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34 NOVEMBER/DECEMBER 2015 | Med Esthetics TONE IT DOWN © GETTY IMAGES Laser and light treatments tend to be more effective than topicals, but do carry the risk of PIH. is much stronger by 12 weeks and 16 weeks," says Green. Though there are several effective skin lightening ingre- dients on the market, one of the most effective topicals to reduce hyperpigmentation remains sunscreen. "Diligent use of sunscreen and avoidance of sun exposure is essential for maintaining an even complexion," says Green. "Clinical studies of up to six months have shown that with continued use, there is continued benefi t. Additionally, an occasional professional peel can signifi cantly boost brightening effects." MANAGING MELASMA Melasma—a chronic, ongoing disorder—is notoriously diffi cult to treat. Success varies widely and continuous maintenance is essential. Dr. Reszko uses Clear + Brilliant Perméa (Valeant) 1927nm laser treatments in combination with a topical blend of retinoids, hydroquinone and a mild steroid for her melasma patients. "I usually recommend pretreatment with topi- cals—including retinoids and bleaching agents like hydroqui- none, kojic acid and/or arbutin—for about a month prior to laser treatments. Patients typically require a series of two to fi ve treatments, usually a month apart," she says. "The Clear + Brilliant Perméa is my favorite because there is minimal downtime—patients experience one day of redness and a burning sensation, and dryness and peeling for about fi ve to seven days post-treatment." Additionally, Dr. Reszko fi nds superfi cial microneedling to be effective for treating melasma. "Microneedling up to 2mm causes superfi cial injury to the skin, and healing mechanisms remove pigment as skin heals," she says. "Several treatments are required for optimal benefi ts in this case as well." At Westlake Dermatology, Dr. Nikolaidis and colleagues use PicoSure (Cynosure) or Fraxel (Valeant) treatments, but only in cases with very resistant melasma. "I tend to stay away from laser treatments to treat melasma. The issue is that although some lasers are FDA approved to treat melasma, it's not uncommon for them to make it worse," says Dr. Nikolaidis. "They are my last line of treatments for melasma. If I do use lasers, I tend to use them at lower energies and densities than I would to treat actinic damage." He prefers instead to apply topical treatments fi rst, opting for Cosmelan 2 by mesoestetic and Lytera by SkinMedica. "Cosmelan 2 is an at-home treatment patients can use; it's primarily arbutin, which is a hydroquinone precursor, and it also has phytic acid and azelaic acid," he says. "I recommend Lytera for patients who can't tolerate Cosmelan (because it's a bit strong). It's a combination of vitamin C, niacinamide, tetrahexyldecyl ascorbate, retinol, squalane—a number of agents that help lighten the skin." Both products will cause some peeling, which is why Dr. Nikolaidis favors them over hydroquinone and retinol alone, though he stresses that his choice of treatment depends on the severity of the hyperpigmentation. In cases where melasma or hyperpigmentation is severe, he graduates to a stronger in-offi ce Cosmelan treatment. "I apply a Cosmelan mask in the offi ce that the patient washes off eight to ten hours later, and then I have them use a Cosmelan 2 product once or twice daily for the next three months at home," says Dr. Nikolaidis. "It's generally going to be topical creams fi rst, the next thing would be Cosmelan masks. After that, I would consider light chemical peels and then potentially either a light Fraxel or PicoSure treatment." For his patients, results with the mask are visible within a couple of weeks, while the topicals alone will yield a better complexion after six to eight weeks. After the melasma is cleared, results will last as long as the patient wears sunscreen and maintains a continuous lightening skincare regimen. "Once you've gotten patients where they want to be with the stron- ger treatments, then you can maintain results with something like the SkinMedica TNS Essential Serum, which is a 2% arbutin product and an all-in-one growth factor, antioxidant and lightening serum," says. Dr. Nikolaidis. He warns that the melasma will come back after even one day in the sun without protection. "I counsel my patients with