HOYA ConBio’s MedLite C6 Laser
Provides Efficacious Melasma Tx
By Bob Kronemyer, Associate Editor
Each year, melasma is believed to affect between five to six What has your experience been with melasma in your practice?
million women in the U.S. alone. Women who are pregnant, Niwat Polnikorn, M.D. – Melasma is the most popular con-
taking contraceptives (oral or patch) or on medication for hor- sultation at our busy aesthetic center. Most of our cases have
mone replacement therapy are especially prone to this disorder. been Fitzpatrick skin types III to V. Most cases – more than 70% –
Despite its prevalence, melasma remains incurable. represent the mixed type of melasma. More than 95% are
females ranging in age from 35 to 55 years old. The majority
There are three types of melasma – determined by its facial of these patients have been treated with a topical triple drug
distribution. The most common is centrofacial (forehead, nose, regimen: hydroquinone (HQ), vitamin A acid and a steroid.
chin and central cheeks), followed by malar (cheeks and bone) There has only been a partial response or recurrence. Some
and mandibular (on the jawline). There are also four types of cases develop complications from topical treatments such as
melasma based on cellular patterns: epidermal being the most ochronosis, contact dermatitis and acne.
common, dermal, mixed epidermal and dermal and inapparent
(seen in extremely dark skinned individuals). Recalcitrant melas- Penpun Wattanakrai, M.D. – Melasma is one of the most com-
ma is particularly challenging to treat and bleaching creams or mon cosmetic problems among Asians. Mixed or dermal compo-
chemical peels may show limited benefit. nent melasma is often difficult to treat, and due to its refractory and
recurrent nature, melasma is often difficult to cure.
Due to the heightened risk factor for this skin disease in
women of Asian, Hispanic and Caribbean descent exposed to Bruce Saal, M.D. – Since approximately one-third of my
sunlight, much of what we have learned about melasma derives patients are Caucasian, one-third Hispanic and about one-third
from Asian physicians. Physicians in Asia are experiencing Asian and Indian, I have a large patient population with pig-
great success in treating this stubborn dermal and epidermal mentation and dyschromia issues. I began using lasers in 1978,
pigment condition with the MedLite C6 Q-switched Nd:YAG but was comfortable with chemical peeling and medical treat-
laser from HOYA ConBio (Fremont, Calif.), as part of a holistic ments for many years before this.
skin rejuvenation regimen.
How do you assess or measure the degree of melasma?
MedLite C6 represents the latest generation of the MedLite
laser best known for its PhotoAcoustic engineering and flat-top Dr. Polnikorn – We use standard photography and measure
beam profile introduced nearly 20 years ago. Unlike most the melanin index with a dermaspectrometer.
American physicians, practitioners in Asia schedule more laser
treatment sessions with the MedLite and often combine laser Dr. Wattanakrai – Initially, we always use topical bleaching
treatment with the use of topical preparations. agents and broad spectrum (UVA plus UVB) sunscreens. Topical
lightening agents include hydroquinone, retinoic acid, azelaic
acid, kojic acid, alpha hydroxyl acid (AHA), licorice and
MedLite C6 represents the latest generation arbutin. Chemical peeling is accomplished with either AHA or
of the MedLite laser best known for its trichloroacetic acid (TCA).
PhotoAcoustic engineering and flat-top beam For research, we divide melasma into epidermal, mixed and der-
profile introduced nearly 20 years ago. mal melasma. We measure the degree of melasma with three meth-
ods: standard digital photography using VISIA-CR from Canfield
Imaging Systems (Fairfield, N.J.); objective measurement of pig-
Editor’s Note:
mentation with a tristimulus colorimeter using the Chromameter CR
In this roundtable, two Asian practitioners (both from Thailand) and
200 from Minolta (Stamford, Conn.) to objectively quantify changes
one American physician share their experience and knowledge of
in skin color using the CIE L*a*b* color system; and subjective
melasma and the effectiveness of the MedLite C6 laser in treating this
assessments with the Melasma Area and Severity Index (MASI).
condition.
2 THE Aesthetic Guide September/October 2008 www.miinews.com
clinical roundtable | MedLite C6
“We have introduced the MedLite C6 laser as the first line
of treatment to reduce hyperpigmentation quickly.”
Dr. Saal – I prefer to understand when the patient first noticed the most prominent
pigmentation; for example, during or after their first or most recent pregnancy, or after
beginning oral contraceptives. Did it become
most noticeable after intense sun exposure or Bruce Saal, M.D.
after a facial treatment? Had it been treated Dermatologist
before? If so, for how long and with what? Lost Gatos, CA
Also, how successful was that treatment? If
patients have used the traditional methods of
hydroquinone and topical retinoids, and have
had light chemical peels, all without much benefit, I know that it’s going to be a long
and difficult process to make much of a lasting change.
Melasma before Tx
I explain to patients that their melanocytes are sensitive to systemic hormones
(because of estrogen receptors) as well as exposure to ultraviolet light. This can help
reduce the frustration patients often feel, when despite using the medications and sun-
screen, their progress/resolution is slow.
Describe your clinical approach, specifically your use of Q-switched Nd:YAG lasers?
Dr. Polnikorn – We have introduced the MedLite C6 laser as the first line of treat-
ment to reduce hyperpigmentation quickly, we then maintain with topical 7% alpha
arbutin plus ascorbyl phosphate palmitate sodium plus fullerene.
Our settings with the MedLite laser are a 6 mm spot size, 3 to 4 J/cm2 and 10 Hz for
20 passes to cover the whole face. We also perform treatment on a small area before
proceeding to adjacent areas. We perform treatment every week for a total of ten ses- Melasma after MedLite C6 Tx
sions. Each session takes about ten minutes. For some difficult cases of mixed or dermal
melasma, we inject transaminic acid (4 mg/ml) intradermally at the lesion site immedi-
ately after laser treatment.
Clinical endpoints include immediate lightening of epidermal hyperpigmentation,
whitening of fine hair and perilesional erythema (for mixed melasma lesions).
Dr. Wattanakrai – We employ the MedLite laser for recalcitrant melasma that does
not respond to standard treatments.
We use a low fluence of between 2.0 and 3.8 J/cm2 with the 1064 nm wavelength,
along with a 6 mm collimated homogenous flat top beam profile. Patients schedule a
treatment once every one to two weeks, initially, then once every two to four weeks to
maintain results. A session generally lasts 10 to 20 minutes. Melasma before Tx
The clinical endpoint has been immediate lightening or mild erythema without
petechiae or immediate whitening. Results are evident by five treatments.
Dr. Saal – I have been using the MedLite laser since it was first introduced in 1992
and have upgraded through the years to the newest series of Q-switched YAG lasers
from HOYA ConBio.
I first have patients wash their face to remove any make-up and sunscreen. I usually
use a large spot size with maximum 1064 wavelength power (7 or 8 mm on the
adjustable spot size handpiece) at 10 Hz. The fluence ranges from 2 to 3.5 J/cm2,
depending on which model you use. I hold the handpiece with the plastic protective tub-
ing about a half inch or so from the skin surface and apply the energy in a sweeping Melasma after MedLite C6 Tx
Photos courtesy of Niwat Polnikorn, M.D.
THE Aesthetic Guide September/October 2008 www.miinews.com 3
clinical roundtable | MedLite C6
“After completing a series of MedLite laser treatments,
we have achieved a statistically significant improvement
in melasma.”
motion to cover the entire skin surface with at least two passes. I also concentrate on the
most heavily pigmented areas performing four to six passes, or until the patient begins
to feel a little warm or tingly. The process takes no longer than three to four minutes.
What cooling agents, if any, do you use with the MedLite C6 laser?
Dr. Polnikorn – We pre-cool skin with cold air before using the laser.
Dr. Wattanakrai – Cooled air with a temperature of about 20° C or an ice pack is
used to protect the epidermis and relieve pain during the procedure.
Dr. Saal – Although it is unnecessary to use any cooling agents with the Q-switched
Melasma before Tx YAG, we can always offer the patient forced air cooling upon request; but this is rare.
In these instances, I have the patient hold ice bags on the treated area for roughly five
minutes to limit any minimal discomfort, swelling or erythema. In addition, patients
may apply moisturizer and make-up immediately after treatment and may resume their
topical medications that same evening. There is really no downtime whatsoever.
Patients return in two weeks for re-evaluation. If there are no problems, I will
increase the fluence to 4 J/cm2 by reducing the spot size to 6 mm and re-treat as men-
tioned earlier. Most patients begin to see improvement in six to eight sessions.
How does the use of the MedLite C6 Q-switched Nd:YAG laser compare to treat-
ment with other modalities, including fractionated devices?
Dr. Polnikorn – A full 66% of our patients
Melasma after MedLite C6 Tx achieved good-to-excellent results after ten
treatment sessions with the MedLite C6; in Niwat Polnikorn, M.D.
Photos courtesy of Niwat Polnikorn, M.D.
other words, an average of 50% to 75% Dermatologic Surgeon
Kasemrad Hospital
improvement.* These are much better results
Bangkok, Thailand
than those achieved with topical triple drug
regimens alone. And with fractional lasers,
we have seen a higher incidence of post-
inflammatory hyperpigmentation (PIH) in our dark skin patients.
Dr. Wattanakrai – After completing a series of MedLite laser treatments, we have
achieved a statistically significant improvement in melasma. This was observed in both
colorimeter (P < 0.001) and the modified MASI score (P < 0.001) in the low fluence
Q-switched Nd:YAG laser side, compared to that of baseline. Side effects include
rebound of melasma and, in less than 1% of patients, transient hypo- or hyperpigmen-
tation — especially in darker skinned patients — which is difficult to treat.
Also, after discontinuing laser treatment, most patients experience a recurrence of
melasma, so this treatment does not cure the melasma. However, there is no downtime
or wounding. We have not performed fractional resurfacing for melasma.
Dr. Saal – Fractional treatments are considerably more time consuming, uncomfort-
able and have at least some element of social downtime. The cost of performing the
procedure is also considerably higher for the practitioner. While occasionally effec-
tive, it can inadvertently cause increased pigmentation because of its greater energy
intensity.
* Niwat Polnikorn, M.D., unpublished data, August 2008
4 THE Aesthetic Guide September/October 2008 www.miinews.com
clinical roundtable | MedLite C6
“We have treated more than 1,000 cases with the MedLite C6
technique, achieving good-to-excellent results in 66% of
patients after six months. This is a higher success rate than with
other treatment modalities.”
When using the MedLite C6 laser, do you pre-treat with any topicals such as
bleaching creams? How about post treatment care?
Dr. Polnikorn – We offer no pre-treatment, whereas post treatment depends on the
history of past treatment. If the patient has been using a triple drug formula, we will
continue with Tri-Luma cream (a combination of hydroquinone, tretinoin and fluoci-
nolone acetonide) from Galderma (Fort Worth, Texas). We prevent recurrence with
broad spectrum sunscreen such as Anthelios XL SPF 50, PA+++ from La Roche-Posay
(New York, N.Y.) and topical fullerene plus APP (I-MED) plus 7% arbutin.
Dr. Wattanakrai – All patients must use top- Penpun Wattanakrai, M.D.
ical bleaching and sunscreen to treat and Training Program Director
control the recurrence of their melasma. No Division of Dermatology Melasma before Tx
additional post-operative care is necessary. Ramathibodi Hospital
However, patients continue using sunscreen Bangkok, Thailand
and topicals.
Dr. Saal – It is imperative to use topical agents along with laser treatment. I rely
heavily on both hydroquinone and retinoids, but unfortunately have not found kojic
acid, azelaic acid or other hydroquinone substitutes to be very effective. Topical non-
fluorinated steroids can help to minimize inflammation and any post-inflammatory
hyperpigmentation associated with treatment, acne, etc. However, it is usually not nec-
essary to pre-treat with medications before initiating a Q-switched YAG laser protocol.
How do you manage patient expectations with the MedLite C6 laser and what
has your success been to date? Melasma after MedLite C6 Tx
Dr. Polnikorn – We advise our patients that this new approach will reduce melasma Photos courtesy of Niwat Polnikorn, M.D.
quickly, but that they still need long-term topical medication and good sunscreen. We
can also avoid problems and side effects associated with well-known topical medica-
tions, for example, hydroquinone. We also take good photographs at every visit.
So far, we have treated more than 1,000 cases with the MedLite C6 technique,
achieving good-to-excellent results in 66% of patients after six months. This is a high-
er success rate than with other treatment modalities we have performed in the past.
Long-term complications with the MedLite have been less than 5%. Patients with mot-
tled hypopigmentation often recover within a few months. Without effective post treat-
ment medication, recurrence is also possible. If there is recurrence, we re-treat with the
same protocol.
Dr. Wattanakrai – The MedLite C6 laser works to improve and clear melasma, but
it does not cure it and there may be side effects. I think the laser should be used for
treatment resistant melasma.
Dr. Saal – It has been my experience over the last four years or so, that virtually
every patient who commits to a series of treatments, lasting six to eight months, with
a Q-switched Nd:YAG laser obtains favorable results.
THE Aesthetic Guide September/October 2008 www.miinews.com 5
