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medestheticsmagazine.com | NOVEMBER/DECEMBER 2015 33 Whether your patient suffers from melasma, UV-related hyperpigmentation or post-infl ammatory hyperpigmenta- tion, the key to offering relief is to help them understand that treatment will require both in-offi ce procedures and consistent home care, and that results will be gradual. Adding to the challenge of patient satisfaction is the fact that pig- mentation problems are often chronic and recurring. "One can think of melanocytes in the areas of hyperpig- mentation or melasma as being preprogrammed to produce extra pigment/melanin," says Anetta Reszko, MD, PhD, assistant professor of dermatology at Weill Cornell Medi- cal College and owner of New York Skin Institute in New York City. "Most of the treatment modalities remove extra pigment, but since the cells are preprogrammed to make increased amounts, the pigment frequently comes back." REVERSING SUN DAMAGE The most common cause of hyperpigmentation is sun damage. For patients with UV-related dark spots, Gregory Nikolaidis, MD, of Westlake Dermatology in Austin, Texas, recommends laser resurfacing or chemical peels. "My most popular treatment for lentigines is the Fraxel DUAL com- bination 1550nm/1927nm erbium fractionated laser," he says. "I also like chemical peels—anything from a modifi ed Jessner's, like the SkinMedica Vitalize Peel, to a TCA peel." For scattered lentigines on patients with fair skin he applies spot treatments using chemical peels or laser. "With skin types IV or darker, I'm less apt to do a spot treatment be- cause it tends to show up more, and if I do a peel treatment then I counsel those patients that there is a high likelihood that they're going to have some temporary post-infl amma- tory hyperpigmentation," says Dr. Nikolaidis. Improvement can be seen after the fi rst session, but most patients will see results after two to three treatments. While the longevity of the results will depend on patients' age and how much time they spend outdoors, Dr. Nikolaidis fi nds that results of in-offi ce treatments typically last one to three years when combined with proper home care. He counsels patients to avoid excessive sun exposure and use sun protection when outdoors to prevent recurrence. "Some patients like to come in once a year for 'refresher' laser treatments or chemical peels," he says. Jeffrey S. Dover, MD, of SkinCare Physicians in Boston also fi nds laser treatments most effective for lentigines, noting that success often depends on the area of the body being treated. "Q-switched lasers, intense pulsed light and frac- tional nonablative Thulium lasers as well as other superfi cial fractional nonablative devices are highly effective treatments," he says. "Facial lesions respond best, and results are less impressive the further you move from the face. The neck and chest do fairly well, arms slightly less well and the legs are somewhat more stubborn." His patients typically achieve optimal results after three treatments and are counseled to return for in-offi ce main- tenance treatments as well. "We suggest that the patient come back 6 to 12 months after the fi nal treatment to consider a polish-up treatment and to set up a maintenance program," says Dr. Dover. Maintenance treatments are typically performed once or twice a year depending on the particular patient. Patients who do not want to undergo laser or chemical peel treatments and those for whom these treatments are contraindicated can use a topical-only regimen, though Dr. Dover notes that it takes longer to lighten lentigines this way. "Topical treatment is highly effective, but it takes one to two years to achieve the best possible result," he says. "Hydroquinone is effective, either alone or in combination with tretinoin, and triamcinolone—Kligman's Formula—is also effective." When treating lentigines with skin-brightening topicals only, Dr. Nikolaidis fi nds that they rarely get rid of sun dam- age entirely. "Lentigines can be lightened to a certain extent with different topical agents, such as tretinoin and retinol, and hydroquinone or hydroquinone precursors like arbutin. You can even use topical vitamin C or azelaic acid," he says. "But if you're going for complete removal, you're not going to get that with topical agents—you're just going to get some degree of lightening." It is a challenge that formulators are looking to overcome. "Melanin production is mediated via the enzyme tyrosinase in a multi-step pathway, producing melanin that is packaged and exported out of the melanocyte cell to neighboring kerati- nocytes. The collections of darkened keratinocytes are seen as areas of hyperpigmentation," says Barbara Green, vice president of clinical research for skincare company NeoStrata. "Each step in the pathway represents a potential target for brightening formulations." To increase the effi cacy of topicals, NeoStrata and others are formulating lines with multiple skin lightening ingredi- ents, each designed to affect a different step in the melanin production process. Ingredients in NeoStrata's Enlighten line include patented NeoGlucosamine, a tyrosinase inhibi- tor and non-acid exfoliant, and SabiWhite, a brightening/ antioxidant ingredient found naturally in the spice turmeric. "With continued use, we have seen in multiple clinical stud- ies that obvious brightening starts to occur at six weeks and "Hi g h ener g y Q-switche d l asers an d IPL sometimes p ro d uce tem p orary im p rovement b ut in the en d can m a k e this con d ition worse. "