Combination therapy in skin of color including

injectables, laser, and light devices

Lark Guss, MD;1 Joanna G Bolton, MD, FAAD;2 and Sabrina Guillen Fabi, MD, FAAD, FAACS3,4

Thus, many recent studies have begun to investigate the benefits of

■ Abstract combining procedures and treatments to maximize benefits while
With the rapid increase in patients seeking cosmetic treat- decreasing the risk of adverse events.
ments, the variation in responses of lightly pigmented skin
versus darkly pigmented skin has become increasingly
apparent. Despite extensive treatment options in patients Face
with skin of color, there is a paucity of well-designed Melasma
studies performed on this patient population. The lack Melasma, an acquired disorder of hyperpigmentation, is one of the
of research is concerning, as it is well documented that most common types of pigmented lesions found in patients with
patients with darker skin types are at an increased risk of skin of color.6 Though its exact cause is unknown, melasma is ex-
adverse events when treated with many of the available quisitely photosensitive and exacerbated by hormones. Traditional
modalities used in cosmetic procedures. Fortunately, by
treatment has typically relied upon strict physical sunblock use in
combining a variety of treatments, these risks may be ab-
rogated, and combination treatments may be a promis- conjunction with a topical combination of tretinoin, hydroquinone,
ing regimen for a wide variety of cosmetic complaints. An and a topical steroid.6 However, although a topical cream may
overview and evaluation of the research of combination lighten epidermal pigment, it does little to alleviate pigment cen-
therapy in skin of color is presented. tered in the dermal layer of the skin. Additionally, prolonged use
Semin Cutan Med Surg 35:211-217 © 2016 Frontline of topical hydroquinone may cause paradoxical hyperpigmentation
Medical Communications due to exogenous ochronosis, and irritation secondary to topical
retinoids may induce skin irritation, increasing the risk of PIH.
Thus, lasers have been investigated for efficacy in treatment of

L
aser, light, and energy devices and a variety of injectable and melasma given their potential to reach deeper depths in the der-
topical products have revolutionized treatment of dyspigmen- mis. In order to bypass epidermal pigment, several studies have
tation, skin texture, and skin laxity over the past few decades. attempted pretreating with an ablative laser to remove the epider-
Combining treatment modalities to achieve better outcomes is mis, thereby decreasing intervening epidermal pigment between
becoming increasingly popular. Although these treatments were a Q-switched (QS) laser and dermal pigment. Angsuwarangsee et
traditionally performed in patients with lighter skin types, the im- al treated 6 Thai patients with an ultrapulse carbon dioxide (CO2)
proved understanding of the effects of these treatments, particu- ablative laser to one side of the face followed by a QS alexandrite
larly lasers, on pigmented skin has led to their increasing use in 755-nm laser to the entire face. Six months following the proce-
skin of color. dure, the side of the face with combination treatment had signifi-
The increased baseline pigment of the epidermis and larger cant lightening. There was no significant reduction of pigment on
melanosomes more widely distributed throughout epidermal ke- the side of the face treated with a QS alexandrite laser alone. No-
ratinocytes confer a greater risk of dyschromia following laser pro- tably, when the 2 sides were compared directly, the difference in
cedures using wavelengths that have melanin as a chromophore.1,2 treatments did not reach statistical significance. Additionally, those
Optimizing laser parameters, such as increasing pulse durations, patients with Type IV-V skin required a topical bleaching agent 3
longer wavelengths, and attached cooling devices, minimize the months after their laser treatment to address their PIH.7 However,
risk of adverse events.3,4 However, treatment of darkly pigmented the relative success of the combination approach confirmed similar
patients continues to be associated with an increased risk of postin- findings found using a pulsed CO2 ablative laser followed by a
flammatory hyperpigmentation (PIH) and prolonged erythema.5 QS alexandrite laser. All 4 patients studied had improvement with
the combination treatment, and no PIH was noted.8 A combination
of intense pulsed light (IPL) followed by a QS 1064-nm Nd:YAG
1
Dermatology Resident, Department of Dermatology, Johns Hopkins Univer- fractionated laser also had a significant lightening effect in patients
sity, Baltimore, Maryland.
with Type III-IV skin with no PIH noted.9 The authors hypoth-
2
Cosmetic Dermatologic Surgery Fellow, Goldman, Butterwick, Groff, Fabi &
Wu, Cosmetic Laser Dermatology, San Diego, California. esized that the success of the treatment relied on the large action
3
Associate, Goldman, Butterwick, Groff, Fabi & Wu, Cosmetic Laser Derma- spectrum of the 2 lasers, with IPL covering epidermal pigment and
tology, San Diego, California. dermal pigment covered by the QS Nd:YAG.
4
Voluntary Assistant Clinical Professor in Medicine/Dermatology, University Low fluence QS Nd:YAG alone can successfully treat melasma;
of California, San Diego, California.
however, numerous weekly treatments are needed, and postproce-
Disclosures: The authors report no relevant conflicts of interest.
Correspondence: Lark Guss, MD; Department of Dermatology; Johns Hop- dure hypopigmentation has been documented.10,11 However, when
kins University; 601 N. Caroline St, 8th floor, Baltimore, Maryland 21287. treated with 5 sessions of IPL immediately following low fluence
Email: [email protected] QS Nd:YAG, 14 out of 18 patients rated their response as good to

1085-5629/13$-see front matter © 2016 Frontline Medical Communications Vol 35, December 2016, Seminars in Cutaneous Medicine and Surgery 211
DOI: 10.12788/j.sder.2016.059

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 ■ ■ ■ Combination therapy in skin of color including injectables, laser, and light devices

A B A B

■ FIGURE 1. (A) A 35-year-old skin type III female with severe ■ FIGURE 2. Figure 2. A 37-year-old skin type IV male with Nevus of
melasma treated over the course of 1 year with 4 consecutive Ota. (A) Baseline; (B) Status post QS alexandrite and picosecond
IPL treatments spaced 1 month apart followed by 8 consecutive 1064-nm and 755-nm treatments over a 17-year period. Treatment
755-nm picosecond laser treatments spaced 1 month apart in remains ongoing for lower eyelid with picosecond wavelengths.
combination with topical product and sun protective measures. Used with permission: Mitchel P Goldman, MD.
A ninth 755-nm picosecond treatment was performed at the
12-month follow-up for maintenance. The photo in (B) was taken
an additional 12 months after the ninth laser treatment (2 years her condition worsened following glycolic and Jessner peels ob-
after baseline). (A) Baseline; (B) 12 months status post ninth laser tained prior to consultation. Over the course of a year, she under-
treatment. Used with permission: Mitchel P Goldman, MD. went 4 consecutive IPL treatments spaced 1 month apart followed
by 8 consecutive treatments with the 755-nm picosecond laser at
1-month intervals. The fluence ranged from 16 to 18 J/cm2 for the
excellent, and only 1 patient developed guttate hypomelanosis.12 IPL treatments, double-pulsed with a 3-mm pulse duration and 30-
Treatment numbers with low fluence QS Nd:YAG may also be ms pulse delay. For the 755-nm picosecond treatments, the spot
lowered by pretreating initially with microdermabrasion. When size ranged from 2.5 mm to 6.0 mm with a fluence range of 0.71
27 women were treated with microdermabrasion followed imme- to 4.07 J/cm2. A ninth 755-nm picosecond laser treatment was per-
diately by QS Nd:YAG, the mean number of monthly treatments formed at her 12-month follow-up appointment for maintenance.
was only 2.6, and 85% of women experienced a 75% or greater Throughout her treatment cycle, regular use of a topical skin light-
improvement in their melasma.13 Additionally, a more recent split- ening product (Lytera, SkinMedica Inc, Carlsbad, California) and
face study compared a QS 1064-nm Nd:YAG laser with a QS 755- strict sun protection measures were practiced. Results have been
nm alexandrite laser using very low fluences of only 1-2 J/cm2 for maintained for greater than 1 year since last treatment.
the treatment of melasma. In 18 patients with types III and IV skin,
pigmentation improved equally well on both sides of the face af- Nevus of Ota
ter 6 weekly treatments, and there were no adverse events aside Nevus of Ota is a dermal melanocytic nevus most often seen in
from minimal transient erythema.14 Thus, though using very low Asian patients as a dark-blue pigmented patch in the trigemi-
fluences requires multiple treatments, it does appear to minimize nal region.16 Numerous QS lasers of varying wavelengths have
the risk of dyschromia while still maintaining efficacy. been shown to be efficacious, though all require numerous treat-
Perhaps because laser and light treatments can be manipulat- ments.17-19 Additionally, swelling, crusting, and hypo- and hyper-
ed to very narrowly target melanocytes in different layers of the pigmentation are well-documented adverse events following
skin, combinations of these treatments appear to work better than treatment.17,20 In comparing a QS alexandrite, QS Nd:YAG, and
combination treatments of lasers with topical treatments such as a regimen alternating between the 2 lasers, the combination treat-
chemical peels. When 30% glycolic acid peels were added to low ment group appeared to have a greater degree of clearing, though
fluence QS Nd:YAG laser sessions, 15 male patients with melasma there was no significant difference when accounting for the num-
were found to have only transient improvement, and 1 patient de- ber of treatment sessions.16 Hypopigmentation was noted to occur
veloped permanent guttate hypopigmentation.15 Thus, combination in all 3 groups and was highest in the combination treatment group
laser treatment does appear to be a viable option in patients with at 38%.16 Thus, for treatment of Nevus of Ota, evidence does not
melasma unresponsive to topical therapy alone. support alternating between 2 types of QS lasers.
In our practice, a combination of IPL (560-nm filter) and 755- With the recent usage of picosecond lasers, there is another tool
nm picosecond laser (Picosure, Cynosure, Inc, Westford, Massa- available for treating Nevus of Ota. The patient in Figure 2 ini-
chusetts) or 755-nm QS laser (Accolade, Cynosure, Inc, Westford, tially presented to our practice in 1999 and received a series of
Massachusetts) in conjunction with topical treatments has been QS alexandrite treatments over 10 years. During this initial set of
utilized to successfully treat a skin type III patient (Figure 1). treatments, the lower eyelid was not specifically targeted, because
The 35-year-old female suffered from severe melasma refractory internal eye shields were not utilized. Following a 5-year lapse in
to conventional topical therapy and sun protective measures, and follow-up, the patient presented desiring additional treatment for

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 Guss et al

remaining pigment in the previously treated areas as well as the

pigment on the lower eyelid. To date, 2 treatments with the 1064-
nm picosecond laser (PicoWay, Syneron Candela, Irvine, Califor-
nia; fluence ranging from 3.0-3.2 J/cm2, 4-mm spot size, 3-4 Hz)
and 1 treatment with the 755-nm picosecond laser (fluence of 2.08
J/cm2, 3.5-mm spot size, 10 Hz) have been performed following
placement of internal metal eye shields. At this time, the patient
remains in follow-up every 6-8 weeks with additional picosecond
laser treatments planned to target remaining pigment.
Nevus of Ota is rarely the only etiology of dyspigmentation on
the face. Patients often have concurrent pigmentary lesions, such
as melasma, pigmented seborrheic keratoses, ephelides, or lentigi-
nes, and thus may be classified as having complex dyspigmenta-
tion.21 Park et al attempted to combine global photorejuvenation
with targeted pigment therapy by beginning with IPL therapy and A B
following with 694-nm QS ruby laser in 25 Korean patients with at ■ FIGURE 3. A 22-year-old skin type IV female with active acne
least 2 pigmentary disorders, and 4 of whom had acquired Nevus and numerous erythematous acne scars. (A) Baseline; (B) 3
of Ota; 60% experienced a 75%-100% improvement as assessed months status post combination PDT utilizing red and blue light
by 2 independent dermatologists. Three patients had transient PIH sources, PDL laser, and use of oral spironolactone and topical
benzoyl peroxide.
that resolved with subsequent IPL treatments, and 1 patient had
PIH.21 As the incidence of PIH can be high regardless of the la-
ser used, the authors commonly perform a test spot to assess skin with an acetone wash. Figure 3 demonstrates a 22-year-old skin
reaction and clearance from the treatment prior to treating the type IV female treated with subpurpuric full-face PDL to activate
entire area. the photosensitizer followed by simultaneous illumination with
a blue light (Blu-U, DUSA Pharmaceuticals, Inc, Wilmington,
Acne scars Massachusetts) source positioned 25 to 50 mm from the skin for
Severe acne can have a significant deleterious impact on quality an illumination period of 16 minutes 40 seconds, light dose 10
of life. Without adequate treatment, the scarring and pigmentary J/cm2, and a red light source (Aktilite CL 128, PhotoCure ASA,
changes may persist indefinitely despite clearance of the acne it- Oslo, Norway) positioned 50 to 80 mm from the skin for a total of
self. Therefore, acne and acne scarring are common complaints 8 minutes, 49 seconds at a standardized fluence of 37 J/cm2. Incu-
in patients seeking dermatologic treatment. Several types of scars bation with ALA was 3 hours prior to treatment. The patient was
may develop after acne through dermal fibrosis or pigmentary al- prescribed oral spironolactone (50 mg twice daily) and instructed
teration, and treatment of the scars is challenging, as more hyper- to use topical benzoyl peroxide as needed for spot treatment, as
pigmentation or scarring may occur. Additionally, multiple types she could not tolerate daily treatment over her entire face. At the
of lesions may be contributing to a patient’s undesired appearance. 3-month follow-up, greater than 75% clearance was noted. The
For example, it is not uncommon to have both an inflammatory patient has continued her oral and topical medications with ad-
and scarring component at the same time. Thus, severe acne and ditional PDL treatments planned as needed, and fractional CO2
acne scarring may be better treated with multiple modalities able resurfacing has been recommended as part of her combination
to target the underlying lesions most effectively. treatment plan.
Though isotretinoin is often effective and first line, many pa- In a pilot study in which 22 subjects (Fitzpatrick Skin Types
tients cannot tolerate the excessive dryness or develop one of the IV-V = 9/22) received 3 treatments 14 days apart with microfo-
rarer, severe side effects. Topical 5-aminolaevulinic acid-photody- cused ultrasound (MFU-V) using the 1.5-mm, 10-MHz (300 total
namic therapy (ALA-PDT) has long been used for treatment of lines to the entire face) and 1- mm, 10- MHz (420 lines to the
actinic keratoses but has also shown efficacy for treatment of acne entire face) depth transducers, a significant decrease in sebum, as
and is safe in patients with pigmented skin.22,23 By using a com- measured by a sebumeter (Courage-Khazaka, Köln, Germany),
bination of both ALA-PDT treatment with an ablative fractional was noted over the forehead, cheeks, and chin 60 days post treat-
Er:YAG 2940-nm laser in 40 patients with skin types III-IV, Yin et ment. Eighty percent of subjects had a decrease in total acne lesion
al showed complete resolution of all active acne lesions after 4-5 count at 60 days, and 100% of subjects showed a decrease at 180
monthly sessions and no new scars. Six months following the last days after the last treatment. It is hypothesized that, with the use
treatment, 80% of subjects’ scars improved by more than 50%, and of 1.5-mm and 1-mm depth probes, sebaceous glands are targeted
25% of scars improved more than 75%.24 A third of patients devel- for coagulation while bypassing the basal layer.25 Data from this
oped transient PIH, though all improved by 6 months. pilot trial suggest that MFU-V could prove to be a promising novel
In our practice, we routinely use a combination of ALA-PDT treatment option to improve acne clearance in those with moder-
and pulsed-dye laser (PDL) for treatment of active acne and ery- ate to severe inflammatory acne.26 An additional study found that
thematous acne scars. In certain cases, IPL is also incorporated 20 patients (75% of whom had skin type III or above) all noted
into the regimen. ALA is applied to the face after extractions and improvement of their atrophic acne scars following 3 monthly ses-
exfoliation with a vibrating microdermabrasion system (Vibra- sions of MFU-V.27
derm, Grand Prairie, Texas) are performed. It is then degreased In a Chinese study, 37 patients with both atrophic scars and in-

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 ■ ■ ■ Combination therapy in skin of color including injectables, laser, and light devices

flammatory lesions were treated with 4-6 successive IPL sessions

(fluence ranging from 14-18 J/cm2, pulse width 3.0-4.0 ms, and de-
lay time of 25-40 ms) followed by 2 sessions of fractional ablative
CO2 laser. Patients were treated with 2 passes of the CO2 laser, the
first with a spot size of 0.12 mm, scan size 10 x 10 mm, repetition
rate of 300-400 Hz, pulse energy 10-15 mJ, and density of 5%
(Deep FX; Lumenis Ltd, Santa Clara, California). The second pass
used a spot size of 1.3 mm, scan size of 7-9 mm, repetition rate of
300-350 Hz, pulse energy of 90-150 mJ, and density setting of 3-5
(Active FX; Lumenis Ltd, Santa Clara, California). Though the in-
flammatory lesions decreased significantly following IPL, scarring
improved only following the CO2 laser treatments. PIH was seen
in almost 40% of patients following the fractional CO2 sessions,
though all resolved by 3 months.28
Though fractional resurfacing is a well-documented treatment of
A B
acne scars, numerous treatment sessions are often required to in-
duce significant improvement.29 Additionally, PIH and scarring are ■ FIGURE 4. A 5-year-old skin type IV female with facial photo-
known side effects. As PIH is much more likely to occur in patients damage. (A) Baseline; (B) 12 months status post soft tissue filler
for the cheeks and chin, and a QS 755-nm alexandrite laser to
of darker skin types, lower density settings and/or longer treatment
target individual pigmented macular seborrheic keratoses, imme-
intervals are often required.30 Thus, combination treatments have diately followed by a 1927-nm fractionated thulium laser to the full
been sought to limit the side effects of ablative resurfacing and to face, followed by neuromodulator injection 2 weeks later.
enhance the therapeutic effect.
Radiofrequency (RF) treatment devices use 1 or 2 electrodes
to heat the dermis and cause collagen contraction and skin tight- damage in skin types III-IV.37 Because the laser forms microscopic
ening.31 Thermal damage also recruits fibroblasts to the areas of holes in the skin, drug delivery is hypothesized to be significantly
injury, which increase collagen synthesis.31 When RF devices are enhanced. Thus, the growth factors in the ADSC medium should
combined with nonablative lasers, atrophic acne scars have been be able to more efficiently recruit dermal fibroblasts and increase
shown to improve by 60%-72%.32,33 dermal collagen. In fact, histologic analysis of the subjects’ skin
Additionally, high-intensity bipolar RF (Infini, Lutronic Inc, showed increased dermal collagen density and more ordered col-
Burlington, Massachusetts) targets the dermis in a highly focused lagen than the facial side treated with laser alone.37
manner by varying the depth of the microneedles on the device.34 For noninvasive treatment of facial wrinkles, a combination of
This technique bypasses the epidermis and directly heats the der- optical energy with RF or heat energy are thought to work syn-
mis to maximize remodeling beneath acne scars. This protective ergistically with each other. First, the optical energy specifically
epidermal effect is particularly beneficial in pigmented skin while heats a target, which then further concentrates the heat energy ad-
maintaining efficacy deeper in the tissue.34 ministered by the RF device.38 Twenty-three patients were treated
Combination treatments utilizing topical applications follow- for facial and neck wrinkles with up to 3 sessions of a combina-
ing laser procedures have also been explored to address scarring. tion diode laser and RF system (Polaris, Syneron Medical Ltd,
In 13 patients with skin types III-IV, facial skin was treated with Yokneam, Israel), after which 30% experienced at least a 50%
the conditioned medium of adipose-derived stem cells (ADSCs) improvement and 66% noted at least a 25% improvement, with
in the hopes that healing of laser-damaged skin would be accel- no reports of pigmentary change.39 Patients had skin phototypes
erated.35 The numerous growth factors secreted by ADSCs into ranging from II to IV, though there were no notable differences in
their surrounding medium, such as basic fibroblast growth fac- efficacy based upon skin type.
tor, keratinocyte growth factor, transforming growth factor, and In our practice, fractionated ablative and nonablative lasers are
vascular endothelial growth factor, may stimulate migration of routinely used for rejuvenation of facial photodamage in skin types
fibroblasts into the dermis in addition to dermal collagen synthe- III-V in combination with other lasers, injectable fillers and neuro-
sis.36 Following 2 passes of a fractional CO2 laser, 1 side of the modulators, and medical grade lightening products. The skin type
face was treated with the conditioned medium of ADSCs. Three IV patient in Figure 4 presented as an anti-aging consult, most con-
monthly sessions were performed. One month following the last cerned about the lentigines, volume loss, and overall photodamage
treatment, participant satisfaction and objective clinical assess- on her face. On the same day, the patient underwent treatment with
ment were both significantly improved on the ADSC-medium a soft tissue filler for the cheeks and chin (Radiesse, Merz, Raleigh,
treated side. No persistent adverse events were noted, and there North Carolina) and a QS 755-nm alexandrite laser to target indi-
was no significant difference in pain or erythema between the vidual pigmented macular seborrheic keratoses (3-mm spot size, 7
2 sides.45 Yet, there was reduced hyperpigmentation using the mJ/cm2, 10 Hz), immediately followed by a 1927-nm fractionated
ADSC medium. thulium laser to the full face (Fraxel Restore, Solta Medical Inc.,
Hayward California) (20 mJ, 50% coverage [treatment level 7] de-
Facial photodamage and rejuvenation livered over 8 passes). Over the course of the year, she also had
The conditioned medium of ADSCs has also been used immedi- neuromodulation (Botox, Allergan, Irvine, California) and started
ately following fractional CO2 laser when treating facial photo- routine use of a skin lightening regimen (SkinMedica Inc, Carls-

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 Guss et al

bad, California). Future treatment with additional filler and MFU- the improvement was moderate at best, combination therapy using
V for skin tightening has been recommended as part of her ongoing heat and mechanical stimulation does appear to be effective and
combination treatment plan. safe for the treatment of cellulite in pigmented patients.
More recently, a subcision approach (Cellfina System; Ulthera
Neck Inc, Mesa, Arizona) has been described that manually dissects the
Skin laxity fibrous network causing dimpling in the dermis. A precise depth of
Due to ultraviolet radiation damage and chronological aging, dissection may be fixed through a vacuum chamber to lift the tis-
dermal collagen and elastin gradually diminish, resulting in skin sue for the needle. As the Cellfina is a non-energy-based device, it
laxity, which may be particularly pronounced over the neck.40 is an attractive treatment option for patients with pigmented skin.
For superficial skin tightening, fractionated ablative CO2 laser Seventy-eight percent of patients enrolled in the original trial were
has been shown to improve neck laxity by an average of 57% at skin type III and above, and 33% of patients had skin type IV or
2 months.41 However, as noted above, even fractional CO2 treat- above. Every subject noted an improvement at 1 year, and no long-
ment of patients with pigmented skin carries a high risk of PIH.28 term adverse events or PIH were recorded.49
Newer devices utilizing radiowave or ultrasound technology have
become increasingly popular for treatment of off-face skin laxity.42 Scars
As neither radio nor ultrasound waves target pigment, their use in Hypertrophic scars and keloids are quite common in skin of color
patients with darker skin types typically carries no greater risk than patients and represent an exuberant healing response to trauma, in-
treatment for patients with less melanin.1 Additionally, ultrasound flammation, or burns.50 In addition to psychological distress caused
technology does not cause enough edema or erythema to interfere by the appearance, keloids may also provoke sensations of pruritis
with subsequent laser applications and thus offers an attractive or pain.51 Though numerous treatments have been proposed to im-
adjunct for the treatment of neck laxity.43 In 60 patients treated prove the appearance and symptoms, keloids are notoriously recal-
initially with microfocused ultrasound with visualization (Ulthera citrant or slow to respond to more conservative treatments such as
System, Ulthera, Inc, Mesa, Arizona) using the 4.5-mm, 4-MHz; intralesional steroid injections. Additionally, dyspigmentation and
3-mm, 7-MHz; and 1.5-mm, 10-MHz transducers at the highest atrophy often accompany any improvement in the texture of the
energy settings delivering the number of lines based on manufac- keloid. Unfortunately, keloids often recur, occasionally even grow-
turer protocol followed immediately with treatment by an ablative ing to a larger size, after more aggressive or destructive techniques.
fractionated laser, the improvement in skin laxity and texture of the By using a combination approach with a 578-nm copper bro-
neck was thought to be greater than the physicians’ prior experi- mide laser to target the vascular component of the scar in addi-
ence using either modality alone. The recovery time was delayed tion to intralesional triamcinolone acetonide, keloids were noted
an additional 3 to 4 days, though the incidence in other adverse to improve by at least 50% in 9 of 12 treated Korean patients when
events was not noted. However, this article did not specify the skin assessed by 2 physicians blinded to the treatment protocol.52 The
types of the patients studied.44 Yet, when MFU-V was studied in 52 increased improvement over injections alone was hypothesized to
patients with skin types III-IV for tightening of the skin of the face occur secondary to thermal injury to the scar microvasculature,
and neck, the only prolonged adverse event noted was erythema in which then induced ischemia and collagen reduction.52 The authors
1 patient.45 also noted significantly less purpura following the laser treatments
If a patient wishes to address both pigmentary change in addi- than would be expected to occur when using a PDL.
tion to skin tightening, Vanaman et al recommend beginning with a Yan et al specifically studied 151 symptomatic keloids, which
vascular laser, either IPL or PDL, then using tumescent anesthesia had been present for greater than 2 years, were greater than 2 cm2
prior to subsurface monopolar RF (ThermiTight, ThermiAesthet- in size, and had failed treatment with 2 or more treatment modali-
ics, Irving, Texas), and completing the session with a QS 532-, ties, including excision, laser, cryotherapy, pressure garments, and
694-, or 755-nm laser for any remaining pigmented lesions. As the radiation. Keloids were first treated with continuous-wave CO2
3 devices all have very different targets, no increased scarring or laser followed by ultra-pulse CO2 laser 5-7 days later in order to
adverse events were noted.43 prevent the proliferation of scar tissue. Following the second CO2
treatment,24 P-patch contact brachyradiotherapy was performed.
Body One hundred and eleven of the keloids responded without a notice-
Cellulite able scar or a cosmetically satisfactory scar following treatment,
Though affecting up to 80% of postpubertal women, cellulite re- and 40 of the keloids resolved into a hypertrophied scar. None
mains a very difficult condition to treat, particularly using non- of the keloids were rated as being as large or larger than baseline
invasive technologies alone.46,47 However, the combination of following treatment, though approximately 50 treated sites were
mechanical manipulation, infrared light, and RF does show prom- notable for residual hyperpigmentation or depigmentation.53 Thus,
ise. Seven patients with skin phototypes ranging from III-V were for particularly recalcitrant keloids, a combination therapy using
treated with an RF light-based device (VelaSmooth, Syneron Med- both laser and radiation may provide significant benefit.
cial Ltd, Yokneam, Israel) that incorporates bipolar RF, infrared
heat energy, and pulsatile vacuum suction through a handheld ap- Striae
plicator. Following 8-9 treatments administered twice weekly, pa- Striae distensae is a common cause of cosmetic concern character-
tients experienced an average of 25% improvement of cellulite on ized histologically by thinning of the epidermis as well as dermal
the abdomen and 50% on the thighs.48 The only adverse event re- collagen and elastin.54 If the striae are erythematous, the pigment
ported was a single blister, which healed without scarring. Though may be treated safely in individuals with pigmented skin with a

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 ■ ■ ■ Combination therapy in skin of color including injectables, laser, and light devices

585-nm dye laser, though the textural change is much more difficult 7. Angsuwarangsee S, Polnikorn N. Combined ultrapulse CO2 laser and Q-switched
alexandrite laser compared with Q-switched alexandrite laser alone for refractory
to improve.55 More recently, a microneedle RF device (INTRAcel,
melasma: split-face design. Dermatol Surg. 2003;29(1):59-64. doi:10.1046/j.1524-
Jeisys, Seoul, South Korea) has been shown to improve numerous 4725.2003.29009.x.
dermal abnormalities such as rhytides, scars, and keloids. The tex- 8. Nouri K, Bowes L, Chartier T, Romagosa R, Spencer J. Combination treatment of
tural improvement is thought to occur through wound remodeling melasma with pulsed CO2 laser followed by Q-switched alexandrite laser: a pilot
study. Dermatol Surg. 1999;25(6):494-497. doi:10.1046/j.1524-4725.1999.08248.x.
and tightening in response to heat-induced collagen denaturation.56 9. Cunha PR, Pinto CA, Mattos CB, Cabrini DP, Tolosa JL. New insight in the treat-
With the combination of both RF technology (Thermage, Solta ment of refractory melasma: Laser Q-switched Nd: YAG non-ablative fractionated
Medical, Inc, Hayward, California) and a 585-nm PDL, almost followed by intense pulsed light. Dermatol Ther. 2015;28(5):296-299. doi:10.1111/
dth.12250.
90% of Asian patients noted an overall improvement in their striae,
10. Wattanakrai P, Mornchan R, Eimpunth S. Low-fluence Q-switched neodym-
with approximately 60% showing “good or very good” improve- ium-doped yttrium aluminum garnet (1,064 nm) laser for the treatment of
ment in the elasticity of their striae.57 In 10 patients with skin type facial melasma in Asians. Dermatol Surg. 2010;36(1):76-87. doi:10.1111/j.1524-
IV, the combination of fractional CO2 laser with microneedle RF 4725.2009.01383.x.
11. Chan NP, Ho SG, Shek SY, Yeung CK, Chan HH. A case series of facial depig-
(Secret; ilooda, Suwon, South Korea) showed greater improve- mentation associated with low fluence Q-switched 1,064 nm Nd:YAG laser for skin
ment in their striae than 20 patients treated with either fractional rejuvenation and melasma. Lasers Surg Med. 2010;42(8):712-719. doi:10.1002/
CO2 laser or microneedle RF alone, with transient PIH occurring lsm.20956.
12. Vachiramon V, Sirithanabadeekul P, Sahawatwong S. Low-fluence Q-switched Nd:
in 30% of patients in the combination group versus 20% in each
YAG 1064-nm laser and intense pulsed light for the treatment of melasma. J Eur
of the other 2 groups.54 Thus, combination treatment was shown to Acad Dermatol Venereol. 2015;29(7):1339-1346. doi:10.1111/jdv.12854.
be more effective without significant increase in adverse events in 13. Kauvar AN. Successful treatment of melasma using a combination of microderm-
treatment of striae. abrasion and Q-switched Nd:YAG lasers. Lasers Surg Med. 2012;44(2):117-124.
doi:10.1002/lsm.21156.
At our site, we have an ongoing split-body comparison trial to 14. Fabi SG, Friedmann DP, Niwa Massaki AB, Goldman MP. A randomized, split-face
evaluate the efficacy of a nonablative fractionated 1565-nm laser clinical trial of low-fluence Q-switched neodymium-doped yttrium aluminum garnet
(ResurFX, Lumenis Ltd, Santa Clara, California) and combination (1,064 nm) laser versus low-fluence Q-switched alexandrite laser (755 nm) for the
treatment of facial melasma. Lasers Surg Med. 2014;46(7):531-537. doi:10.1002/
1064-/532-nm fractionated picosecond laser (PicoWay Resolve,
lsm.22263.
Syneron Candela, Irvine, California) in the treatment of striae. 15. Vachiramon V, Sahawatwong S, Sirithanabadeekul P. Treatment of melasma in men
Skin types I-IV have been treated. Subjects receive 3 treatments with low-fluence Q-switched neodymium-doped yttrium-aluminum-garnet laser
spaced 3 weeks apart. Preliminary data reveal comparable efficacy versus combined laser and glycolic acid peeling. Dermatol Surg. 2015;41(4):457-
465. doi:10.1097/DSS.0000000000000304.
between the laser treatments; however, there is more discomfort 16. Chan HH, Leung RS, Ying SY, et al. A retrospective analysis of complications in
associated with the 1565-nm laser. In addition, PIH lasting longer the treatment of nevus of Ota with the Q-switched alexandrite and Q-switched
than 1 month has been observed in the majority of subjects on the Nd:YAG lasers. Dermatol Surg. 2000;26(11):1000-1006. doi:10.1046/j.1524-
4725.2000.0260111000.x.
sides treated with the 1565-nm wavelength, whereas long-lasting
17. Watanabe S, Takahashi H. Treatment of nevus of Ota with the Q-switched ruby la-
PIH has not been appreciated on the sides randomized to the pico- ser. N Engl J Med. 1994;331(26):1745-1750. doi:10.1056/NEJM199412293312604.
second laser. Final data will be available later this year. 18. Alster TS, Williams CM. Treatment of nevus of Ota by the Q-switched alexan-
drite laser. Dermatol Surg. 1995;21(7):592-596. doi:10.1111/j.1524-4725.1995.
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Conclusion 19. Tse Y, Levine VJ, McClain SA, Ashinoff R. The removal of cutaneous pigmented
With each year, new medical, injectable, surgical, and device-based lesions with the Q-switched ruby laser and the Q-switched neodymium: yttrium-alu-
therapies, used alone or in combination, are reported in the pursuit minum-garnet laser. A comparative study. J Dermatol Surg Oncol. 1994;20(12):795-
800. doi:10.1111/j.1524-4725.1994.tb03707.x.
of treating skin of color safely and successfully. The efficacy of
20. Lowe NJ, Wieder JM, Sawcer D, Burrows P, Chalet M. Nevus of Ota: treatment
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optimal cosmesis. Additional research of combination treatment is 21. Park JM, Tsao H, Tsao S. Combined use of intense pulsed light and Q-switched
ruby laser for complex dyspigmentation among Asian patients. Lasers Surg Med.
necessary to document safety, to quantify the benefits, to establish 2008;40(2):128-133. doi:10.1002/lsm.20603.
the duration of effects, to review cost-effectiveness, and to evalu- 22. Sakamoto FH, Lopes JD, Anderson RR. Photodynamic therapy for acne vulgaris: a
ate the psychological improvement and quality of life for patients critical review from basics to clinical practice: part I. Acne vulgaris: when and why
consider photodynamic therapy? J Am Acad Dermatol. 2010;63(2):183-193; quiz
using the various treatment modalities.
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23. Yin R, Hao F, Deng J, Yang XC, Yan H. Investigation of optimal aminolaevulinic
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