Recalcitrant melasma

Most beneficial in treating recalcitrant melasma and post-inflammatory hyperpigmentation... 

Fig. 10.2. a Patient with recalcitrant melasma unresponsive to glycolic acid or salicylic acid peels, b Responded to combination salicylic acid/TCA peeling... 

There is minimal published data on the use of combination peeling protocols in deeply pigmented skin (Fitzpatrick skin types IV-Vl). The author has reported the efficacy of combination peeling with salicylic acid 20 and 30% in combination with 10% TCA for recalcitrant melasma patients. This peeling regimen was well tolerated with minimal side effects in darker racial ethnic groups (see Salicylic acid/TCA peel section). 

Erbil, H., Sezer, E., Tastan, B. et al. (2007) Efficacy and safety of serial glycolic acid peels and a topical regimen in the treatment of recalcitrant melasma. The Journal of Dermatology, 34, 25-30. 

At 10-25%, TCA produces an injury superficial to the papillary dermis. Applied every 2 weeks for patients with recalcitrant melasma, it provided a more favorable response as to time and degree of improvement, compared with 55-75% GA peel. However, relapse was noted to be more common with TCA compared to GA... 

Comparing the QS laser with the long-pulsed 532-nm Nd YAG laser in the treatment of melasma, the latter produced less PIH because it lacks the photomechanical effects of the QS laser [126]. QS alexandrite laser or PLDL combined with 15-25% TCA peel and/or Jessner s solution was shown to be effective, safe, and relatively inexpensive treatment modalities in the recalcitrant pigmentary disorders [92]. Combination of QS alexandrite and ultrapulse CO lasers yielded statistically significant result in improving refractory melasma compared to QS alexandrite laser alone [5]. Erbium YAG used on patients with skin phototypes II-V may have demonstrated improvement but transient PIH developed 3-6 weeks after laser treatment [100]. 

The most common indications we use TCA peels to treat are solar lentigos and severe acne scars [Figure 13.3). TCA can also be combined with salicylic acid for treatment of solar lentigos. For the treatment of recalcitrant hyperpigmentation and melasma, TCA can be combined with salicylic acid or glycolic acid. 

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