For melasma, Dr. Bucay said energy-based treatments are absolutely her last resort. Lasers cannot alter the underlying genetic propensity toward melasma, she explained.
Dr. Bucay treats recalcitrant melasma very gently – usually with at least six Q-switched Nd:YAG sessions using the M22 laser from Lumenis (San Jose, Calif.), with a 6 mm spot and fluence of 1.6 J/cm2. “I use very low fluences and these treatments go on for a while, because I do not want to traumatize the skin and cause hypopigmentation.”
Dr. Bucay’s most striking melasma case involved a darker-skinned Hispanic woman who had been previously treated at another practice with an unspecified laser that left hypopigmented squares surrounded by darkened outlines. Dr. Bucay began treating the patient with the Fraxel 1550 nm wavelength from Solta Medical (Hayward, Calif.) plus chemical peels.
“She was coming along, but we could only get so far. She always had a lighter spot in the middle, and we were trying to lighten up the surrounding area to match.”
Ultimately, Dr. Bucay added (off-label) oral tranexamic acid (250 mg twice daily for three to six months) to the patient’s regimen.4
Recently, Dr. Bucay has started applying a 5% tranexamic acid solution after radiofrequency (RF)-assisted microneedling performed with the Genius Intelligent RF Platform from Lutronic (Billerica, Mass.). She treats to an endpoint of pinpoint bleeding, then applies the solution, which patients keep using twice daily until they run out. “It accelerates results by 20% to 25% because of the enhanced penetration.”
For acne scarring, Dr. Downie often alternates the non-ablative Fraxel Restore (Solta) with INTRAcel RF-assisted microneedling from Perigee (Tracy, Calif.).
“Both devices act in different ways to deliver optimal treatment,” she explained. “Moderate scarring typically requires at least six treatments; severe scarring requires more. With the Fraxel Restore, Dr. Downie typically uses settings of 40 mJ/cm2 and around 35% density, depending on skin type, whereas for Caucasian patients she gradually increases these levels over successive treatments. For skin type VI, she might use 20 mJ/cm2 and 35% density.
For rosacea in Hispanic patients, Dr. Bucay commonly uses the excel V long-pulsed 1064 nm laser from Cutera (Brisbane, Calif.). “But we can also use the built-in 532 nm KTP wavelength to look for hemoglobin. The device has a cooling handpiece, and I have found treatment to be safe and very helpful in skin of color, whether we are treating vascular lesions or skin conditions,” she said.
Many dermatologists have abandoned laser hair removal because multitudinous spas and salons offer this service at cheap, commodity prices, Dr. Bucay noted. Moreover, early hair removal lasers could not distinguish between melanin in the skin versus the hair follicle, often resulting in PIH.
Currently, Dr. Bucay treats upper-lip hair in Hispanic women with the 1064 nm laser. First, she prepares them with a topical bleaching agent for two weeks before applying at least six treatments.
“The long-pulsed Nd:YAG is the safest for laser hair removal in skin of color because the 1064 nm wavelength falls at the end of melanin’s absorption spectrum,” Dr. Bucay explained. “This allows it to injure dark, coarse hairs, while sparing epidermal melanin.
Additionally, the laser’s adjustable pulse width allows energy to be delivered over a longer period of time, allowing heat to dissipate and epidermal cooling to occur.”
Dr. Downie offers laser hair removal with the excel V because her patients demand no-downtime treatments and like that she performs the treatment herself. “This laser works very well. My patients love it, and I love it. My practice has always been pretty busy with energy-based treatments for skin of color simply because I am skin of color.”
When it comes to the observable signs of aging, “we know that certain ethnicities – particularly African-Americans – age on average up to 10 to 20 years slower than their light-skinned counterparts. So, they may not have fine lines and wrinkles, but they will have some volume loss in the midface, or they will want to tighten up skin around the neck,” Dr. Bucay pointed out. For these patients, “high-intensity focused ultrasound (HIFU) devices are safe because this modality bypasses the epidermis, thus avoiding melanin,” she noted.
For skin tightening of the lower face and neck, Dr. Downie likes the IntraGen RF device (Perigee).
“Pigmentary considerations are not as important of a consideration in energy-based modalities that treat layers beneath the skin – layers that do not involve the melanocyte layer, which is essentially the dermal-epidermal junction,” Dr. Wu explained.
Fat reduction and/or body shaping therapies are two of the most in-demand energy-based treatments across the entire patient spectrum.
In Dr. Downie’s experience, EmSculpt from BTL (Marlborough, Mass.) is among the hottest nonsurgical body shaping treatments. This device uses non-invasive high-intensity focused electromagnetic (HIFEM) technology to stimulate the underlying musculature for fat reduction and increases in muscle mass.
According to Dr. Downie, using BTL Vanquish™ prior to EmSculpt can prove beneficial for larger patients. In practice she has been able to remove two to three – and sometimes more – inches of waist circumference with the Vanquish, and at least two additional inches with EmSculpt. She usually has patients undergo six treatments with EmSculpt, ideally once weekly.
Solving the PIH predicament
With any laser procedure, post-treatment care and close follow-up are extremely important, Dr. Bucay emphasized. “PIH emerges at four to six weeks, and there is a chance to intervene early to impede a severe incidence.”
For topical treatment of PIH, Dr. Downie, Dr. Jegasothy and Dr. Bucay all depend on Cysteamine Cream (Scientis SA).
According to Dr. Downie, a soon-to-be-completed study will show that it is more effective than Kligman’s formulation, but it is a biogenic, non-cytotoxic molecule. “Patients are very excited about it.”
Additionally, Dr. Downie personally performs at least six to eight superficial or medium-depth chemical peels (Rejuvenize from SkinMedica or VI Peel from VI Aesthetics) for these patients. However, she will not treat any patients, regardless of indication, who refuse to use SPF 30 sunscreen exactly as directed.
Dr. Bucay discussed a dramatic PIH case that involved a woman who had undergone fractional CO2 resurfacing for atrophic acne scars at another practice. The patient’s skin was fair, but her dark hair suggested Italian or Mediterranean lineage, she recalled. “She came to see me because she had severe PIH that lasted for months, and her existing physician could not help her.” Dr. Bucay treated her with a series of peels and topical agents, with dramatic results.
1. Freedberg, Irwin M; Fitzpatrick, Thomas B, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. New York: McGraw-Hill, Health Professions Division, 1999.
2. Wat, H; Wu, DC; Chan, HH. Fractional resurfacing in the Asian patient: Current state of the art. Lasers Surg Med. 2017;49(1):45-59.
3. Guss, L; Goldman, MP; Wu, DC. Picosecond 532 nm neodymium-doped yttrium aluminium garnet laser for the treatment of solar lentigines in darker skin types: safety and efficacy. Dermatol Surg. 2017;43(3):456-459.
4. Bala, HR; Lee, S; Wong, C; Pandya, AG; Rodrigues, M. Oral tranexamic acid for the treatment of melasma: a review. Dermatol Surg. 2018;44(6):814-825.
Dr. Downie is or has been a consultant for Allergan, BTL, Cutera and Scientis SA. Dr. Wu is a consultant, researcher, speaker and trainer for Allergan, Syneron-Candela, Galderma, Merz Aesthetics and Thermi Aesthetics. Dr. Jegasothy is a paid speaker for Senté Laboratories, the U.S. distributor of Cysteamine Cream. Dr. Bucay reports no relevant financial interests.