Journal of Cutaneous and Aesthetic Surgery
Print this page
Email this page
Small font size
Default font size
Increase font size
Home About us Current issue Archives Instructions Submission Subscribe Editorial Board Partners Contact e-Alerts Login 

   Table of Contents     
Year : 2019  |  Volume : 12  |  Issue : 2  |  Page : 76-84
Laser toning in melasma

1 Department of Dermatology, Ashwini Ruaral Medical college, Solapur, Maharashtra, India
2 Consultant Dermatologist, Dr. J W Aurangabadkar New Skin clinic, Hyderabad, Telangana, India

Click here for correspondence address and email

Date of Web Publication9-Jul-2019


Melasma is a common acquired disorder of hyperpigmentation. A variety of treatment options has been suggested for the management of melasma. A range of different lasers had been tried in the treatment of melasma. Q-switched Nd-YAG laser (QSL) is the most commonly used laser in the treatment of melasma. Recently, laser toning or low-fluence, multi-pass technique has become popular in treatment of melasma. Authors aimed to review the procedure, its effectiveness, combination therapies using laser toning, and complications of laser toning. A PubMed search was made using keywords such as laser toning, QSL, melasma, and lasers in melasma, and relevant articles were reviewed.

Keywords: Laser toning, melasma, Q-switched Nd:YAG laser
Key Messages: Laser toning is a safe and effective treatment in the management of melasma. Combination therapies including laser toning and topicals often produce satisfactory responses. It is considered as a third-line option in the management of melasma in those patients who failed to respond adequately to trial of medicines and peels. A careful watch should be kept on side effects such as mottled hypopigmentation.

How to cite this article:
Shah SD, Aurangabadkar SJ. Laser toning in melasma. J Cutan Aesthet Surg 2019;12:76-84

How to cite this URL:
Shah SD, Aurangabadkar SJ. Laser toning in melasma. J Cutan Aesthet Surg [serial online] 2019 [cited 2020 Jul 6];12:76-84. Available from:

   Introduction Top

Melasma is a common acquired disorder of hyperpigmentation characterized by symmetrical hyperpigmentation, appearing as light brown to dark brown patches typically on malar areas, forehead, and chin. Although it is just a benign hyperpigmentary condition, it can adversely affect the patient’s self-esteem and quality of life.[1] The prevalence of melasma varies with the ethnicity of the population[2] and contribute to 4%–10% of new cases in dermatological clinics.[3] It affects females more than males.[4] The etiopathogenesis of melasma is unclear and multifactorial with genetic and environmental factors playing their role.[5] The most important risk factors for melasma are Fitzpatrick skin type III and above, ultraviolet (UV) light exposure, pregnancy, exogenous hormones, drugs, and thyroid dysfunction.[5]

Because of unclear etiopathogenesis and recurrent and relapsing nature of the disease, the treatment of melasma is difficult and frustrating for the treating physician and the patient.

A variety of treatment options has been suggested for the management of melasma. These include topical medications (such as hydroquinone, azelaic acid, arbutin, kojic acid, tranexamic acid), chemical peels, oral medications (antioxidants, tranexamic acid), lasers, and lights.[6] An Indian pigmentary expert group proposed a treatment algorithm for melasma.[7] They proposed various topicals and sunscreens as the first-line treatment, chemical peels as a second-line treatment, and lasers and light as a third-line therapy. The lasers and light treatment were reserved for patients with refractory melasma who failed to respond to topicals and chemical peels.[7]

Melasma can be of epidermal, dermal, or most commonly of mixed type. Topicals and peels often produce a satisfactory response in epidermal melasma but are partially effective in dermal or mixed melasma. These patients often require lasers for the treatment.

A range of different lasers had been tried in the treatment of melasma including full-face resurfacing using CO2 or erbium YAG laser, a variety of fractional ablative and non-ablative lasers, intense pulsed light (IPL), and q-switched Nd-YAG laser (QSL).[8]

QSL at 1064nm is the most commonly used laser in the treatment of melasma because of its deeper penetrating properties and safety in pigmented skin. However, earlier reports of treatment of melasma using QSL were not encouraging,[9],[10] and many articles reported complications such as relapse,[11] exacerbation of melasma, or hypopigmentation.[12]

Goldberg and Metzler[13] in the year 1999 proposed the concept of laser toning. They used multiple passes of low-fluence QSL to improve photoaged skin. Kim et al.[14] used the same technique in zebrafish skin to selective destroy the melanosomes without the cell death. This opened up a new and safe modality of the treatment of melasma. Since then, many reports were published especially from Asia, which proves its safety and efficacy.

   Laser Toning Top

Laser toning or low-fluence, multi-pass technique is a popular method for treatment of refractory melasma. The term “laser toning” originates from the improvements in skin tone that result from the use of the laser.[15]

The procedure

The procedure of laser toning is relatively simple:

  • Choose 1064-nm wavelength of QSL.
  • The largest spot, 6–10mm available on the system, should be chosen.
  • The fluence chosen will be in between 0.8 and 2 J/cm2 depending on the spot size of the laser. The starting fluence is chosen according to the spot size available with system and color of melasma. For a spot size of 8–10mm, the fluence range should be between 0.8 and 1.4 J/cm2.
  • The handpiece should always be held perpendicular to the skin.
  • Frequency should be 5–10 Hz.
  • There should not be an overlap of more than 10%–15% between the two pulses.
  • The endpoint of the treatment will be faint erythema or three to four passes (if there is no perceptible erythema).
  • The darker the melasma, lesser will be fluence and vice versa.
  • A minimum of 10–12 sessions with a weekly interval or once in 15 days should be conducted. The authors use it once in 15 days because we have found that once-a-week treatment increases the chances of mottled hypopigmentation in Indian skin.
  • After procedure, broad-spectrum sunscreen is used. Patients can resume their topical after 1–2 days after procedures.

Mechanism of action

Treatment of melasma with laser is always a controversial issue. The traditional QSL treatment is based on the principle of selective photothermolysis, which uses a high fluence to destroy the pigment-containing cell. Because of cell death, there will be release of prostaglandins and cytokines, which results in inflammatory state and damage to basement membrane,[11] resulting in relapse, exacerbation of melasma, or pigmentary changes.

The collimated flattop beam, large spot size, ultrashort pulse duration, low-fluence, and multiple passes of QSL are believed to cause minimal damage to the melanocytes, but it can destroy the melanosomes and melanin granules within melanocytes and keratinocytes but keeping the cell membrane and nucleus intact, thus avoiding cell death. This mechanism is known as “subcellular selective photothermolysis.”[14] The long dendritic processes of hyperactive melanocytes are cutoff (dendrectomy), and there is functional downregulation of melanocytes, which results in the production of a reduced number of melanosomes.[15]

As there is no cell death and heating of skin is kept to a minimum, there are fewer chances of exacerbation of melasma.

Melasma can be an epidermal, dermal, or more often of mixed type. Using large spot size and longer wavelength, the depth of penetration can be increased even with less fluence. This helps in targeting the deeper component of melasma and melanophages in dermis. It is mandatory to use a system with top-hat fluence for laser toning. The top-hat beam distributes the fluence all along the spot and thus avoids the hot spot as in Gaussian beam lasers. Laser toning uses low-fluence and multi-pass technique as against the single-pass high fluence treatment of selective photothermolysis. Using the multiple passes, the melanosomes are heated slowly and destroyed, but the cell membrane and nucleus of the cell are kept intact and thus the cell death is avoided.

Various studies confirmed these findings. Kim et al. studied histopathology of eight Korean women treated with laser toning. They reported that the treated skin showed a decrease in the number of melanosomes and reduced expression of melanogenesis-associated proteins with a normal number of melanocytes.[15] They postulated that the decreased function of melanocytes occurs via the downregulation of melanogenesis, tyrosinase, TRP-1, and TRP-2. Melanogenic stimulators, including a-MSH and NGF, were also reduced. Similar results were also reported by Nam et al.[16] They also reported that there is a positive correlation between number of passes and pigmentation improvement. Omi et al.[17] compared ultrastructural changes after toning with QSL to q-switched ruby laser and concluded that QSL toning offered superior results with less epidermal disruption and cellular damage, thus, confirming the safety of toning with QSL.

To study the pattern of relapse after discontinuation of laser toning, Kim et al.[18] studied the recovery of pigmentation after laser toning in adult zebrafish skin. They found that melanosomes may regenerate within melanocytes if melanocytes are not destroyed. If tyrosinase inhibitors are combined with laser toning, they prevent the relapse of melasma till the patient is on the drugs, thus creating an opportunity to maintain remission. Arbutin and Kojic acids that are commercially available tyrosinase inhibitors do not completely shutdown melanin regeneration.[18]

Review of literature

Laser toning is found to be effective in the treatment of melasma. It can effectively reduce the size, homogeneity, and pigmentation of melasma lesions. Various studies in the past few years confirmed these findings [Table 1].
Table 1: Studies demonstrating efficacy of laser toning in melasma

Click here to view

Polnikorn[19] successfully treated two cases of refractory melasma with laser toning. He combined it with 7% arbutin cream to prevent recurrence. Suh et al.[22] in their study using 1064-nm QSL at the 1-week interval for 10 weeks showed that it is a safe and effective modality for treating melasma in Asian patients.

Sim et al.[23] used laser toning to treat melasma in 50 Asian patients with 15 weekly treatments. They reported good improvement on average with an improvement rate of 50%–74%.[23] Kim et al.[25] studied 22 Korean women with laser toning with a total of 5 sessions of low-fluence pulse to pulse (PTP) mode Nd:YAG laser treatment at 2-week interval. They reported significant improvement in 60% of their patients with a reduction in melasam area severity index (MASI) score by 20% and lightness measured by colorimeter was significantly increased by 1.3 points.[25]

Tian[24] studied the effect of laser toning in 38,970 cases. He reported 21,940 patients (56.3%) reported fair improvement; 8,690 (22.3%) had good improvement; and 1,987 (5.1%) had excellent improvement. A total of 3,273 (8.4%) patients had noticeable improvement, whereas 3,080 (7.9%) had little or no improvement.[24]

Gokalp et al.[26] studied 34 patients and reported 58.8% patients to have at least a 50% improvement in melasma severity with the mean modified melasma area severity index (mMASI) score decreased from 6.7 to 3.2. However, when these patients were followed up for 1 year, recurrence was observed in 20 patients (58.8%) and the mean mMASI score increased from 3.2 to 5.8 in all patients.[26]

Kaminaka et al.[27] studied laser toning in 22 patients and reported a 50% reduction in melanin index after a series of weekly 10 sessions. They also reported a recurrence rate of 16.7% in their study.[27]

In a recent study, Choi et al.[28] reported 20 patients treated with 10 weekly sessions of toning. They reported good to fair improvement in 70% of their patients with two developing mottled hypopigmentation and hyperpigmentation.[28]

   Combination Therapy Top

Laser toning can be combined with various other topical or physical treatment modalities to obtain better efficacy and to increase the safety of treatment by minimizing complications. Topical therapy with hydroquinone is the cornerstone of treatment of melasma. Wattanakrai et al.[29] treated 22 patients with melasma in a split-face trial. They compared the combined treatment of laser toning and 2% hydroquinone with 2% hydroquinone alone. After five weekly treatments, the combination worked better.[29]

Jeong et al.[30] studied a combination of topical triple combination (TC) with laser toning. They treated 13 patients with topical treatment with TC cream or 1064-nm QSL treatment on opposite sides of the face for 8 weeks, and then treatments were reversed for 8 weeks and concluded that treatment after topical TC cream was found to be safer and more effective than the posttreatment use of topical agents.[30]

Bansal et al.[31] compared efficacy of toning with topical 20% azelaic acid cream and their combination in melasma in 3 study groups of 20 patients each. They concluded that the combination of toning and topical 20% azelaic acid cream yields better results as compared to low-fluence QSNYL and azelaic acid alone.[31]

Chemical peeling is a popular method of treatment in the management of melasma. Saleh et al. compared laser toning alone or in combination with modified Jessner peel in 19 patients. They treated one side of the face with laser toning and alternating laser and modified Jessner peel on another side. They found that both methods were equally effective; however, the incidence of mottled hypopigmentation is significantly less in the side treated with a combination and skin texture, brightness, and color homogeneity were improved more commonly with combination therapy.[32]

Vachiramon et al.[33] studied the combination of laser toning alone and in a combination of 30% glycolic acid peels in 15 male patients in a split-face study. They reported temporary improvement in both sides but the side effects such as post-inflammatory hyperpigmentation or even depigmentation (in one case) were more common in the side treated with combination protocol.[33]

Kauvar[34] demonstrated good efficacy using a combination of microdermabrasion and low-fluence QS Nd: YAG laser, applying topical lighteners between laser sessions.[34]

Ustuner et al.[35] studied 16 patients of refractory melasma with laser toning against laser toning plus microneedling and topical vitamin C in a split-face study. They reported significant improvement of combination-treated side than the laser-treated side. In another split-face study of melasma by Lee et al.[36] conducted on eight patients, four sessions of the toning combined with the ultrasonic application of topical vitamin C resulted in a faster clinical response, more significant improvement, and higher patient satisfaction compared to laser monotherapy.

Interactions between the altered cutaneous vasculature and melanocytes have been implicated in the development of hyperpigmentation in melasma.[37] Human melanocyte shows functional VEGF receptor and hence they can respond to angiogenic factors.[38] Na et al.[39] reported that only the area affected by melasma presents a pronounced vascular change, showing significant increases in the number and size of dermal blood vessels. Moreover, they considered that the number of vessels is positively related to the degree of pigmentation.[39] Park et al.[40] demonstrated that the degree of erythema is positively correlated with that of pigmentation in a melasma lesion. Hence dermal vasculature can be a target for melasma treatment.

Kong et al.[41] combined pulsed dye laser (PDL) with laser toning in 17 patients with melasma. All patients received nine sessions of toning on both sides of the face and one side received three sessions of PDL along with toning. They found no difference in outcome on both sides with equal improvement in all but seven patients. These seven patients had widened capillaries on dermoscopy and responded better to the combination of PDL and toning.[41]

Choi et al.[42] combined quasi-long pulsed Nd:YAG and laser toning in very low fluences in the management of 30 patients with aggravated melasma because of previous treatment. They reported significant improvement in all patients with a mean reduction of MASI from 10.84 to 3.22. They postulated the quasi-long pulsed Nd:YAG melasma activity to prevent rebound hyperpigmentation via dermal remodeling and its effect on dermal vasculature.[42] They postulated 300-µs pulsed mode used in dual toning induces a good wound-healing response with release of heat shock proteins, reduction of proinflammatory interleukin 8, and induction of transforming growth factor b. This results in active collagenesis and remodeling and results in better clearance of melasma with improved skin tone.

Shin et al.[43] studied combination of oral tranexamic acid with laser toning in 48 patients. They found the results were superior with combination than in laser alone patient group.[43]

Toning can be combined with other light-based therapies. Kim et al.[44] did a split-face study in which QSL was combined with 1550-nm fractional erbium glass laser on one side and only QSL on another side. They found no difference in outcome on both sides.[44]

Cunha et al.[45] studied six patients of refractory melasma with the combination of IPL with toning at a monthly interval and reported significant improvement in all the patients. Similar results were also reported by Yun et al.[46] in 12 Korean patients treated with fractionated IPL and laser toning. They reported significant improvement in combination group than IPL alone group.[46]

Kwon et al.[47] studied the combination of fractional microneedling radiofrequency with laser toning to laser toning alone in a retrospective study. They treated 56 patients with 10 weekly sessions of combination or QSL alone. They reported not only the combination group improved better (68%–54%), but also the treatment-related side effects such as mottled hypopigmentation and rebound hyperpigmentation were less on combination-treated side.[47]


Safe and effective laser toning is not free from complications. Reported complications from laser toning include pain during the procedure, rebound of melasma, hyperpigmentation, guttate leukoderma, physical urticaria, acneiform eruption, minute petechiae, whitening of fine facial hair, and herpes simplex reactivation. Most of these complications are mild and self-limiting except hypo- or depigmentation.

Relapse and worsening of melasma have been reported after toning. The risk factors for relapse may be high cumulative fluence and small spot used for the treatment. Hofbauer Parra et al.[48] studied 20 Latin American patients with laser toning and reported significant improvement in all patients with minimal side effects. However, 81% of their patients relapsed or worsened after discontinuation of treatment.[48] The high relapse rate was also reported in other studies.[18],[26],[27]

Confetti-like hypopigmentation or punctate leukoderma is the most distressing complication of repeated low-fluence laser therapy. It can develop after several sessions or as early as the second session.[49] The cumulative dose of repetitive laser treatment may affect melanocyte function, resulting in the development of hypopigmentation.[50]

Various studies and case reports[29],[49],[51] reported a higher incidence of mottled hypopigmentation in patients treated with laser toning for melasma. The exact etiology of this complication is not known.

In one study, the authors indicate hypopigmentation might be due to the destruction of melanocytes. The number of melanocytes was reduced in the hypopigmented lesion. However, they did not compare the number of melanocytes in normally pigmented skin.[52]

A study by Ryu and Kim[53] described a case of toning-induced hypopigmentation that had decreased number of functional melanocytes on histology but normal melanocyte number.[53] Similar finding was also reported by Wong et al.[54] in one Chinese patient who has received 40–50 sessions over a 6-month period.

Sugawara et al. studied the influence of the frequency of laser toning on the occurrence of hypopigmentation. They divided 147 patients into 3 groups and treated either weekly, biweekly, or monthly frequency. They reported that an overall incidence of hypopigmentation was 2% without any significant statistical difference in the different group. They also advised using UV imaging for early diagnosis of leukoderma.[55]

Tian[56] reviewed 23 patients of melasma who underwent biweekly toning for the period of 2 months and noticed confetti-like hypopigmentation in all of them. He recommended the frequency of treatment every 2 weeks.[56]

Laser-toning-induced hypopigmentation in patients with melasma generally does not respond well to treatment. Such hypopigmentation often persists for many years despite a variety of topical and phototherapy treatments. Various treatment options such as topical steroids, topical tacrolimus, narrowband UVB therapy, and TCA CROSS have been tried with limited success.[57]

   Conclusion Top

Laser toning has become an extremely popular procedure in recent years. Various studies point out that it is moderately effective in the management of melasma and is not free from side effects. There is no marker predictive of successful outcome while choosing the patient for the treatment, and hence patients should be properly counseled before starting the treatment.

Authors have used laser toning in those patients who failed to respond all standard lines of treatment, and got mixed results [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. In the authors experience, laser toning with 1064-nm QSL with a spot size of 10mm, fluence of 0.85–1.2 J/cm2, 10-Hz repetition rate, multiple passes (average 3–4) performed once in 15 days for a total of 8–10 sessions yields good results. The chances of hypopigmentation are minimal with the use of 10-mm spot size and minimal overlap of pulses. The authors also combine either dual toning (quasi-long pulse and laser toning) or gold toning (585-nm QSL with laser toning in selected cases with reasonably good outcomes.
Figure 1: Excellent response to laser toning after nine sessions

Click here to view
Figure 2: Moderate response to refractory melasma after 10 sessions of toning

Click here to view
Figure 3: Moderate response to refractory melasma after six sessions of toning + microneedling + topical vitamin C

Click here to view
Figure 4: Mottled hypopigmentation due to toning after six sessions

Click here to view
Figure 5: No response to melasma after 12 sessions

Click here to view

The Indian study group has recommended combination therapy as a third-line of treatment in melasma and it should be strictly followed in day-to-day practice.[7]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

   References Top

Deshpande SS, Khatu SS, Pardeshi GS, Gokhale NR. Cross-sectional study of psychiatric morbidity in patients with melasma. Indian J Psychiatry 2018;60:324-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
Achar A, Rathi SK. Melasma: a clinico-epidemiological study of 312 cases. Indian J Dermatol 2011;56:380-2.  Back to cited text no. 2
[PUBMED]  [Full text]  
Failmezger C. Incidence of skin disease in Cuzco, Peru. Int J Dermatol 1992;31:560-1.  Back to cited text no. 3
KrupaShankar DS, Somani VK, Kohli M, Sharad J, Ganjoo A, Kandhari S, et al. A cross-sectional, multicentric clinico-epidemiological study of melasma in India. Dermatol Ther (Heidelb) 2014;4:71-81.  Back to cited text no. 4
Lee AY. Recent progress in melasma pathogenesis. Pigment Cell Melanoma Res 2015;28:648-60.  Back to cited text no. 5
Suggs AK, Hamill SS, Friedman PM. Melasma: update on management. Semin Cutan Med Surg 2018;37:217-25.  Back to cited text no. 6
Sarkar R, Aurangabadkar S, Salim T, Das A, Shah S, Majid I, et al. Lasers in melasma: a review with consensus recommendations by Indian Pigmentary Expert Group. Indian J Dermatol 2017 62:585-90.  Back to cited text no. 7
[PUBMED]  [Full text]  
Trivedi MK, Yang FC, Cho BK. A review of laser and light therapy in melasma. Int J Womens Dermatol 2017;3:11-20.  Back to cited text no. 8
Ho SG, Chan HH. The Asian dermatologic patient: review of common pigmentary disorders and cutaneous diseases. Am J Clin Dermatol 2009;10:153-68.  Back to cited text no. 9
Rajaratnam R, Halpern J, Salim A, Emmett C. Interventions for melasma. Cochrane Database Syst Rev.2010 Jul 7;(7):CD003583.  Back to cited text no. 10
Torres-Álvarez B, Mesa-Garza IG, Castanedo-Cázares JP, Fuentes-Ahumada C, Oros-Ovalle C, Navarrete-Solis J, et al. Histochemical and immunohistochemical study in melasma: evidence of damage in the basal membrane. Am J Dermatopathol 2011;33: 291-5.  Back to cited text no. 11
Lipper GM, Anderson RR. Lasers in dermatology. In: Freedburg IM, Eisen AZ, Ketal W, editors. Fitzpatrick dermatology in general medicine. 7th ed. New York: McGraw Hill; 2007. p. 2274.  Back to cited text no. 12
Goldberg D, Metzler C. Skin resurfacing utilizing a low-fluence nd:YAG laser. J Cutan Laser Ther 1999;1:23-7.  Back to cited text no. 13
Kim JH, Kim H, Park HC, Kim IH. Subcellular selective photothermolysis of melanosomes in adult zebrafish skin following 1064-nm Q-switched Nd:YAG laser irradiation. J Invest Dermatol 2010;130:2333-5.  Back to cited text no. 14
Kim JE, Chang SE, Yeo UC, Haw S, Kim IH. Histopathological study of the treatment of melasma lesions using a low-fluence Q-switched 1064-nm neodymium:yttrium-aluminium-garnet laser. Clin Exp Dermatol 2013;38:167-71.  Back to cited text no. 15
Nam JH, Min JH, Kim WK, Yim S, Kim WS. Melanogenesis inhibition in mice using a low-fluence 1064-nm Q-switched neodymium-doped yttrium aluminum garnet laser: a pilot study. Lasers Med Sci 2017;32:1063-9.  Back to cited text no. 16
Omi T, Yamashita R, Kawana S, Sato S, Naito Z. Low fluence Q-switched Nd: YAG laser toning and Q-switched ruby laser in the treatment of melasma: a comparative split-face ultrastructural study. Laser Ther 2012;21:15-4.  Back to cited text no. 17
Kim JH, Kim DH, Kim JH, Lee SG, Kim HS, Park HC, Kim IH. Recovery of pigmentation following selective photothermolysis in adult zebrafish skin: clinical implications for laser toning treatment of melasma. J Cosmet Laser Ther 2012;14: 277-85.  Back to cited text no. 18
Polnikorn N. Treatment of refractory dermal melasma with the medlite C6 Q-switched nd:YAG laser: two case reports. J Cosmet Laser Ther 2008;10:167-73.  Back to cited text no. 19
Jeong SY, Chang SE, Bak H, Choi JH, Kim IH. New melasma treatment by collimated low fluence Q-switched Nd: YAG laser. Korean J Dermatol 2008;46:1163-170.  Back to cited text no. 20
Cho SB, Kim JS, Kim MJ. Melasma treatment in Korean women using a 1064-nm Q-switched nd:YAG laser with low pulse energy. Clin Exp Dermatol 2009;34:e847-50.  Back to cited text no. 21
Suh KS, Sung JY, Roh HJ, Jeon YS, Kim YC, Kim ST. Efficacy of the 1064-nm Q-switched Nd:YAG laser in melasma. J Dermatolog Treat 2011;22:233-8.  Back to cited text no. 22
Sim JH, Park YL, Lee JS, Lee SY, Choi WB, Kim HJ, et al. Treatment of melasma by low-fluence 1064nm Q-switched nd:YAG laser. J Dermatolog Treat 2014;25:212-7.  Back to cited text no. 23
Tian B. Laser toning for melasma: a single-centre experience with 38970 cases. J Cosmet Laser Ther 2017;19:140-2.  Back to cited text no. 24
Kim JY, Choi M, Nam CH, Kim JS, Kim MH, Park BC, et al. Treatment of melasma with the photoacoustic twin pulse mode of low-fluence 1,064nm Q-switched nd:YAG laser. Ann Dermatol 2016;28:290-6.  Back to cited text no. 25
Gokalp H, Akkaya AD, Oram Y. Long-term results in low-fluence 1064-nmQ-Switched Nd:YAG laser for melasma: is it effective? J Cosmet Dermatol 2016;15:420-6.  Back to cited text no. 26
Kaminaka C, Furukawa F, Yamamoto Y. The clinical and histological effect of a low-fluence Q-switched 1,064-nm neodymium: yttrium-aluminum-garnet laser for the treatment of melasma and solar lentigenes in Asians: prospective, randomized, and split-face comparative study. Dermatol Surg 2017;43:1120-33.  Back to cited text no. 27
Choi JE, Lee DW, Seo SH, Ahn HH, Kye YC. Low-fluence Q-switched nd:YAG laser for the treatment of melasma in Asian patients. J Cosmet Dermatol 2018;17:1053-58.  Back to cited text no. 28
Wattanakrai P, Mornchan R, Eimpunth S. Low-fluence Q-switched neodymium-doped yttrium aluminum garnet (1,064nm) laser for the treatment of facial melasma in Asians. Dermatol Surg 2010;36:76-87.  Back to cited text no. 29
Jeong SY, Shin JB, Yeo UC, Kim WS, Kim IH. Low-fluence Q-switched neodymium-doped yttrium aluminum garnet laser for melasma with pre- or post-treatment triple combination cream. Dermatol Surg 2010;36:909-18.  Back to cited text no. 30
Bansal C, Naik H, Kar HK, Chauhan A. A comparison of low-fluence 1064-nm Q-switched Nd: YAG laser with topical 20% azelaic acid cream and their combination in melasma in Indian patients. J Cutan Aesthet Surg 2012;5:266-72.  Back to cited text no. 31
[PUBMED]  [Full text]  
Saleh F, Moftah NH, Abdel-Azim E, Gharieb MG. Q-switched nd: YAG laser alone or with modified Jessner chemical peeling for treatment of mixed melasma in dark skin types: a comparative clinical, histopathological, and immunohistochemical study. J Cosmet Dermatol 2018;17:319-27.  Back to cited text no. 32
Vachiramon V, Sahawatwong S, Sirithanabadeekul P. Treatment of melasma in men with low-fluence Q-switched neodymium-doped yttrium-aluminum-garnet laser versus combined laser and glycolic acid peeling. Dermatol Surg 2015;41:457-65.  Back to cited text no. 33
Kauvar AN. Successful treatment of melasma using a combination of microdermabrasion and Q-switched nd:YAG lasers. Lasers Surg Med 2012;44:117-24.  Back to cited text no. 34
Ustuner P, Balevi A, Ozdemir M. A split-face, investigator-blinded comparative study on the efficacy and safety of Q-switched nd:YAG laser plus microneedling with vitamin C versus Q-switched nd:YAG laser for the treatment of recalcitrant melasma. J Cosmet Laser Ther 2017;19:383-90.  Back to cited text no. 35
Lee MC, Chang CS, Huang YL, Chang SL, Chang CH, Lin YF, et al. Treatment of melasma with mixed parameters of 1,064-nm Q-switched nd:YAG laser toning and an enhanced effect of ultrasonic application of vitamin C: a split-face study. Lasers Med Sci 2015;30:159-63.  Back to cited text no. 36
Kim EH, Kim YC, Lee ES, Kang HY. The vascular characteristics of melasma. J Dermatol Sci 2007;46:111-6.  Back to cited text no. 37
Kim EJ, Park HY, Yaar M, Gilchrest BA. Modulation of vascular endothelial growth factor receptors in melanocytes. Exp Dermatol 2005;14:625-33.  Back to cited text no. 38
Na JI, Choi SY, Yang SH, Choi HR, Kang HY, Park KC. Effect of tranexamic acid on melasma: a clinical trial with histological evaluation. J Eur Acad Dermatol Venereol 2013;27: 1035-9.  Back to cited text no. 39
Park GH, Lee JH, Choi JR, Chang SE. The degree of erythema in melasma lesion is associated with the severity of disease and the response to the low-fluence Q-switched 1064-nm nd:YAG laser treatment. J Dermatolog Treat 2013;24:297-9.  Back to cited text no. 40
Kong SH, Suh HS, Choi YS. Treatment of melasma with pulsed-dye laser and 1,064-nm Q-switched nd:YAG laser: a split-face study. Ann Dermatol 2018;30:1-7.  Back to cited text no. 41
Choi CP, Yim SM, Seo SH, Ahn HH, Kye YC, Choi JE. Retreatment using a dual mode of low-fluence Q-switched and long-pulse nd:YAG laser in patients with melasma aggravation after previous therapy. J Cosmet Laser Ther 2015;17:129-34.  Back to cited text no. 42
Shin JU, Park J, Oh SH, Lee JH. Oral tranexamic acid enhances the efficacy of low-fluence 1064-nm quality-switched neodymium-doped yttrium aluminum garnet laser treatment for melasma in Koreans: a randomized, prospective trial. Dermatol Surg 2013;39: 435-42.  Back to cited text no. 43
Kim HS, Kim EK, Jung KE, Park YM, Kim HO, Lee JY. A split-face comparison of low-fluence Q-switched nd: YAG laser plus 1550nm fractional photothermolysis vs. Q-switched nd: YAG monotherapy for facial melasma in Asian skin. J Cosmet Laser Ther 2013;15:143-9.  Back to cited text no. 44
Cunha PR, Pinto CA, Mattos CB, Cabrini DP, Tolosa JL. New insight in the treatment of refractory melasma: laser Q-switched nd: YAG non-ablative fractionated followed by intense pulsed light. Dermatol Ther 2015;28:296-9.  Back to cited text no. 45
Yun WJ, Moon HR, Lee MW, Choi JH, Chang SE. Combination treatment of low-fluence 1,064-nm Q-switched nd: YAG laser with novel intense pulse light in Korean melasma patients: a prospective, randomized, controlled trial. Dermatol Surg 2014;40:842-50.  Back to cited text no. 46
Kwon HH, Choi SC, Jung JY, Park GH. Combined treatment of melasma involving low-fluence Q-switched Nd:YAG laser and fractional microneedling radiofrequency. J Dermatolog Treat 2018;28:1-5.  Back to cited text no. 47
Hofbauer Parra CA, Careta MF, Valente NY, de Sanches Osório NE, Torezan LA. Clinical and histopathologic assessment of facial melasma after low-fluence Q-switched neodymium-doped yttrium aluminium garnet laser. Dermatol Surg 2016;42:507-12.  Back to cited text no. 48
Kim MJ, Kim JS, Cho SB. Punctate leucoderma after melasma treatment using 1064-nm Q-switched nd:YAG laser with low pulse energy. J Eur Acad Dermatol Venereol 2009;23:960-2.  Back to cited text no. 49
Jang YH, Park JY, Park YJ, Kang HY. Changes in melanin and melanocytes in mottled hypopigmentation after low-fluence 1,064-nm Q-switched nd:YAG laser treatment for melasma. Ann Dermatol 2015;27:340-2.  Back to cited text no. 50
Chan NP, Ho SG, Shek SY, Yeung CK, Chan HH. A case series of facial depigmentation associated with low fluence Q-switched 1,064nm nd:YAG laser for skin rejuvenation and melasma. Lasers Surg Med 2010;42:712-9.  Back to cited text no. 51
Kim T, Cho SB, Oh SH. Punctate leucoderma after 1,064-nm Q-switched neodymium-doped yttrium aluminum garnet laser with low-fluence therapy: is it melanocytopenic or melanopenic? Dermatol Surg 2010;36:1790-1.  Back to cited text no. 52
Ryu HJ, Kim J. A case of mottled hypopigmentation after low-fluence 1,064-nm Q-switched neodymium-doped yttrium aluminum garnet laser therapy. J Cosmet Laser Ther 2013;15:290-2.  Back to cited text no. 53
Wong Y, Lee SS, Goh CL. Hypopigmentation induced by frequent low-fluence, large-spot-size QS nd:YAG laser treatments. Ann Dermatol 2015;27:751-5.  Back to cited text no. 54
Sugawara J, Kou S, Kou S, Yasumura K, Satake T, Maegawa J. Influence of the frequency of laser toning for melasma on occurrence of leukoderma and its early detection by ultraviolet imaging. Lasers Surg Med 2015;47:161-7.  Back to cited text no. 55
Tian B. The Asian problem of frequent laser toning for melasma. J Clin Aesthet Dermatol 2017;10:40-2.  Back to cited text no. 56
Chandrashekar BS, Sriram R, Madura C. Novel method of treatment of post-Q-switched nd-YAG laser depigmentation with trichloroacetic acid: a report of two cases. J Cutan Aesthet Surg 2014; 7:56-7.  Back to cited text no. 57
[PUBMED]  [Full text]  

Correspondence Address:
Swapnil D Shah
441, Shukrawar peth, Manik chowk, Solapur, Maharashtra, 413002.
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCAS.JCAS_179_18

Rights and Permissions


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

   Laser Toning
   Combination Therapy
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded306    
    Comments [Add]    

Recommend this journal