In the ideal world, you could combine lasers with skin lightening creams for the best results. But we don't live in the ideal world where money is unlimited. We often have to prioritize and choose the treatments that give the best outcomes for the amount spent. We also have to be careful not to do too many treatments in a rush that may inadvertently harm the skin in the process.
I would really recommend the following step-wise approach to the treatment of skin pigmentation like melasma.
One Established Approach
- Start with a peeling agent like AHA to remove the excessive dead squames. Introduce sun protection to be diligently used henceforth. There are oral sunblocks that one can consider as well.
- Add retinol or retin A to promote skin cell renewal. Add anti-oxidants like Vitamin C or Coenzyme Q10 when the skin is adequately prepared.
- Up the retin A strength and add hydroquinone until before the skin irritation gets unbearable. Regular follow ups at this stage is critical to gauge the end point for tolerability. These products are strong medical grade skin care. And they should be used under medical supervision. Usually most pigmentation gets controlled pretty well after the above.
- For the slightly more stubborn pigmentation problems, it depends on the depth of the pigments. Superficial pigments like sun-damage or freckles, add a few sessions of fractional CO2 and/or Intense Pulsed Light (IPL).
- For deeper pigmentation problems like melasma, use a Dual Yellow Laser to disrupt the accumulated pigments and "zap" away the excessive small blood vessels around the melasma lesions.
- Another important step in the treatment of melasma is to use a technology called Sylfirm to re-build the basement membrane of the epidermis.
All the above steps can take months to fine tune. Rushing into any treatment or when throwing to many harsh elements at the skin often result in an "injury" reaction called Post Inflammatory Hyperpigmentation (PIH). Too much hydroquinonone can in very rare instances result in a condition called Ochronosis.
Also, the development of hyperpigmentation is a dynamic process. Melanocytes (pigment producing cells) are continuously affected by the swings in hormone levels, especially oestrogens. So the treatment may have to be continuously adjusted between using topical creams and lasers.
Creams or laser, it really depends on the stage of the pigmentation problem and how it has responded to other treatments before. There should not be a fixed formula. Besides, everyone's skin reacts somewhat differently although there is a proper methodology (like above) to approach the problem.
Also, there are many other skin pigmentation conditions that can mimic melasma. And thee treatments call for different treatments.