JAN-FEB 2019

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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PHOTOS COURTESY OF WENDY ROBERTS, MD 28 JANUARY/FEBRUARY 2019 | Med Esthetics Dr. Roberts limits hydroquinone use to eight consecutive weeks before rotating the patient to a nonprescription light- ener. She notes that many young patients are wary of using hydroquinone and may opt to start with nonhydroquinone skin lighteners. "A lot of our younger patients will say, 'I don't want anything with hydroquinone in it,' so you want to be prepared with alternatives," she says. She recommends Cysteamine Cream from Scientis Pharma and Colorescience's Even Up. "Even Up is a nice product because it camoufl ages while you're treating and it has a number of nonhydroquinone actives, including licorice, and also mineral pigments that cover the brown spots and provide sun protection," she says. "You always want to think about both treating and covering. Because that coverage offers camoufl age and added protection." In addition to nonprescription skin lighteners, Dr. Roberts starts all of her melasma patients on both topical and oral antioxidants. "Antioxidants are very important in melasma to fi ght the sun damage. The internal antioxidant I like is polypodium leucotomos (Heliocare)—and this is particularly important for people who live in the Sun Belt because they are constantly exposed to UV rays," she says. For topical protection, she recommends vitamin C and E products, such as Skinceuticals' C E Ferulic. "That's the one I use the most. Then you need sun block. I like to use a tinted sun block for my melasma patients because these formula- tions include both chemical and mineral sun blocks, so they are broad-spectrum, and the tint provides some camou- fl age," says Dr. Roberts. "Then you have your makeup. I encourage melasma and PIH patients to wear foundation, because it creates another layer of protection for their skin." In addition to sun block, antioxidants and lighteners, me- lasma patients need to be counseled on sun avoidance, as exposure to UV rays can cause recurrence. "Patients need to think about personal shade structures—hats, long sleeves and umbrellas," says Dr. Roberts. "Their car windows should also be tinted. You want to do everything you can to decrease sun exposure to the face. If we're not addressing UV exposure, none of the treatments will work." IN-OFFICE PROCEDURES For some patients, topicals and sun avoidance do not offer satisfactory outcomes. In these cases, in-offi ce procedures, such a chemical peels, microdermabrasion and laser treat- ments can help banish unwanted pigment. Dr. Alexis begins with low-concentration glycolic acid peels. "I start at 30 percent, working up slowly to as high as 70 percent. For skin of color, modifi ed Jessner peels and salicylic acid peels are my go-to treatments," he says. "Patients with superfi cial cases of melasma are great candidates for chemical peels," says Dr. Roberts. "With me- lasma, you have the epidermal variant, the dermal variant and the mixed. Peels are very effective for the epidermal." She uses the modifi ed Jessner peel, noting that any peel that has lactic acid and resorcinol is a good choice for melasma. "There are many commercial peels out there that have those ingredients. I love the Vitalize peel by SkinMedi- ca," she says. Nonablative fractional lasers are also an option for melasma patients, but must be used carefully to prevent PIH, particularly in patients with darker skin types. "The low-powered diode 1,927nm Clear+Brilliant Permea is a lot safer for darker skin types than the traditional 1,927nm thulium laser," says Dr. Alexis. "It has very simplifi ed set- tings—low, medium and high—and I tend to stick to low or medium. This offers a good mix of effi cacy and safety in terms of minimizing risk." Dr. Roberts has two lasers that she uses for melasma: the Fraxel 1,550nm and the Aerolase Lightpod Neo 1,064nm 650 nanosecond laser. "This is my newest device, and I'm getting really nice results. It's very short-pulsed and is a great laser for melasma," she says. While the 1,550nm Fraxel is indicated for all skin types, Dr. Roberts notes that it can cause PIH in skin types IV and higher. "It's very technique- and user-dependent. You have to use very low energy and density settings and do more sessions," she says. When adding chemical peels or laser treatments to your melasma treatment regimen, topical retinoids should be FADE OUT This melasma patient underwent one treatment with the Aerolase Lightpod Neo 1,064nm laser. BEFORE AFTER

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