Efficacy of Intense Pulsed Light Treatment in Melasma

Abstract

Melasma is a challenging pigmentation disorder for both the patient and the physician, particularly due to its frequent recurrences and resistance to standard therapies. Light and laser-based treatments are generally preferred when the condition is resistant to topical treatments. Intense pulsed light (IPL) is a light therapy that is both effective for epidermal and dermal melasma as well as vascular components, due to its broad range of energy. Compared to lasers and other energy-based devices, IPL offers broader wavelength coverage, deeper penetration, and the capacity to treat larger surface areas with reduced risk of collateral tissue damage. In this review, we will discuss about IPL mechanism in melasma and studies in the literature about IPL efficacy in melasma including its use as monotherapy and in combination with other modalities. While IPL monotherapy shows moderate improvement, the literature predominantly consists of combination therapy studies, limiting the ability to isolate IPL’s direct effectiveness. Future prospective studies with standardized protocols and extended follow-up are needed to define IPL’s optimal role in the management of melasma.

Introduction

Melasma, characterized by persistent hyperpigmentation, presents challenges for both patients and physicians due to its frequent recurrences and resistance to treatment. Light and lasers serve as a third-line treatment option for melasma that is resistant to topical treatments or when a rapid treatment response is desired. Many patients perceive light and laser therapies as miraculous solutions for melasma. However, it’s crucial to communicate the potential risk of post-inflammatory hyperpigmentation (PIH) that may arise with these treatments. Patients should be informed that complete recovery from melasma may not always be achievable, and recurrence is possible. In this review, we will explore the use of intense pulsed light (IPL) treatment in managing melasma. Given the limited number of original studies focusing on long-term outcomes of IPL monotherapy in melasma, this review aims to summarize current findings and highlight the need for future prospective trials.

Characteristics of IPL

IPL is a non-coherent light source emitting light within the range of 500 nm–1200 nm. Introduced for use in dermatology in 1992, IPL devices vary in parameters such as wavelength, currency, and pulse duration. The broad energy spectrum of IPL allows it to target both superficial areas like epidermal melanin and deeper areas like dermal melanin. During IPL application, colourless gels such as ultrasonography gel are commonly used on the skin to distribute surface heat evenly, enhancing light penetration by minimizing the refractive index between air and skin. Caution is advised in patients with tanned or dark skin, where there is a risk of epidermal damage leading to vesicle formation, scar development, and post-inflammatory hyper or hypopigmentation with high-dose applications. Lower doses are recommended for these individuals. Ideally, IPL application should be delayed in patients with tanned skin. Special attention should be given to the potential hair removal effect in the eyebrow and beard areas for men.[1,2,3]

The effectiveness of light and laser treatments in pigmented lesions relies on the principle of selective photothermolysis, emphasizing minimal damage to the surrounding tissues, while targeting specific molecules.[4] The objective of these treatments is to eliminate target molecules, such as haemoglobin and melanin, without causing harm to the adjacent tissue. The broad spectrum of light emitted by IPL allows for absorption by both haemoglobin and melanin in the skin, making it effective in addressing both the pigment and vascular components of melasma. Furthermore, due to its ability to penetrate multiple skin layers, IPL proves efficacious in treating both epidermal and dermal melasma.[5,6]

IPL presents several advantages over lasers in melasma treatment, including its superior ability to penetrate deeper into the skin, effectiveness on both vascular and pigment components, and the capacity to cover large treatment areas efficiently, thanks to its broad IPL head.[2] The pulse time in IPL devices is measured in milliseconds. This longer duration, exceeding the thermal relaxation rate of melanosomes, allows IPL to impact not only activated melanocytes, but also all structures containing melanin and melanosomes.[5] The selection of energy power requires careful consideration. Low energy may not provide sufficient treatment efficiency, while high energy increases the risk of pigmentation.[6] In specific facial areas, such as the malar and zygomatic regions, higher energy levels can be applied, whereas lower doses are recommended for the neck and perioral areas.[3]

IPL treatment in melasma

IPL is generally regarded as moderately effective for melasma treatment, and recurrence may occur post-treatment. Consequently, ongoing pigment management should be maintained following IPL therapy. Notably, epidermal melasma exhibits a more favourable response to IPL treatment. There are documented cases where IPL is utilized as monotherapy or in combination with topical agents or lasers.

Ertam Sagduyu et al.[7] assessed the efficacy of two or three sessions of IPL in 50 patients with epidermal or mixed-type melasma. The study revealed an average improvement of 43% in MASI scores, with a higher reduction observed in patients subjected to three IPL sessions (46%) compared to those with two sessions (33%). Li et al.[8] conducted a study involving 58 female melasma patients, applying four sessions of OPT (optimal pulse technology) IPL at 3-week intervals. Results showed a remarkable 70% decrease in MASI scores, accompanied by a significant reduction in pigment and erythema indices measured by mexameters. No recurrence was reported during the 3-month follow-up period. Zoccali et al.[9] reported excellent results in 47% of 38 melasma patients and good results in 29% after three to five sessions of IPL applications. In a study by Bae et al.,[10] encompassing 20 melasma patients, low-current and short-duration IPL treatment with energy levels of 10 J and 13 J was applied to different groups. Both groups exhibited a decrease in MASI and melanin index, with the 13 J group showing a greater reduction in MASI, although this difference was not statistically significant.

Studies in the literature have also explored comparisons between IPL and the Kligman formula. Goldman et al.,[11] conducted a study involving 56 melasma patients, applying an inactive cream and two sessions of IPL to one side of the face, while the other side received the Kligman formula, along with two sessions of IPL. Results indicated a significant improvement on the side where the Kligman formula and IPL were applied together compared to the side treated with only IPL. In the study by Figueiredo Souza et al.,[12] 62 melasma patients were divided into two groups. Thirty-one patients received one session of IPL in addition to the Kligman formula, while the remaining 31 patients used only the Kligman formula. Notably, the IPL group exhibited a significant 49.4% decrease in MASI at the sixth month, whereas the Kligman-only group experienced a modest 2.4% decrease. Shakeeb et al.,[13] conducted a randomized study involving 96 patients with epidermal melasma, categorizing them into three groups: Kligman treatment only, IPL treatment only (four sessions spaced 2 weeks apart), and a combination therapy of IPL and Kligman. The observed reductions in MASI were 69% in the Kligman formula group, 62.5% in the IPL group, and a substantial 93.8% in the IPL and Kligman combination group. In a study by Wang et al.,[14] 17 patients with melasma received four sessions of IPL along with hydroquinone cream, while a control group of 16 patients received only hydroquinone cream. The IPL group demonstrated a 40% reduction in the melanin index, whereas the control group exhibited a 12% reduction.

Combined or comparative studies exploring different IPL technologies and lasers are prevalent in the literature. Fractionated IPL, for instance, can provide more than 40 sub-pulses in milliseconds, extending the duration to 40 μs. Regarded as safer than conventional IPL, this technology possesses properties such as reducing non-selective heat diffusion and fractionating the fluence. In a study by Yun et al.,[15] classical IPL was applied (three sessions with a 3-week interval) to one half of the face, while fractionated IPL was applied (six sessions once a week) to the other half of the faces of 30 female patients with melasma. The authors reported that fractionated IPL, considered safer in terms of complications due to the reduced heat dissipation, demonstrated moderate efficiency in treating melasma and presented itself as an alternative to conventional IPL treatment. In a study by Hassan et al.,[16] PDL was applied to one half of the face, and IPL (three sessions) was applied to the other half of 28 patients with melasma. The study did not find a statistically significant difference between the two groups concerning efficacy and the decrease in vascular endothelial growth factor (VEGF) expression in the tissue. However, the authors noted that IPL demonstrated superiority in patients with epidermal and vascular melasma. In this study, a remarkable 61% improvement was observed in MASI in the IPL group. Tong et al.,[4] implemented a treatment protocol comprising two cycles, each consisting of three sessions of Q-switched ruby laser and one session of IPL. Comparisons were made between melanin and erythema indices with MASI values, revealing a significant 22% decrease in the melanin index, with no relapse observed over a 3-month period. Additionally, a 19% reduction was noted in the erythema index. The substantial 61% decrease in MASI values was sustained for the entire 3-month duration. The authors highlighted that the reduction in the erythema index was comparatively less than their previous study involving four sessions of IPL. In a study by Yun et al.,[17] 12 patients with melasma underwent six sessions of simultaneous fractionated IPL and low flow Qs-Nd: YAG treatment, while another 12 patients received only six sessions of fractionated IPL. The reduction in MASI was notably higher in the combined treatment group at 47%, compared to a 15% reduction in the group treated with IPL alone.

Na et al.[18] observed a significant 59% decrease in MASI and a 26% reduction in the melanin index in a cohort of 20 female patients with mixed-type melasma. The patients underwent treatment consisting of one session of IPL followed by four sessions of low-flow Q-switch ND: YAG, administered once a week. Vachiramon et al.[19] conducted a study involving 20 female patients with mixed-type melasma, applying low-flow QS-Nd-YAG for five sessions once a week to one half of the face and five sessions of QS-Nd: YAG plus three sessions of IPL to the other half. Results revealed a 40% reduction in MASI for the monotherapy group and a 60% reduction in the combined therapy group. During the follow-up period, recurrence rates were 11% in the monotherapy group and 33% in the combined group. Micro crusting, which improved within a week, was observed in 70% of the patients. Additionally, hypomelanosis was observed in one patient who received combined therapy.

Cunha et al.[20] reported a 29% improvement in MASI value after conducting three sessions of combined IPL and QS-Nd: YAG lasers in the same session, targeting 10 resistant melasma patients. In a study by Cho et al.,[21] 51 patients were randomized into two groups. One group received one session of IPL followed by three or four sessions of low-flow QS-Nd: YAG, along with 500 mg/day of tranexamic acid. The other group underwent only IPL and low-flow QS-Nd: YAG treatments. The results showed a MASI reduction of 43% in the group receiving tranexamic acid and 23% in the other group.

In general, IPL is considered safe, with no serious side effects expected after application. The most reported side effects in the literature include edema, erythema, purpura, crusting, and blistering, typically lasting up to 2 days. Mild discomfort may be experienced post-application. Post-inflammatory hypopigmentation or hyperpigmentation may develop because of IPL treatment. To minimize the risk of side effects, the practitioner’s experience and adherence to device parameters are crucial.[22] Since melasma recurrence can occur after IPL treatment, it is recommended to use topical treatments for at least 6–12 months post-application.[23]

While most available studies assess IPL in combination with other treatment modalities, this reflects real-world clinical practice, where combination therapies are commonly preferred due to the treatment-resistant and recurrent nature of melasma. However, this also poses a limitation in evaluating the true efficacy of IPL alone, underlining the need for future prospective studies focusing specifically on IPL monotherapy with long-term follow-up. Another important limitation in the current literature is the lack of long-term follow-up in many studies evaluating IPL for melasma. Given the chronic and recurrent nature of the disease as well as the risk of post-inflammatory hyperpigmentation future studies should include standardized follow-up periods to better assess the durability of treatment outcomes.

Conclusion

In conclusion, IPL is considered a moderately effective method that can be complemented with topical and laser treatments for melasma management. According to the literature findings, its effectiveness tends to increase when combined with other therapeutic approaches. Notably, epidermal melasma demonstrates a more favourable response to IPL treatment compared to dermal and mixed melasma cases.[23] Caution is advised, particularly in individuals with dark skin types, due to the potential risk of PIH.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.