• [HELIOS Series]Fractional Q-switched Nd:YAG Laser: Ideal Treatment of Melasma



    Product Overview and Purchasing

    I started using HELIOS II around 2009 when I was becoming more interested in melasma treatments. It offered unique benefits with the stable bulk beam pattern and the DOE (diffraction optical element) fractional 1064nm handpiece which produced consistent fluence and penetration depth for every spot.



    The Q-switched Nd:YAG laser allows setting the target at melanosome or subcellular structure depending on the lesion type. You can also set cellular level as target for cell membrane degradation (destroying the cell membrane leads to inflammation by cell membrane phospholipid and ultimately PIH. Therefore, careful inflammation control is important). Based on literature and my clinical experience, fluences up to 4J/cm2 target the subcellular level and those above 4J/cm2 target the cellular level (this, of course, can be adjusted with stacking technique).

    For epidermal type melasma, targeting subcellular level with low fluence brings quick improvements. However, for dermal type where dermal melanophages are involved, a higher fluence is needed to destroy cell membranes of dermal melanophages (this technique should always be combined with complete inhibition of tyrosinase activity, dermal environment improvement and promotion of ECM (extracellular matrix) remodeling). HELIOS Series enables a safe and effective treatment with their consistent beam profiles and the safety zone between fractional beam spots.



    In melasma, the treatment goal should go beyond just pigment removal. Melasma is not just limited to melanocytes and is caused by intercellular signal transduction between keratinocytes, melanocytes fibroblasts mast cells and macrophages, etc. A key etiological mechanism is driven by melanocytes trying to protect the keratinocyte nuclei through keratinocyte derived signaling. Therefore, focusing only on clearing away pigments without tackling the cause can exacerbate melasma. That is, it is crucial to tackle the skin’s susceptibility to melasma and enable it to protect against future melasma lesions (Figure 1).

    Consultation on family history, sun protection according to skin type, skin barrier health, hormone balance, phototoxic medication history, irritation from cosmetic products, and nutritional imbalance, etc. is important For example, in tamoxifen induced melasma, tamoxifen acts as an estrogen antagonist in the breast but as an estrogen agonist in the skin. This can cause a bizarre pattern melasma. It is important to inhibit tyrosinase activity in the early phase.


    Figure 1. It is crucial to tackle the skin’s susceptibility to melasma and enable it to protect against future development.


    Optimizing Treatment Outcome

    In treating melasma, the endpoint is more important than parameters. A relatively safe and effective endpoint is delayed perilesional erythema. Erythema does not develop immediately after irradiation but occurs around the lesion some time after initial irradiation. This indicates energy slightly higher than minimal level needed to remove the lesion has been used. It is important to read subtle changes like this to infer that the right amount of energy is given.

    After seeing delayed perilesional erythema in the first treatment, perform the second treatment 2 weeks later. If improvement is seen 4 weeks after two treatments, maintain the same parameters. If no improvement is seen, set the endpoint at immediate perilesioal erythema. In epidermal type, this approach usually shows improvement in 8-10 weeks (Figure 3). If you want to set a new endpoint, upward titrate the fluence gradually from a low level (stacking).


    The Q-switched Nd:YAG laser cannot be applied to all types of melasma and should be combined with ECM remodeling. My personal preference is the long-pulsed Nd:YAG laser to raise the papillary dermis temperature to 42-45 C and promote collagenesis. I also simultaneously combine raising reticular dermis temperature to about 60 C to target elastic fiber and improve solar elastosis.

    Especially, intractable lesions like perioricular melasma are the dermal type and dermal melanophage should be tackled. I also simultaneously carry out tyrosinase activity control and ECM remodeling and watch for immediate perilesional erythema as the endpoint (Figures 2, 3 show endpoint and before and after treatment). I do not always use this endpoint. This patient had history of long-term, ineffective laser toning and had experienced exacerbation from previous combined laser therapy with long-pulsed 755nm laser before visiting my practice).


    Figure 2. Tyrosinase activity control and ECM remodeling are simultaneously performed and the first endpoint is immediate perilesional erythema.


    Why I recommend HELIOS II

    Treatment of melasma should go beyond pigment removal and aim to change the skin environment where melasma will no longer develop. I believe that the Q-switched Nd:YAG laser can determine the speed of melasma treatment and the long-pulsed Nd:YAG laser the direction of the treatment.

    HELIOS Series is particularly beneficial in melasma due to their consistent beam profile and precise DOE fractional handpiece. This allows easy customization and high stability in various melasma lesion types. 

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