5
D : 2
H : 1
CO2 laser 1 session
QSRL 5 sessions
None
3M54A : 1
D : 2
H : 1
A : 2
D : 2
H : 1
A : 2
D : 2
H : 1
A : 1
D : 2
H : 1
CO2 laser 1 session
QSRL 5 sessions
None
4F39A : 2
D : 3
H : 3
CO2 laser 1 session
QSRL 5 sessions
None
5F42A : 2
D : 3
H : 2
A : 1
D : 2
H : 1
A : 1
D : 2
H : 1
CO2 laser 1 session
QSRL 4 sessions
None
6M63A : 2
D : 3
H : 1
A : 2
D : 3
H : 1
CO2 laser 1 session
QSRL 5 sessions
None
7F62A : 3
D : 4
H : 1
A : 3
D : 4
H : 1
A : 1
D : 4
H : 1
CO2 laser 1 session
QSRL 3 sessions
Blister
8F38A : 2
D : 2
H : 3
CO2 laser 1 session
QSRL 5 sessions
Erythema
9M55A : 2
D : 3
H : 1
A : 2
D : 3
H : 1
CO2 laser 1 session
QSRL 5 sessions
None
10F71A : 2
D : 3
H : 3
CO2 laser 1 session
QSRL 5 sessions
None
11F49A : 2
D : 3
H : 1
A : 3
D : 3
H : 1
CO2 laser 1 session
QSRL 5 sessions
Blister
12F48A : 2
D : 4
H : 1
CO2 laser 1 session
QSRL 5 sessions
Erythema
13F45A : 2
D : 4
H : 1
A : 3
D : 3
H : 1
A : 3
D : 3
H : 1
CO2 laser 1 session
QSRL 3 sessions
None
14F40A : 2
D : 3
H : 1
A : 2
D : 3
H : 1
CO2 laser 1 session
QSRL 4 sessions
None
15M59A : 1
D : 1
H : 1
A : 3
D : 3
H : 1
A : 3
D : 3
H : 1
A : 3
D : 3
H : 1
CO2 laser 1 session
QSRL 4 sessions
None

M, male; F, female; A, area in melasma area and severity index (MASI) score; D, darkness in MASI score; H, homogeneity in MASI score; QSRL, Q-switched ruby laser.



Each patient’s mean MASI and MSS scores were assessed using photographic images. Mean MASI and MSS score decreased on completion of the combination laser therapy. The mean MASI score decreased from 5.82 ± 2.6393 before the treatment to 2.607 ± 1.6973 after the treatment (p = 0.001). The mean MSS score decreased from 2.67 ± 0.488 to 1.20 ± 0.561 (p < 0.001). There were statistically significant differences after our procedure in both MASI and MSS scores. Furthermore, there were no statistically significant differences between post-procedure and on 6-month follow up in MASI (p = 0.891) and MSS score (p = 0.046; Tables 2, 3, Fig. 1).

Table 2 . Melasma area and severity index (MASI) scores

Patient no.MASI score

Pre-treatmentPost-treatment6 months after treatment
14.81.81.8
29.63.93.9
34.82.01.6
43.60.60.4
54.80.81.2
64.82.42.4
710.56.06.4
83.00.90.6
94.82.42.4
103.60.90.9
116.03.63.6
123.01.21.2
1310.25.15.1
144.83.03.0
159.04.54.5


Table 3 . Melasma severity scale (MSS) scores

Patient no.MSS score

Pre-treatmentPost-treatment6 months after treatment
1311
2321
3311
4210
5311
6311
7322
8200
9311
10211
11321
12211
13311
14211
15211


Figure 1. MASI score and MSS score before the treatment, after the treatment and 6 months follow-up after the treatment. There were significant changes in both MASI (p = 0.001) and MSS (p < 0.001) between pre-treatment and post-treatment. In addition, there were no significant change in both MASI (p = 0.891) and MSS (p = 0.046) after 6 months from treatment. MASI, melasma area and severity index; MSS, melasma severity scale.

Three patients (20%) were very satisfied, 9 patients (60%) were satisfied, and 3 patients (20%) rated “fair”. None of the patients were dissatisfied or very dissatisfied with our laser treatment.

Figs. 2, 3 are representative photographs before treatment, after final treatment, and 6 months follow up.

Figure 2. Pre-treatment (A), post-treatment (B), and 6 months follow up photographic (C) findings of 42-year old Korean female patient show lightening of melasma on forehead and cheeks.

Figure 3. Pre-treatment (A), post-treatment (B), and 6 months follow up photographic (C) findings of 40-year old Korean female patient show lightening of melasma on cheeks.

After the treatment of CO2 laser, there were 2 cases of erythema and 2 cases of blister formation. They resolved within 7 days after treatment with ofloxacin. No major complications, hypopigmentation, or hyperpigmentation were observed.

DISCUSSION

Melasma presents as brown macules or patches on the sun-exposed areas including cheeks, forehead, upper lip, and mandible.9 Histologically melasma is divided into 3 types, epidermal, dermal, and mixed subtypes.9 Current treatments including topical agents, chemical peels and laser therapies target melanosome in epidermis and dermis.

Laser treatment is one of the preferable treatment modalities for melasma. Various lasers used in melasma include CO2 laser, QSRL, Intense Pulse Light (IPL), Q-switched neodymium-doped yttrium aluminum garnet (QSNYL), and pulsed dye laser (PDL). Wang et al.10 suggested that IPL is a safe and effective treatment for melasma. In a study by Kaminaka et al.,11 QSNYL showed over 50% pigmentation improvement in half of the patients. Passeron et al.12 reported that PDL can improve melasma and decrease the rate of relapse.

In some cases, pigmentation can be treated by combination laser therapy. Yun et al.13 tried the combination therapy of Fractionated IPL and low-influence QSNYL, in which 41% of patients reported over 50% improvement in their hyperpigmentation. Angsuwarangsee and Polnikorn14 showed that combination of CO2 laser and Q-switched alexandrite (QSAL) was also effective in melasma compared to CO2 laser or QSAL laser alone; satisfaction was reported in 50% of patients.14,15

In this study, we performed the combination therapy with CO2 laser and QSRL. On completion, 83% of patients reported satisfaction and over 50% improvement in their hyperpigmentation. There was statistically significant difference in pigmentation in both MASI and MSS scores between data from baseline and on completion of the regimen. In addition, favorable outcomes were maintained up to 6 months after the treatment.

In the publication of the results from one trial that studied the effects of QSRL alone without prior CO2 laser treatment to patients with melasma, there was 30% improvement from baseline MASI score after 6 treatment sessions.16 Other study also showed 40% improvement from baseline MSS score after 8 treatment sessions.17 In comparison with these previous studies, our combination therapy achieved more improvement of MSS and MASI score in significantly fewer treatment sessions.

In terms of treatment duration, periods ranging from 3 to 9 months have been reported.9 Duration of our procedure was 3 to 5 months, which was relatively short compared to previous studies.

MSS score was maintained or decreased in all patients, but MASI score increased in 2 patients after 6 months. It can be inferred that the occurrence of other new lesions that were not treated with combined laser therapy led to increase in MASI score, since MASI score is a scoring method that evaluates the entire face.

Limitations in this study include a small sample size. Further studies with larger samples are warranted. In addition, there was no histologic evaluation of the lesion to determine the depth of melasma. Nevertheless, our combined laser procedure using CO2 laser and QSRL can be useful treatment of melasma.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Concept and design: All authors. Analysis and interpretation: All authors. Data collection: All authors. Writing the article: JDP, SYW. Critical revision of the article: All authors. Final approval of the article: SYW. Statistical analysis: JDP, SYW. Overall responsibility: SYW.

FUNDING

None.

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