Abstract: Melasma represents a pigmentary disorder that is difficult to treat.

This study aims to broadly

review the use of ablative lasers (Er:YAG and CO2) in the treatment of melasma, presenting the level of
evidence of stud-ies published to date. A total of 75 patients were enrolled in four case series studies
(n=39), one controlled clini-cal trial (n=6) and one randomized controlled clinical trial (n=30). Studies on
the Er:YAG laser showed better results with the use of short square-shaped pulses, which determined
low rates of post-inflammatory hyperpig-mentation and long-lasting maintenance of results. Likewise,
studies on the CO2 laser proved the benefits of short pulse duration along with low-density energy. Post-
treatment maintenance with the use of antipigmenting creams was necessary and effective to sustain
long-term results. Ablative lasers may represent another useful and effective tool against melasma.
Postinflammatory hyperpigmentation and difficulty in sustaining long-term results still represent the
main limitations to a broader use of ablative lasers. Based on actual evidence, the use of this technology
should be restricted to patients with recalcitrant disease. Further studies will help establish opti-mal laser
parameters and treatment regimens.
Keywords: Carbon dioxide; Erbium; Laser therapy; Lasers, gas; Melanosis

INTRODUCTION
Melasma is a common acquired symmetric cutaneous hypermelanosis that represents a disrup-tion
of the skin pigmentary system. It affects mainly Asian and Latin women most frequently aged 30 to 55
years. Lesions are often light brown to blackish mac-ules of irregular but sharp borders. They mainly
affect areas chronically exposed to sun light like the cheeks, forehead, temples, upper lip and chin. Many
factors have been linked to the appearance and worsening of melasma, although pregnancy, use of
contraceptive pills and exposure to UV radiation are frequently reported. 1,2
Despite the fact that melasma is one of the most common reasons for women to seek dermatological
care, only a small number of drugs and procedures to treat this disorder has been launched in the market in the
last decade. Conventional treatments usually fail to induce long-term remission, as is commonly seen with the
use of first-line therapies such as Kligmans formula.3,4 This fact has prompted the search for inno-vative
treatments to manage the disease. It is the case of non-ablative fractioned lasers, which have been established
to treat melasma after initial positive results by Rokhs & Fitzpatrick (2005). These results were later reproduced
by others.5-8
Ablative lasers have also been sporadically used by many professionals to treat melasma, although
there is a lack of scientific data supporting this indication. The exact mechanism of action of both ablative
and non-ablative lasers is also unknown, although many have been hypothesized. 9
Therefore, the objective of this study is to present a review of available data from the medical literature
about the use of resurfacing ablative fractioned lasers (CO2 and Er:YAG) to treat melasma. We also attempt to
define the actual level of evidence for their use.

METHODS
A broad search for original studies was made on Pubmed, Scielo, LILACS (Latin America and Caribbean)
and DOAJ (Directory of Open Access Journals) databases. The search was done by crossing the primary
key-words melasma and chloasma with the secondary terms Carbon Dioxide Laser and Erbium
Doped Yttrium Aluminum Garnet Laser, as specified by Medical Subject Headings (MesH). Once
retrieved, all the studies were evaluat-ed by one of the authors for selection of only primary clinical
studies (case report/series, case control stud-ies and clinical trials) developed with human subjects about
the treatment of melasma. Studies were then discussed and classified according to their level of evi-dence
as proposed by the Oxford Centre for Evidence-Based Medicine.10
RESULTS
After an individual review of all the studies retrieved, only six studies met the selection criteria and
were included for discussion. A total of 75 patients were enrolled in the studies and were distrib-uted
among four case/series studies (CS, n=39), one controlled clinical trial (CCT, n=6) and one random-ized
controlled clinical trial (RCCT, n=30).11-16 Three studies analyzed the CO2 laser, two analyzed the Er:YAG
laser, and the other investigated the Q-switched alexandrite (QSAL) laser, although one of them involved
the use of CO2 laser.11-16 The study by Nouri et al. (1999) was also compiled as a case series study given
both its small sample and small area treat-ed, which did not allow for statistical analysis or gen-
eralizability of results.11
Nouri et al. (1999) first published a pilot study about the use of CO2 laser to treat melasma. 11 Eight
patients with Fitzpatrick skin prototype (FSP) IV to VI with dermal melasma were pretreated with
Kligmans formula from day 1 to 14. Subjects were then random-ly assigned to receive treatment in a
melasma spot area of 1cm2. One group was treated with CO2 laser alone, whereas the other group
received combination therapy (first pass CO2 laser, followed by a second pass with QSAL). The authors
stated that the combi-nation laser was highly effective since treatment determined complete resolution
inside the area treat-ed and maintenance of results at 24-week follow-up. Level of evidence: IV.
A split-face study designed by Angsuwa-rangsee et al. (2000) evaluated the efficacy of QSAL laser
isolated and in combination with CO2 laser to treat facial melasma. 15 Six female Thai patients with FSP II to V
and refractory melasma participated in the study. Only facial sides receiving combined therapy showed
statistically-improved maintenance in both Melasma Area Severity Index (MASI) and Melanin Index (MI),
measured by reflectance spectrometry, at 6 months follow-up (p=0.02 for both); however, statisti-cal analysis
failed to show significant differences between treatments at that time (p=0.08), formerly a reflection of the
small sample studied. On the other hand, patients with FPS IV and V showed transient postinflammatory
hyperpigmentation in both sides treated. Level of evidence: III.
Trelles et al. (2010) developed the most recent randomized controlled clinical trial available in the lit-
erature comparing CO2 laser with traditional Kligmans formula.16 Thirty female patients with melasma,
mean age of 38 years, FSP II-IV, were ran-domly allocated to three groups. Group A received post-
procedure treatment for 15 days with Kligmans formula followed by maintenance topical cream pro-
gram (hydroquinone 2%, kojic acid, glycolic acid); group B, only CO2 laser fractional resurfacing using
high power, fixed pulse width and low frequency; and group C, both laser and maintenance topical
cream program. Subjects of all three groups received pre-intervention treatment with antipigmenting
topical cream for a period of 16 days. The satisfaction index and overall efficacy in groups A, B and C
were 100% at month one in all groups, but progressively decreased in further assessments, except for
group C, in which better scores were maintained throughout. MASI score was assessed by blinded
evaluators using standard photographs. It showed a statistically signif-icant improvement in group C
compared to A and B at six and 12 months follow-up (p<.001, for both). The study presented a suitable
methodology regarding randomization, blinding and appropriate control group. Level of evidence: II.
A report of the case of a 59-year old woman with melasma treated with CO2 laser was also recent-
ly published by Neeley et al. (2010).12 The patient had FSP V and a refractory malar dermal melasma. She
had been irresponsive to previous 17 sessions of non-ablative fractional lasers (1320, 1440 and 1550nm) as
well as to topical treatment. The patient underwent seven sessions of CO2 laser over a period of 10
months, with a reasonable improvement in skin pig-mentation and texture. No follow-up comments were
presented by the authors. Level of evidence: IV.
No controlled clinical trial about the treatment of melasma with Er:YAG laser has been found in
the literature. However, a well-conducted case series study was developed by Wanitphakdeedecha et al.
(2009) in Thailand. The study involved 20 female patients with epidermal melasma. 13 All the patients
were treated monthly for a total of two treatments with an Er:YAG laser set at square pulse parameters.
This measure aimed to minimize nonspecific heating of the surrounding tissues by avoiding the slow rise
and the longer fall of laser pulse power commonly observed in conventional laser technology platforms.
The patients were evaluated by MI measurement and were also clinically evaluated using a visual analog
scale and MASI scoring system at baseline and 1, 2, and 4 months postoperative. Both MI and MASI score
showed significant improvement at 2-month, but not at 1- and 4-month follow-up visits (p>0.05).
Furthermore, clinical improvement assessed by blind-ed dermatologists showed that only 15% of patients
sustained improvement greater than 50% after 4 months of follow-up. Level of evidence: III.
Another recent case series study using Er:YAG laser was developed by Manaloto et al. (2009). 14 Ten female
patients with FPS II to V presenting with facial melasma unresponsive to previous therapy of bleach-ing
creams and chemical peels were selected to receive full-face skin resurfacing with Er:YAG laser. No pre-
intervention treatment was offered to the patients. There was marked improvement of melasma immedi-
ately after the laser procedure; however, between 3 and 6 weeks postoperative, all patients exhibited
post-inflammatory hyperpigmentation demanding inter-vention with daily use of 20% azelaic acid and
glycol-ic acid peels biweekly. At six months postoperative, universal clinical improvement of
pigmentation was observed as well as reduction in MASI and melanin reflectance spectrometry
measurements (p=.027). Level of evidence: III.
A summary of laser parameters and side effects reported in the studies is presented in table 1. 11-16

DISCUSSION
It is known that skin affected by melasma con-tains more active epidermal melanocytes. These
cells produce a higher number of mature dendritic melanosomas transferring them to keratinocytes,
which ultimately leads to skin hyperpigmentation.2,3 The distribution of melanin pigments in the skin lay-
ers is an important factor related to the success or fail-ure of melasma treatment. This is particularly
impor-tant in cases of mixed melasma, in which removal of dermal pigment has been found to be
strongly diffi-cult with standard therapies.2,3
Ablative lasers, by targeting water, can indirect-ly reduce melanin deposits from both the epidermis and
dermis. Due to tissue vaporization, the number of abnormal epidermal melanocytes and melanin con-tent are
reduced, as probably occurs with the amount of melanin deposited into dermal melanophages occa-sionally
reached by laser beams. Also, during the heal-ing process, the epidermis is regenerated from the appendiceal
units; therefore, it is believed that the inward migration of new melanocytes to the epider-mis is unable to
produce localized areas of hyperpig-mentation.11,15 Nevertheless, a challenge still remains. Reducing residual
thermal damage, which represents the mainstay for the development of postinflammato-ry hyperpigmentation
commonly observed after abla-tive laser treatments, is difficult.11,15 Pulses shorter than thermal relaxing time of
the epidermis are important to minimize this risk.16
Initial studies on the use of CO2 laser to treat melasma were developed using non-fractional tech-nology
and showed a high rate (50%) of postinflam-matory hyperpigmentation.11,15 In the same studies,
combined treatment with QSAL targeting dermal melanin was found to increase treatment efficacy, 11,15
but controversially failed to prevent postinflammato-ry hyperpigmentation.15 These poor results were
quite discouraging as many years passed until the develop-ment of new studies addressing the issue.
Ultimately, a new study was developed in 2010 using fractional CO2 laser, a technology that is
already well established for skin resurfacing treat-ments. Trelles et al. opted to use high power energy
(150mJ/pulse) combined with short pulse duration (350ms) and low-density energy (11.3J/cm2) in order
to minimize residual thermal damage which could trigger pigmentation rebound. 16 This approach pro-
moted deep but narrow non-selective ablation zones also capable of reaching dermal melanophages. The
results of the combination therapy group (laser and antipigmenting cream) were quite impressive, with
maintenance of improvement after a 12-month fol-low-up. These data, along with the poor results
obtained by the laser-only group, reinforce the major role of antipigmenting cream in preventing recur-
rence of melasma. In fact, its use was considered mandatory by the authors. 16
The same principle of minimizing residual thermal damage was used by Wanitphakdeedecha et al. when
studying the use of Er:YAG laser to treat melasma. The short square-shaped pulse (300s) pro-duced more
controlled heating and minimized post-inflammatory hyperpigmentation when compared to conventional
short-pulsed Er:YAG.13,14 The mechanism of action proposed by the authors involved ablation depth
limited to the epidermis, probably eliminating excess epidermal melanin as well as stimulating epi-
dermal turnover.13 However, even such superficial ablation wasnt enough to reduce post-inflammatory
hyperpigmentation.

CONCLUSION
Both Er:YAG and CO2 lasers have already been studied in the treatment of facial melasma, although only
a small number of patients were enrolled in clin-ical trials. To date, studies have shown that short puls-es
along with low-density energy seem to be rational parameters to target melasma because they limit
residual thermal damage and the risk of post-inflam-matory hyperpigmentation. Both Er:YAG and CO2
laser were safe to treat patients even with high skin phototypes. High rates of post-inflammatory hyper-
pigmentation were adequately targeted with the use of antipigmenting agents, which makes them
manda-tory. No final conclusions can be made about the advantages between Er:YAG and CO2 laser,
since no study has directly compared them. Further studies are necessary to better establish optimal laser
parameters and treatment regimens.