Low Fluence Q-Switched Neodymium-Doped Yttrium Aluminium

Garnet (LFQSNd:YAG 1064nm) versus Combination of LFQSND:

YAG 1064nm and Microneedle Fractionated Radiofrequency

(MFRF) for Treatment of Indonesian Melasma Patients. Which is

Better?

Ary Widhyasti Bandem

, Ni Putu Susari Widianingsih

, Trisniartami Setyaningrum

, Cita Rosita

Sigit Prakoeswa

Surabaya Skin Centre, Indonesia

Departement of Dermato-Venerology Dr Soetomo Teaching Hospital Surabaya, Indonesia

Keywords: melasma, laser, microneedle fractionated radiofrequency, Janus

Abstract: Melasma treatment is still very challenging and cannot definitely be cured, since recurrence are high. Many

modalities used to treat melasma, such as broadspectrum sunscreen, lightening agents, intense pulsed light,

lasers, and a newly microneedle fractionated radiofrequency specially design to treat melasma. In this study,

we enrolled 5 Indonesian melasma patients, Fitzpatricks skin type III-IV, 36-65 years old and given low

fluence Q switched Nd:YAG 1064 nm and other half face added the microneedle fractionated

radiofrequency treatment. Patients were given 4 treatments 2-4 weeks apart. Parameters for the laser

treatment using spot size 6 or 8 mm, 1,6- 1,8 J/cm2, 10 Hz, endpoint slight erythema, and for the

microneedle fractionated radiofrequency, power 3, depth 1-1,5 mm, 100-150 shots The improvement of

pigmentation lesion, skin tone and side effects were evaluated using the Janus imaging system. Conclusion:

Melasma treatment using combination low fluence Q Switched Nd:YAG 1064 nm and microneedle

fractionated radiofrequency was better than low fluence Q Switched Nd:YAG1064 nm alone and no serious

side effects found during both treatment.

1 INTRODUCTION

Melasma is considered one of the most challenging

hyperpigmentation disorder to treat, especially in

Indonesian skin type. Many factors contribute in

developing melasma, such as genetic factors, sun

exposures, pregnancy, oral contraceptives,

phototoxic and photo allergic drugs and cosmetics.

Melasma appears as symmetric facial

hypermelanosis, with irregular light brown to dark

brown macules and patches on face, predominantly

on malar areas, forehead, and chin but until now the

etiology and pathogenesis are not fully understood.

Many treatments modalities are used to cure

melasma in Indonesia, including broad spectrum

sunscreen, topical lightening agents, retinoids,

corticosteroid, chemical peelings, lasers and other

light based energy devices. Unfortunately, there is

no definite cure for melasma. Lasers may worsen the

melasma and cause post inflammatory hyper

pigmentation, but recently laser experts have found

that using the low fluence parameters (laser toning)

give better results (Kim et al., 2012; Fabi et al.,

2014; Trivedi, Yang, and Cho, 2017; Kauvar).

New

treatment for melasma is always awaited.

In 2016, a new device with microneedle

fractionated radiofrequency technology was

specially design to treat melasma, particulary

refracter melasma with the vascular involvement.

5-7

However there is no report on the safety and

effectiveness in Indonesian melasma patients. Aim

of this study is to evaluate the changes in skin tone

and spot pigmentation on the face of melasma

patients, comparing the low fluence Q switched

Nd:YAG 1064 nm versus the combination of low

fluence Q switched Nd:YAG 1064 nm and

microneedle fractionated radiofrequency using the

Janus imaging system.

Bandem, A., Widianingsih, N., Setyaningrum, T. and Prakoeswa, C.

Low Fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet (LFQSNd:YAG 1064nm) versus Combination of LFQSND:YAG 1064nm and Microneedle Fractionated Radiofrequency

(MFRF) for Treatment of Indonesian Melasma Patients. Which is Better?.

DOI: 10.5220/0008156903330337

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 333-337

ISBN: 978-989-758-494-7

333

2 METHODS

We enrolled 5 Indonesian woman patients with

melasma, age 36-65 years old, Fitzpatricks Skin type

III-IV in this study. Before treatment, patients signed

informed consent and given topical anesthesia using

topical eutectic mixture of 2,5% lidocain and 2,5 %

prilocaine. All patients were treated with low

fluence Q switched Nd:YAG 1064 nm spotsize 6 or

8 mm with fluence 1,6-1,8 J/cm, 10 Hz, with end

point slight erythema, and half face of each patients

received an addition of microneedle fractionated

radiofrequency treatment. The parameters of

microneedle fractionated radiofrequency were:

power 3, depth 1-1,5 mm, 100-150 shots. Interval

treatment was 2-4 weeks and all other treatments

were continued such as broadspectrum sunscreens,

and topical lightening agents. Photographs were

taken using normal light, polarization light and UV

light with the skin analyzer Janus 2 done by the

same technician. Evaluation of data and photographs

was done by another dermatologist.

3 RESULTS

Table 1: Mean value of skin tone and spot pigmentation using Janus imaging system

Area Treatment LFQS1064nm LFQS1064nm & MFRF

Upper chee

Before 32.2 ± 2.6 (29-36) 33.6 ± 2.7 (31-38)

Skin Tone Afte

32.6 ± 1.5 (30-34) 32.6 ± 2.6 (29-35)

Lower chee

Before 32.4 ± 0.5(32-33) 32.9 ± 0.2 (33-32.9)

Afte

32.3 ±0.7 (31.5-33) 32.9 ± 0.2 (33-32.9)

Spot Upper chee

Before 32.6 ±12.8 (19-46) 38.8 ±10,4 (29-53)

Pigmentation Afte

27.8 ±14.9 (10-43) 28.6 ±10.9 (15-40)

Middle

chee

Before 33.2 ±7.4 (21-40) 36 ±13.8 (22-52)

Afte

31.4 ± 13.1 (10-45) 24.4 ± 11.3 (13-40)

Lower

Chee

Before 34.6 ± 9.5 (23-45) 33.8 ±10 (24-47)

Afte

39 ± 9.9 (28-51) 19.4 ± 8.4(12-30)

LFQS1064nm : Low fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet 1064nm

MFRF: Microneedle Fractionated Radiofrequency

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

334

Figure 1: The line graph of skin tone and spot pigmentation (before-after) in split face control and interventional area.

Low Fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet (LFQSNd:YAG 1064nm) versus Combination of LFQSND:YAG

1064nm and Microneedle Fractionated Radiofrequency (MFRF) for Treatment of Indonesian Melasma Patients. Which is Better?

335

Figure 2: Photograph using Janus Imaging System: left side of patient: combination LFQSNd:YAG1064nm and

Microneedle Fractionated Radiofrequency. right side: LFQSNd:YAG1064nm.

4 DISCUSSION

Janus imaging system take images in 3 different

lights, normal light for evaluating wrinkles and

pores, polarized light for evaluating spot and

pigmentation while UV light to evaluate sebum and

porphyrin (p.acnes). In the polarized imaging of the

Janus system we found that the skin tone for our

patients in this study did not improve consistently in

both treatments, the LFQS1064nm and the

combination LFQS1064nm and microneedle

fractionated radiofrequency (figure 1,2,6,7). Skin

tone is level of darkness of the overall skin. The skin

tone can be uneven due to excessive workload,

stress, pigmentation, sunburn, keratin and skin

problems. Janus imaging system record that

melasma patients have poor skin tone before and

after treatment. We conclude in this study that skin

tone in Janus imaging system is not a realible

parameter to evaluate the efficacy of melasma

treatment. These findings were similar to research

done by Prakoeswa CRS, Pratiwi FD, et al. Skin

tone was found not significant to evaluate the

improvement in photoaging before and treatment

using amniotic membrane stem cell conditioned

medium (AMSC-CM) (Prakoeswa, nd).

Evaluation of the skin pigmentation and spots of

melasma decrease on both sides of the face, except

two patients (the middle cheek), and three patients

(the lower cheek) that were only given LFQS1064

nm. These areas showed an increase value of

pigmentation (figure 2,4). These findings may be

due to that the lesion had more intense pigmentation,

darkening effect post laser treatment or the lesions

were refracter to LFQS 1064nm treatment. Spots

and pigmentation in the upper, middle, and lower

cheeks with combination treatment, we found that

the pigmentation consistently decreased after

treatment (figure 8,9,10). This may due to the

proposed mechanism of the microneedle fractionated

radiofrequency, where the microneedle fractionated

radiofrequency may work through modes of action,

including enhancing permeability of topical

lightening agents and increasing degradation of

dermal vasculature (Choi and Choi; Choi, et al.,

2015). The therapeutic topical lightening agents are

known to be limited by their poor transepidermal

penetration, so maybe the microneedle

radiofrequency creates micro channels to enhance

transdermal drug delivery. This micro environment

altered by the microneedle fractionated

radiofrequency may caused the reversal of solar

elastosis, causing decrease melanogenesis and

lightening of the melasma. Not like the fractionated

lasers which cause more crusting, the microneedle

fractionated radiofrequency did not show any

obvious microcrusting or increased epidermal

Splitface:

Before treatment

After 4 treatments

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336

shedding. The effectiveness combination treatment

of microneedle fractionated radiofrequency and

topical lightening agents reported by Choi et al,

showed good improvement in melasma lesion (Choi

and Choi; Choi, et al., 2015).

Laser toning using low fluence Q Switched

Nd:YAG 1064 nm for melasma treatment has gain

popularity since a few years ago. It is an addition

treatment to previous treatment such as topical

lightening agents, broadspectrum sunscreens, and

chemical peelings. The exact mechanism of laser

toning on the improvement of melasma is still

unclear. It has been proposed that melanin granules

are fragmented and dispersed into the cytoplasm

without destruction by repetitive laser energy with a

subphotothermolytic fluence over large spot size

known as subcellulear selective photothermolysis.

Effectiveness of this treatment various and melasma

lesions can recur or get darkened and rebound

hyperpigmentation can occur. Common side effects

were physical urticaria, acneiform eruption, minute

petechiae, whitening of fine facial hair, herpes

simplex reactivation, leukoderma and mottled

hyperpigmentation (Sim et al., 2014). In this study

patients tolerated the laser toning and the

microneedle fractionated radiofrequency and found

no serious side effect, only slight erythema which

subside after few hours.

Future studies to evaluate effectiveness treatment

of melasma may easily done using Janus imaging

system by evaluating spot pigmentation, and for

generalization of the treatment effectiveness still

need larger subjects, more treatment sessions, and

long term follow up to monitor recurrences.

5 CONCLUSION

Patients recieving low fluence Q switched

Nd:YAG1064nm laser and microneedle fractionated

radiofrequency showed better improvement in spots

pigmentation of melasma compared to only using

low fluences QSNd:YAG 1064nm laser. Treatments

were well tolerated and no serious side effects notice

during both treatments.

ACKNOWLEDGEMENT

The work was supported by Surabaya Skin Centre

and PT Regenesis

DECLARATION OF INTEREST

The authors report no conflicts of interest. The

authors alone responsible for the content and

writing of the paper.

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Low Fluence Q-Switched Neodymium-Doped Yttrium Aluminium Garnet (LFQSNd:YAG 1064nm) versus Combination of LFQSND:YAG

1064nm and Microneedle Fractionated Radiofrequency (MFRF) for Treatment of Indonesian Melasma Patients. Which is Better?

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