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Published Mar 2, 2024

Why isn't my melasma improving even after trying Pico laser in Singapore? 

“The unsightly dark brown melasma patches on my face since my early 40s seem to defy every attempt at concealment. Frustrated, I decided to try Pico laser treatments, which have caught my attention on social media due to their promising results for pigmentations like melasma. 

Unfortunately, after undergoing various Pico laser sessions at different clinics in Singapore, I don't see the expected obvious improvement to my melasma issue. I’m losing hope now, preparing to live with it for life” — Melani.

Introduction

Melasma is a common unsightly pigmentation issue occurring primarily on the face, especially in middle-aged women. It is a complex skin pigmentary condition influenced by multiple external and intrinsic factors, including excessive sun exposure, hormonal influence, female gender, age, and genetic predispositions [1].

melasma skin damage
Melasma is a common pigmentation problem that occurs primarily on the face.

Over 10 years as a skincare doctor, I've encountered countless patients (like Melani) grappling with melasma, often persistent and distressing. A common theme shared during the consultation with me is that many of them have previously undergone various treatments or multiple sessions of laser therapy (including Pico or Picosecond laser) without substantial improvement.

Also, these patients experience much frustration and disappointment as their melasma often rebounds with a vengeance after stopping their laser treatments. As such, they wonder if laser treatments are required in the long term to control their melasma.

Furthermore, as a common misconception, many take up laser therapy (including Pico laser), thinking that lasers will eradicate their melasma once and for all, so they will never have to deal with it anymore.

Thus, these stories have motivated me to find a more effective and sustainable solution for patients struggling with melasma. Empathising with the despair of patients who have placed their only hope in laser treatments, I strongly believe in a more holistic treatment approach to help melasma patients sustainably in the long run. 

For more background information about melasma, read about how Dr David has helped 3 tough cases of melasma

Can Pico lasers really treat hyperpigmentation like melasma in Singapore?

This is a frequent enquiry from patients. Pico lasers have a treatment role in addressing hyperpigmentation like melasma (especially with 1064 nm wavelength) [2,3]. Its exceptional ultra-short (10-12 second) pulses and precise targeting are particularly effective in breaking down skin melanin particles to lighten pigmentation.

Nevertheless, Pico laser is just one of the newer technologies used to treat pigmentations like melasma. Many patients may not be aware of other types of laser or energy-based device technology [4] with long-standing history proven for treating melasma, e.g. fractional 1550-nm non-ablative laser, pulsed dye laser (PDL), copper-bromide laser, Q-switched Nd: YAG toning mode, and intense pulsed light (IPL).

Please don’t get me wrong. I warmly welcome and get hyped up with new medical technologies and believe that the spirit of constant technological innovation is essential for the healthy progress of medical aesthetics treatments.

However, I still believe that hyperpigmentation, like melasma, should be approached holistically instead of just relying on laser therapy alone. Factors such as sun protection, proper skincare, lifestyle choices, and uncovering triggering factors also play equally significant roles in the success of any laser treatment.

picosecond laser
Laser therapy (e.g. Pico laser) is often used to treat melasma. 

So why don’t you see improvement in melasma after Pico laser in Singapore? 

Based on my clinical experience over the years, various factors may have contributed to patients not getting the desired improvement in their melasma despite undergoing laser therapy (including Pico laser). 

  1. Inaccurate diagnosis of melasma

Different hyperpigmented spots (e.g. melasma, Hori’s naveus, lentigines, etc) on the skin can look very similar, but they behave differently and require different laser settings for effective results. 

Furthermore, patients often have mixed pigmentations on their faces, so diagnosing them can be challenging. If an incorrect diagnosis is made, inappropriate Pico laser settings may be used; thus, one will not achieve the desired treatment results.

  1. Clinical experience with lasers

The outcome of Pico laser treatment also depends on the clinical experience and expertise of the doctor, which can take months or years to master. Inappropriate parameter settings (e.g. wavelength, power, end-points, or treatment intervals) can affect the effectiveness of the laser therapy. Different practitioners would inevitably have varying competency and experience in handling the Pico laser device.

  1. Inadequate pre and post-laser care

This aspect is solely within the control of patients. To get the best results with Pico lasers, patients must closely follow the pre and post-laser care instructions. For instance, melasma results will certainly be affected if patients are NOT compliant with the correct application of sunscreen and sun protection measures and yet still receive excessive sun exposure during laser treatments.

  1. Melasma cases are unique in their own way

As mentioned at the start, melasma is caused by multifactorial external and intrinsic influences[1]. Triggering factors (e.g. hormonal) for the particular patient should be addressed as well.

As such, the type or severity of melasma will vary amongst different individuals, which makes it challenging to achieve uniform results with just a one-size-fits-all approach – like depending on Pico laser treatment alone.

Thus, each patient has to be treated according to their unique melasma condition, skin type, lifestyle and treatment response. 

For more details, please read: Why your pigmentation is not improving after laser treatment
sun exposure pigmentation
Persistent melasma issues can be due to excessive sun exposure or hormonal influence.

Any potential side effects of laser therapy (including Pico laser) when treating melasma? 

Laser therapy (e.g. Pico laser) can indeed bring positive results for various indicated skin issues. 

However, it's also essential for patients to be aware of potential side effects from lasers, ESPECIALLY with melasma, a challenging pigmentation.

For instance, there is a real risk of post-inflammatory hyperpigmentation (PIH, i.e. darker spots) or confetti hypopigmentation (i.e. abnormal white spots) [5]. This can occur especially if the laser settings are not appropriately adjusted (e.g. set too intensely with much redness, scabbing downtime) or if laser sessions are scheduled too closely (e.g. weekly sessions) [5]. 

Post-Inflammatory Hyperpigmentation (PIH)
Hypopigmentation

So, is there any alternative treatment for melasma?

Many patients have the misconception that laser therapy (including Pico lasers) is the ONLY treatment (if not the Holy Grail treatment) to treat melasma, which is far from the truth. There are ALTERNATIVE effective treatments [4,6] for melasma, including topical medical creams, chemical peels, oral medications, microneedling, and sun protection measures. 

I recommend treating melasma cases by starting with simple topical medical-grade creams like hydroquinone [4,6] and basic sun protection measures. The advantages of topical creams are that they are easy to use and cost-effective (usually cheaper than Pico laser therapy for a given treatment duration), and you may be pleasantly surprised that sometimes they can lighten melasma as well as laser, if not better

Topical medical creams may cause temporary skin irritative side effects (like redness or peeling) in some susceptible individuals. Still, these issues can be EASILY managed or prevented with the correct application techniques and under the doctor’s supervision. Not a big issue at all! 

topical melasma treatment
Topical medical-grade creams such as hydroquinone are simple and cost-effective treatment options for melasma. 

What happened to Melani in the end?

During the detailed consultation with Melani, I had identified underlying hormonal influence as a significant contributor to her persistent melasma. She had noticed her melasma become more prominent after she started taking oral hormonal pills from her gynaecologist to regulate her menstruation cycles. She was still taking the hormonal pills while receiving Pico laser treatment for her melasma.

Thus, in Melani’s case, her concurrent oral hormonal pill therapy [1] was clearly exacerbating her melasma, so no amount of treatment (including Pico laser) was going to effectively clear her melasma if the underlying hormonal influence trigger was still not addressed. 

My approach for Melani involved co-managing with her gynaecologist to treat her melasma and handhold her while waiting for her oral hormonal pill regimen to be completed in a couple of months. Furthermore, I had also prescribed Melani a simple regimen of topical medical creams (e.g. hydroquinone) [4,6] and basic skincare and stressed the importance of rigorous sun protection measures. 

melasma management asian
Self-confidence regained after overcoming melasma.

There is really no point wasting time and money in considering laser therapy (including Pico laser) when her hormonal pills regimen was still exacerbating her melasma at the same time. I had also educated Melani on the chronic nature of melasma and the need for long-term sun protection and maintenance to minimise its recurrence.

As expected, once Melani was taken off her hormonal pills by her gynaecologist, within 2-3 months, her melasma improved remarkably together with the topical skincare regimen prescribed, without the need for laser therapy. Needless to say, she was extremely thrilled and liberated as her face finally cleared up radiantly. 

Not too long ago, she had lost all hope and was about to give up hope on treating her melasma, being prepared to live with it for the rest of her life.

Please refer to this article for more information on why your melasma is not improving.
melasma treatment
At One Face Clinic, we provide a comprehensive yet personalised approach to treating melasma and pigmentation issues.

A one-size-fits-all approach is often disappointing for melasma

As mentioned above, melasma is due to the complex interplay of multiple factors, so each case is unique in its own way.

Thus, taking time to understand the circumstances and triggers of each patient is essential because a one-size-fits-all approach (e.g. just depending on laser therapy like Pico laser) often falls short in treating melasma.

With more than a decade of clinical experience focusing on melasma and pigmentation treatments, our cornerstone approach at One Face Clinic is to provide personalised and practical care to our patients. The journey begins with the preliminary consultation, which helps us understand the patient’s melasma issues in depth. By discovering the triggering causes of their melasma, we gain important insights to develop the targeted treatment plan for each individual.

In addition, effective management for melasma typically also involves a comprehensive approach, such as:  

  1. Sun protection: Consistent use of broad-spectrum sunscreen (SPF 50, PA+++) and practical sun avoidance measures are fundamental.
  1. Lifestyle changes: Maintaining a healthy lifestyle, including a balanced diet, proper sleep and stress management, may positively support melasma management.
  1. Identifying triggers: Uncovering and avoidance of triggers, whenever feasible. For instance, hormonal factors in Melani’s case.
  1. Professional guidance: Consulting with the right doctor and team in melasma management is absolutely essential for the right personalised treatments, and to handhold the patients throughout the journey to achieve the eventual real and sustainable results. 
melasma management singapore
Sun protection and lifestyle changes are part of the effective management of melasma.

Conclusion

Melani's stubborn melasma case highlights the importance of uncovering triggering factors via thorough consultation, an individualised treatment strategy, and comprehensive care to improve melasma outcomes significantly. 

Remember, effective and sustainable melasma management is achieved through a holistic patient-centric approach rather than a one-size-fits-all or standalone treatment, such as depending on laser therapy alone (including Pico laser treatment).

If you also suffer from persistent melasma concerns like Melani or have any questions regarding your melasma and pigmentations, feel free to WhatsApp me at +65 9822 2989 or call me at +65 6222 2262. You can also email me at: askdrdavid@onefaceclinic.com 

All the Best,

Dr David Ng C. H.

References 

  1. Melasma.
    DermNet NZ New Zealand Dermatological Society Incorporated; Last updated Oct 2020  https://dermnetnz.org/topics/melasma
  1. Christina S M Wong, Mandy W M Chan, Samantha Y N Shek, Chi Keung Yeung, Henry H L Chan Fractional 1064 nm picosecond laser in treatment of melasma and skin rejuvenation in Asians, a prospective study. Lasers Surg Med. 2021 Oct;53(8):1032-1042
  1. Jiangfeng Feng, Sihao Shen, Xiuzu Song, Wenzhong Xiang
    Efficacy and safety of picosecond laser for the treatment of melasma:
    A systematic review and meta-analysis
    Lasers Med Sci. 2023 Mar 10;38(1):84
  1. Apratim Goel​, Nishi Trivedi
    Current updates on melasma treatments
    CosmoDerma 2023;3:79.
  1. Yisheng Wong, Siong See Joyce Lee, and Chee Leok Goh
    Hypopigmentation Induced by Frequent Low-Fluence, Large-Spot-Size QS Nd:YAG Laser Treatments
    Ann Dermatol. 2015 Dec; 27(6): 751–755.
  1. Krupa Shankar et al
    Evidence-Based Treatment for Melasma: Expert Opinion and a Review
    Dermatol Ther (Heidelb) December 2014, Volume 4, Issue 2, pp 165–186

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