Efficacy and Safety of Intense Pulsed Light in Treatment of

Melasma in Chinese Patients

YUAN-HONG LI, MD,

JOHN Z.S. CHEN, MD,

y
HUA-CHEN WEI, MD,
z
YAN WU, MD,

MEI LIU, MD,

YUAN-YUAN XU, MD,

GUANG-HUI DONG, PHD,

y
AND HONG-DUO CHEN, MD

BACKGROUND Melasma is commonly seen in the Asian population. Traditional therapies are less
effective and may cause adverse effects.
OBJECTIVE The objective was to study the efficacy and safety of a new intense pulsed light (IPL) device
in the treatment of melasma in Chinese patients.
METHODS Eighty-nine women with melasma were enrolled in this open-labeled study. Subjects re-
ceived a total of four IPL treatments at 3-week intervals. Changes in facial hyperpigmentation and tel-
angiectasis were evaluated using an objective, skin colorimeter (Mexameter, Courage & Khazaka),
the melasma area and severity index (MASI), and a global evaluation by the patients and blind
investigators.
RESULTS Sixty-nine of 89 patients (77.5%) obtained 51% to 100% improvement, according to the over-
all evaluation by dermatologists. Self-assessment by the patients indicated that 63 of 89 patients (70.8)
considered more than 50% or more improvement. Mean MASI scores decreased substantially from 15.2
to 4.5. Mexameter results demonstrated a significant decrease in the degree of pigmentation and ery-
thema beneath the melasma lesions. Patients with the epidermal-type melasma responded better to
treatment than the mixed type. Adverse actions were minimal.
CONCLUSION IPL treatment is a good option for patients with melasma. Adverse actions of IPL were
minimal and acceptable.
The authors have indicated no significant interest with commercial supporters.
M
elasma is acquired hyperpigmented
macules or patches, occurring symmetrically
on sun-exposed areas of the body. Lesions are
ill-defined brown macules, usually involving the
centrofacial region, including the forehead, cheeks,
upper lip, nose, and chin. African Americans, Asians,
and Hispanics are the most susceptible populations.
Melasma skin contains increased amount of melanin,
melanosomes, and melanocytes. Melasma is classified
histologically into three patterns: an epidermal type,
in which melanin is deposited solely in the epidermis;
a dermal type, in which melanin-laden macrophages
are primarily located in the dermis; and the mixed
type, in which melanin deposition is found in both
epidermis and dermis.
1
Of the many etiologic factors
associated with melasma, genetic predisposition, sun-
light exposure, pregnancy, oral contraceptives, and
stress appear to be the most significant risk factors.
Traditional therapies, including depigmenting agents
(e.g., hydroquinone, azelaic acid), chemical
peels (e.g., glycolic acid, b-hydroxyl acid, trichloro-
acetic acid), topical hormones, and sunscreens have
some therapeutic effects but are often unsuccessful
for refractory melasma. The use of laser in the
treatment of melasma is controversial. The 510-nm
dye laser and the 694-nm Q-switched ruby laser have
proved to be ineffective and could cause postin-
flammatory hyperpigmentation (PIH).
24
Facial re-
surfacing with erbium laser, pulsed CO
2
laser, and
& 2008 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing
ISSN: 1076-0512 Dermatol Surg 2008;34:693701 DOI: 10.1111/j.1524-4725.2008.34130.x
693

Department of Dermatology, No. 1 Hospital of China Medical University, Shenyang, China;

y
Sheftel Associates Der-
matology, Tucson, Arizona;
z
Department of Dermatology, Dermatology Research Laboratories, The Mount Sinai
Medical Center, New York, New York;
y
Department of Biostatistics, China Medical University, Shenyang, China
[Correction added after online publication 03-Mar-2008: All author names have been transposed; Dr. Chens name
updated as John Z.S. Chen, MD.]
ultrapulsed CO
2
laser, alone or in conjunction with
Q-switched alexandrite laser, has been reported suc-
cessful but gives significant downtime, and there is a
risk of adverse sequelae.
57
Fractional laser therapy
with the 1,550-nm erbium fiber laser has recently been
studied in a pilot study. Six of 10 female patients
(60%) with melasma showed more than 75% im-
provements. Yet one patient (20%) developed PIH.
8
Intense pulsed light (IPL), a broadband light source
that emits a continuous spectrum in the range of 515
to 1,200nm with low-end cutoff filters, was also
studied in the treatment of melasma. Wang and col-
leagues reported that 6 of 17 patients (35%) obtained
more than 50% improvement in the treatment group
(Vasculight, ESC, Santa Clara, CA; four sessions at
an interval of 4weeks with topical hydroquinone)
compared with 2 patients (14%) in the control group
(topical hydroquinone only) at Week16.
9
Traditional IPL sources have some shortcomings: the
energy peak of V-shaped pulses could possibly
cause overload burning and PIH; the energy slope
below the therapeutic threshold is not sufficient to
produce photothermolysis on the targeted chro-
mophores. A new IPL source (Lumenis One, Lu-
menis Co., Santa Clara, CA), incorporates a genuine
breakthrough in the form of optimal pulse technol-
ogy (OPT). The essence of OPT is the systems ability
to control the pulse shape and to deliver homoge-
nous squared-off pulses, resulting in more even
distribution of the energy within each individual
pulse and between subpulses. This novel pulse shape
control mechanism enables use of lower fluency lev-
els and can result in safer, more effective, and more
reproducible treatments. In this study we investigat-
ed the use of this new IPL device in the treatment of
melasma in Chinese female patients.
Patients and Methods
Enrollment and Preparation of the Patients
Eighty-nine female subjects (Fitzpatrick III and IV),
who had been unresponsive to previous therapy of
bleaching creams, chemical peels, or traditional
Chinese medicine for at least 3 months, were en-
rolled from the outpatient clinic in Department of
Dermatology, No. 1 Hospital of China Medical
University, from July 2005 to October 2006. Patients
who could not avoid overexposure to sunlight were
excluded. The study was approved by the Medical
Ethic and Human Research Committee of China
Medical University. Before enrollment into the study,
all patients were informed of the risks, benefits, and
possible complications of the treatment and in-
formed consent was obtained from each patient.
All 89 patients completed the full course of study.
Enrolled patients were all females with Chinese
heritage, with a mean age of 32.7 years (range, 26
56years). The duration of melasma ranged from
6months to 30years (mean, 9.4 years). According to
Woods lamp assessment, 80.9% of patients (72/89)
had a mixed-type melasma and 19.1% (17/89) had
an epidermal-type melasma. Among the 89 patients
investigated in this study, none of them have dermal-
type melasma. Under Woods light examination,
there is always some part of the pigmented macules
being more prominent than under regular light.
Some believe that there is no real dermal-type
melasma at all (Dr. Henry Chan, personal commu-
nication, February 2007). In addition, 37 patients
had Fitzpatrick Skin Type III, and 52 patients, Skin
Type IV.
Before treatment, patients were asked to wash their
faces with a neutral lotion thoroughly and rest in
the temperature-controlled (201C) and humidity-
controlled (40%) room for at least 30 minutes.
Photos prior to each session were taken under
normal light and Woods lamp (courtesy
of Vichy, LOreal, China), to determine whether
the melasma was an epidermal, dermal, or
mixed type.
Equipment
A new IPL device (Lumenis One) was used
throughout the study.
DERMATOLOGI C SURGERY 694
I PL TREATMENT OF MELAS MA
Treatment Protocols
Patients received four IPL sessions at 3-week inter-
vals. No topical anesthesia was required prior to the
treatment. Before the IPL irradiation, water-based
gel (coupling gel, Lumenis Co.) of a temperature of
41C (stored in a refrigerator) was applied in a 5- to 8-
mm thin layer onto the target areas. The energy
density for treatment ranged from 13 to 17 J/cm
2
,
depending on the patients skin type, melasma se-
verity, and pain tolerability. Test spots were per-
formed on each patient 30 minutes before the first
session. Usually, we utilized 560-/590-nm filters,
double pulse for patients with epidermal type, and
590-/615-/640-nm filters, triple pulse for patients
with mixed type (3- to 4-ms pulse, 25- to 40-ms
pulse delay). Further adjustments were made
according to the patients skin complexion, age,
melasma severity and location, Fitzpatrick skin
phototypes, histologic types under Woods lamp, and
their responses to the treatment. Patients were in-
structed to apply cold wet compress immediately
after treatment followed by a fewdays of the appli-
cation of a bland moisturizer. Patients were in-
structed to avoid the use of any bleaching and
antiwrinkle agents during the course of treatment.
They were also instructed to avoid sun exposure and
wear a broad-spectrum sunscreen during and after
the treatment.
Evaluation Criteria
Before each session and 3months after the last ses-
sion, an objective, skin color-measuring device
(Mexameter, MX18, Courage & Khazaka, Elec-
tronic GmbH, Cologne, Germany) was used to
measure the melanin index (MI) and erythema index
(EI) on the highest point on cheekbones. Melasma
area and severity index (MASI) scores were evalu-
ated by two investigators independently before each
session and 3 months after the last session.
10
At the 3-month follow-up visit, both the investiga-
tors and the patients rated the level of improvement
according to four categories: 0% to 25%, 26% to
50%, 51% to 75%, and 76% to 100%. The patients
also rated their overall level of satisfaction with the
IPL treatment according to the following scale: sig-
nificant improvement, moderate improvement, mild
improvement, no change, and worsening. They were
also requested to report a mean pain score from a
scale of 1 to 10, with 1 as a mild pain and 10 as
severe bee stinglike pain.
For database management and statistical analysis,
we used computer software (SAS, Version 6.12, SAS
Institute Inc., Cary, NC). Continuous variables and
categorical variables were presented as mean values
and frequencies, respectively. Continuous data from
different groups were evaluated using analysis of
variance. In the presence of significant F values, in-
dividual comparisons between means were made
using the Student-Newman-Keuls test. All statistical
tests were two-tailed and p values r.05 were con-
sidered statistically significant.
Results
Therapeutic Efficacy of IPL evaluated with MASI
Mean MASI score decreased dramatically from 15.2
before the treatment to 8.1 after one session, 8.6
after two sessions, 6.4 after three sessions, 5.2 after
four sessions, and 4.5 at the 3-month follow-up visit
(F=20.77, po.001). Figure 1 shows the representa-
tive photos of a patient with melasma before and
after IPL treatment. Table 1 summarizes the changes
in the mean MASI scores by two investigators based
on the patients Fitzpatrick skin type, histologic type
and age (Figure 1, Table 1).
The trend analyses were further performed based on
the histologic type (Figure 2) and age (Figure 3). As
shown in Figure 2, both types of melasma responded
well to IPL treatments. Epidermal-type melasma
exhibited a better response than the mixed type, but
in a similar fashion. We further analyzed the impact
of stratified age groups on the outcome of IPL
treatments. As shown in Figure 3, all three age
groups displayed a paralleled response with the in-
creasing number of treatment sessions, though
the melasma patient at the age of 35 to 45years old
34: 5: MAY 2008 695
LI ET AL
had relatively higher MASI scores at the baseline
and the end of treatment. We speculate that
these variations probably result from the high
level of female hormones, use of contraceptives,
and excessive outdoor activities in this age
group.
A B C
Left side of face
A B C
Right side of face
Figure 1. A representative photograph of a melasma patient before and after IPL treatments: (Top row) Left side of face;
(bottom row) right side of face. (A) Pretreatment; (B) after 4 sessions; (C) at 3-month follow-up visit.
TABLE1. MASI Score Changes with IPL Treatment in Women with Melasma
Type Subtype No.
Mean MASI Scores Evaluated by Two Investigators
Before T1

T2 T3 T4
3-Month
Follow-up
y
Fitzpatrick type III 37 14.13 8.07 8.41 6.23 5.12 4.38
IV 52 16.01 8.16 8.65 6.42 5.30 4.60
Histologic type Epidermal 17 15.26 7.01 7.32 5.24 4.11 3.31
Mixed 72 15.22 8.39 8.85 6.61 5.50 4.79
Age (years) o35 38 14.81 7.31 8.29 6.01 4.85 4.13
3545 23 17.04 12.61 11.14 8.16 7.02 6.64
445 28 14.32 5.53 6.81 5.32 4.28 3.27
Total 89 15.23 8.12 8.56 6.35 5.23 4.51

MASI scores measured 3 weeks after one session of treatment.

y
MASI scores measured at 3-month follow-up visit.
DERMATOLOGI C SURGERY 696
I PL TREATMENT OF MELAS MA
Effect of IPL Treatment on MI and EI
At the highest point of cheekbone, MI decreased
from 140.8 before the treatment to 133.0 after one
session, increased a little to 136.1 after two sessions,
dropped down to 129.4 after three sessions, 121.1
after four sessions, and 119.7 at the 3-month follow-
up visit (F= 38.67, po.001; Figure 4A). In addition,
quantification of EI at the highest point of cheek-
bone indicated a substantial decrease from 390.4
before the treatment to 338.2 after one session,
310.4 after two sessions, 279.4 after three sessions,
213.2 after four sessions, and 201.9 at the 3-month
follow-up visit (F= 58.73, po.005; Figure 4B).
Global Evaluation by Blind Investigators
Two independent dermatologists not involved in the
study examined the serial photos and gave their
judgments of the overall improvements of melasma
based on the lesion color, size, telangiectasis, and
skin texture (Figure 5). After one session, 56.2% of
the patients (50/89) showed more than 50% im-
provement, according to the investigators evalua-
tion. The percentage of improvement reached 75.3%
(67/89) after four sessions and 77.5% (69/89) at the
3-month follow-up visit, respectively.
Self-Assessment of Improvement by
Patients
Before each session and at the 3-month follow-up
visit, the patients were asked to assess their treat-
ment results according to a five-point scale (wors-
ening, no change, mild, moderate, or significant
improvement). After one session, 49.4% (44/89) of
patients rated themselves to have significant or
moderate improvements. This percentage increased
to 73.0% (65/89) after four sessions of IPL
treatments and remained at 70.8% (63/89) at the
3-month follow-up visit, respectively (Figure 6).
Adverse Effects
Side effects were very limited with IPL treatment.
The transient erythema and slight edema were ob-
served and usually resolved 0.5 to 12hours after
procedure on the cold wet compress. Temporary
desquamating microcrusts lasting 7 to 10days were
observed on the cheekbone regions in 72 patients.
Three patients with mixed-type melasma had obvi-
ous PIH after one or two sessions of treatment. They
were instructed to wait 1 to 3months until the PIH
resolved before the next session. Topical hydrocor-
tisone cream (Class VII) was given 3days before and
7days after the treatment for the 3 patients with
obvious PIH. In addition, patients reported an av-
erage pain score of 3.7 (16) on a scale of 1 to 10.
However, all patients tolerated the discomfort well
throughout the full course of treatment. No scarring
or hypopigmentation occurred during and after the
treatment. All patients could return to work and
resume normal daily activity without downtime im-
mediately after the treatment.
0
5
10
15
20
0 T1 T2 T3 T4 3m fu
Epidermal-type Mixed-type
Figure 2. Effect of IPL on epidermal-type and mixed-
type melasma: The mean MASI scores of both types
decreased significantly with the number of IPL treatments
(po.001), with the epidermal-type melasma even better in
effectiveness.
0
5
10
15
20
0 T1 T2 T3 T4 3m fu
M
A
S
I

s
c
o
r
e
s
<35 yrs. 3545 yrs. >45 yrs.
Figure 3. Effect of age on MASI scores by IPL treatment. In all
the three age groups, the mean MASI score significantly
decreased with the number of IPL treatment (po.005),
especially in those younger than 35years or older than
45 years.
34: 5: MAY 2008 697
LI ET AL
Discussion
This study is the first report of the treatment of
melasma in Chinese women with the new IPL device.
By delivering an evenly distributed pulsed light with
lower fluency levels, this modality provides a safer
and more effective treatment of melasma in Asian
populations.
With the serial IPL treatments, MASI scores de-
creased gradually from 15.23 to 4.51 (po.005). The
therapeutic efficacy is relatively higher in patients
with epidermal-type melasma than those in the
mixed type. This phenomenon could possibly be
related with the location of the melanin. In the
epidermal-type melasma, the melanosomes in the
epidermis rapidly migrate to the skin surface and
shed off with the microcrusts.
11
This process occurs
rapidly and the whitening effect is observed even
after one session of treatment. In mixed-type me-
lasma, the melanin-laden macrophages in the dermis
could barely be damaged. Thus the therapeutic
effects are attributed mainly to the photothermolysis
of the melanosomes in the epidermis. In our clinical
experience, a laser source targeted at dermal mela-
nin-laden macrophages could be more appropriate
for the treatment of its dermal part, unless PIH is a
major concern.
105
110
115
120
125
130
135
140
145
A B
0 T1 T2 T3 T4
M
e
l
a
n
i
n

i
n
d
e
x

(
M
I
)
MI
0
50
100
150
200
250
300
350
400
450
3m
fu
0 T1 T2 T3 T4 3m
fu
E
r
y
t
h
e
m
a

i
n
d
e
x

(
E
I
)
EI
Figure 4. Effect of IPL on MI and EI in women with melasma. (A) MI at the highest point of cheekbone decreased gradually
with the IPL treatment, with a little rebound after the second session. At the 3-month follow-up visit, MI remained at a low
level. (B) EI at the highest point of cheekbone decreased gradually with each session of treatment. At the 3-month follow-up
visit, EI remained at a low level.
14
25
34
16
12
22
35
20
7
19
39
24
4
18
38
29
4
16
37
32
0
20
40
60
80
100
T1 T2 T3 T4 3m fu
76%100%
51%75%
26%50%
0%25%
Figure 5. Overall evaluation of the efficacy of IPL treatments
by two nonparticipating physicians. The Z-axis represents
the number of patients. Legends for therapeutic efficacy of
IPL are expressed by percentage of improvement. Purple
bar = 0% to 25%; pink bar = 26% to 50%; yellow = 51% to
75%; blue = 76% to 100%.
0
20
40
60
80
100
T1 T2 T3 T4 3m fu
significant
improvement
moderate
improvement
mild
improvement
no change
worsening
Figure 6. The patient subjective self-assessments of IPL
treatments. The Z-axis represents the number of patients.
Legends for therapeutic efficacy of IPL are expressed by
percentage of improvement. Purple bar = worsening; pink
bar = no change; yellow bar = mild improvement; blue =
moderate improvement; green = strong improvement.
DERMATOLOGI C SURGERY 698
I PL TREATMENT OF MELAS MA
It is noteworthy to mention that the patients ages
seemed to be another important factor to affect the
therapeutic effect of IPL on melasma. The patients
younger than 35years or older than 45 years re-
sponded much better to the treatment, especially
after one session (po.005). For the elderly patients,
especially those in postmenopausal stages, the epi-
dermal melanocytes are not as active as before,
partly because of the low hormone level (both es-
trogen and progestogen). Once the residual melano-
somes are evacuated, no new ones are replenished.
This can explain the reason why melasma sponta-
neously resolves in aged skin. For those young pa-
tients, accumulation of melanosomes and melanin in
epidermis is relatively low and shallow due to the
short course of disease. Thus the newly formed
melanosomes in the epidermis are much easier to be
targeted and shed off. Besides, the epidermal turn-
over in young patients is higher than in old patients.
In this study, hyperpigmented macules were observed
on cheekbone areas of all patients. Thus we com-
pared the MI and EI on the highest point of cheek-
bone with each session. With the broken-up
pigmented particles shed off from the skin, the mean
MI decreased dramatically from 140.8 before the
treatment to 121.1 after four sessions and continued
to decline even at 3-month follow-up visit (po.005).
Interestingly, MI rebound slightly after the second
session (Figure 4A) and this can be explained as the
triggering of inflammation and PIH by IPL, which
was commonly observed 3 days after each session.
With the accelerated turnover of melanosomes, the
PIH resolved spontaneously in 7 to 10 days. After the
second session, the newly synthesized melanosomes
overwhelmed those removed from skin. This phe-
nomenon is consistent with our following clinical
observations. After the first session, the patients
observed obvious depigmentation after the shed off
of the microcrusts. They were satisfied and expected
more. However, in the following sessions, no mi-
crocrusts occurred and the patients observed no ob-
vious changes until after the fourth session. The
exact mechanism of this phenomenon remains un-
clear and needs further investigation in the future.
In addition, we observed that most melasma patients
suffered from the coexisting erythema and tel-
angiectasis. EI, which represented the extent of ery-
thema and telangiectasis, decreased substantially
from 390.4 at the baseline to 213.2 after four ses-
sions of IPL treatments and continued to decrease at
3-month follow-up visit. The trend analysis was
statistically significant (po.005). Up to now, there is
no evidence to support that melasma is correlated
with the facial erythema and telangiectasis in Chi-
nese women. It is hypothesized that since hydroqui-
none is forbidden as bleaching agent and steroids are
available over the counter (OTC) and at beauty sa-
lons, the facial erythema and telangiectasis are
probably caused by long-term use of topical steroids,
either from OTC medications or illegally added in
cosmetic products sold by the beauty parlors.
According to the patient self-assessment, 73.0% (65/
89) of patients in this study claimed that their me-
lasma improved by more than 50% after four ses-
sions of IPL treatments. The patients self-
assessments are well in agreement with the global
evaluation by blind investigators, in which more
than 50% improvement of melasma was observed in
75.3% (67/89) of patients. At the 3-month follow-up
visit, the patient self-assessment and the investigator
global evaluation maintain the similar level of effi-
cacy of 74.2% (66/89) and 77.5% (69/89), respec-
tively. One-year follow-up is still required to
determine its long-term efficacy and safety.
Our results are far better than what Wang and oth-
ers
9
have reported with the use of a nonchilled, peak-
shaped IPL device. Melasma lesion is easily aggra-
vated by any stimulation, including sunshine, irritant
chemicals, etc. Without efficient cooling and other
protection modalities, IPL may induce subtle me-
lasma itself.
12
The traditional IPL devices (e.g., Vasculight used by
Dr. Wang) do not have the cooling system, while the
new device incorporates a cooling mechanism that
provides continuous contact cooling to the treatment
area. Instant cooling could minimize thermal injury,
34: 5: MAY 2008 699
LI ET AL
thus reducing possible complications, such as ther-
mal necrosis, induced erythema, and hyperpigmen-
tation. Besides, traditional IPL devices produce peak-
shaped fluency. The peak fluency may cause over-
dose damage, which limits its application in a more
or less extent. After the peak, the fluency gradually
decreased in a slope. If the fluency dropped below
the effective threshold, the energy could not produce
photothermolysis to the melanosomes. However, the
new IPL device produces even distributed energy. All
the fluency is restricted between the effective
threshold and dangerous threshold. Thus it provides
a safer and more effective treatment than before.
Our clinic is located in North China, with a Sibe-
rianlike climate. The summer season lasts only
3months. Thus, we suggest that the patients undergo
this treatment in other seasons.
Conclusion
Our study demonstrated that OPT-IPL is a safe and
effective treatment of melasma in Chinese female
patients. There is no rebounding of melasma at a
3-month follow-up visit. The therapeutic efficacy is
related to the histologic typing of melasma and age
of the patients.
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Address correspondence and reprint requests to: Hong-
Duo Chen, MD, Department of Dermatology, No. 1
Hospital of China Medical University. 155N. Nanjing
Street, Shenyang 110001, China, or e-mail: chenhd@
cae.cn
COMMENTARY
Melasma is one of the most common acquired pigmentary conditions in Asians and is also one of the most
challenging conditions to be treated. Previous studies indicated that lasers or intense pulsed light sources,
although they can be effective in some cases, can lead to deterioration in others.
14
One of the main
reasons for melasma to be so difficult to tackle is due to the etiology of this condition. It has been
suggested that in epidermal and mixed type of melasma, characterized by epidermal hyperpigmentation,
the pathogenesis involves an increased number of melanocytes and increased activity of melanogenic
enzymes overlying dermal changes caused by solar radiation.
5
This recent observation may explain the
DERMATOLOGI C SURGERY 700
I PL TREATMENT OF MELAS MA
development of hyperpigmentation after the use of pigment laser. An increase in melanogenic enzyme
activity suggests that melanocytes are hyperactive. Sublethal laser/light source damage to these diseased
melanocytes can increase the production of melanin and result in hyperpigmentation.
In this study, the investigators demonstrated that the use of an intense pulse light source device with a
uniform pulse profile for the treatment of epidermal and mixed melasma and were able to achieve
excellent results (77.5% of treated subjects had over 50% improvement 3months after treatment)
with low risk of increase in pigmentation (3%). This was despite the lack of topical bleaching agents
during the study period. Their findings differ significantly from previous data. Wang and coworkers
4
used
IPL for the treatment of melasma in patients that were already treated with topical bleaching agents.
There was a 39.8% improvement of the relative melanin index in the treatment groups compared to
11.6% improvement in the control group at Week 16. However, 2 of 17 patients (11.7%) developed
increase in pigmentation.
Although the uniform profile of this IPL device may be the main reason for such observation as suggested
by the investigators. In my opinion, other factors are likely to contribute to the differences in clinical
outcome. Beijing is situated in the northern part of China and beside summer months, ultraviolet light
exposure is not a major issue. This differs significantly from places such as Hong Kong, Singapore, or
California. Another issue is the recruitment criteria. In this study, subjects that were resistant to 3months
of topical bleaching agents, traditional Chinese medicine (TCM), or chemical peels were recruited. While
the safely and efficacy of topical bleaching agents and chemical peels were well established, the effec-
tiveness of TCM is not known. Some of these patients that were previously on TCM may represent a less
severe subtype and were therefore more susceptible to IPL treatment.
Nonetheless, the findings of this study are significant. However, before IPL or other flat-beam profile
lasers can be considered as the standard of care for the treatment of epidermal and mixed type of
melasma, further studies are necessary. Until then, a laser/intense pulsed light source should be used as an
adjunctive and second-line therapy to topical bleaching agents for the treatment of epidermal and mixed
type of melasma.
DR. HENRY HL CHAN, MBBS, MD, FRCP
Hong Kong, China
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34: 5: MAY 2008 701
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