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ISSN: 0954-6634 (print), 1471-1753 (electronic)

J Dermatolog Treat, 2014; 25(6): 523–528

! 2014 Informa UK Ltd. DOI: 10.3109/09546634.2013.848261

ORIGINAL ARTICLE

A comparative study of low-fluence 1064-nm Q-switched Nd:YAG laser

with or without chemical peeling using Jessner’s solution in melasma
patients
Dan Bi Lee, Ho Seok Suh, and Yu Sung Choi

Department of Dermatology, Ulsan University Hospital, Ulsan, Korea

Abstract Keywords
Background: Although low-fluence 1064-nm Q-switched Nd:YAG laser (QSNYL) is widely used 1064-nm Q-switched Nd:YAG laser, Jessner’s
for the treatment of melasma, multiple treatments are necessary for clinical improvement. solution, melasma
Superficial chemical peeling using Jessner’s solution has been used for treatment of melasma
conventionally. History
Objectives: To evaluate the additional therapeutic effect and adverse effects of Jessner’s peel
when combined with 1064-nm QSNYL for melasma patients in a double-blind, placebo- Received 17 July 2013
controlled design. Accepted 5 September 2013
Methods: Total of 52 patients were included. Patients who received 10 sessions of 1064-nm Published online 2 December 2013
QSNYL plus chemical peeling with placebo (group A) in a two-week interval and those who
received 10 sessions of 1064-nm QSNYL plus chemical peeling with Jessner’s solution (group B)
in a two-week interval were analyzed. Responses were evaluated using the Melasma Area and
Severity Index (MASI) score, physician’s global assessment (PGA) and subjective self-assessment.
Results: At 8 weeks, the mean MASI score decreased from 8.68  4.06 to 8.60  3.88 in group A
and from 8.98  3.72 to 7.13  2.57 in group B, showing a significant difference (p50.001).
But at 20 weeks, there was no significant difference on reduction of MASI, self-assessment and
PGA between the two groups. No serious adverse effects were reported with the additional
Jessner’s peeling.
Conclusion: This study suggests Jessner’s peel is a safe and effective method in the early course
of treatment for melasma when combined with low-fluence 1064-nm Q-switched Nd:YAG laser.

Introduction post-inflammatory hyperpigmentation and relapse. Jessner’s

solution is a superficial chemical peeling agent composed of
Pigmentary disorders of facial skin pose severe psychosocial
lactic acid, salicylic acid, resorcinol and ethanol. It is easier to use
stress and significant negative impact on the affected patients’
than GA, because it does not require neutralization, and relatively
quality of life (1). Among these pigmentary disorders, melasma,
safer than TCA because it has superficial depth (8,9). Although it
which presents as localized persistent hyperpigmentation of facial
has been used widely in acne and various types of hyperpig-
skin, is one of the most common disorder and yet the hardest one
mented lesions, there is little published evidence of efficacy on
to treat.
the treatment of melasma.
14
There are two aspects in categorizing melasma. Clinically,
20
On the other hand, treatments such as intense pulsed light
it is divided into centrofacial, malar and mandibular type, and
(IPL), Q-switched Ruby lasers and fractional photothermolysis
histopathologically, it is divided into epidermal, dermal or mixed
have also been used to treat melasma with variable results, but
type, representing the location of melanin pigmentation in the
such therapy pose risk of inflammation, post-inflammatory
layers of skin (2–4). Epidermal types respond well to topical
hyperpigmentation and thermal damage (10–12).
treatment, whereas dermal and mixed types, which are more
Recently, the so-called laser toning treatment was introduced
common in Asia, respond poorly, hence, combined methods are
that uses a collimated low-fluence 1064-nm Q-switched neodym-
recommended.
ium-doped yttrium aluminum garnet (Nd:YAG) laser. This laser
Treatment of melasma is often quite difficult, despite the
treatment minimizes thermal damage by using top-hat beam
availability of a range of treatment modalities. Historically,
mode, short pulse width, high peak power and low fluence
bleaching creams such as topical hydroquinone or chemical peels
(13–15). Although considered as a safe method, the limitation is
using glycolic acid (GA), trichloroacetic acid (TCA) and lactic
prolonged downtime, requiring at least five sessions of treatment
acid have been popular (5–9). However, in darker skin types, the
for acceptable results.
choice of the peeling agent becomes limited due to risk of
In recent studies, combined methods such as GA peels
combined with 1064-nm QSNYL treatment, topical 20% azelaic
Correspondence: Yu Sung Choi, Department of Dermatology, Ulsan acid combined with 1064-nm QSNYL and triple combination
University Hospital, Jeon-ha 1-dong, Dong-gu, Ulsan, Korea. Tel: 82-52- cream combined with 1064-nm QSNYL have yielded better
250-7090. Fax: 82-52-250-7155. E-mail: uuhderma@daum.com results compared to monotherapy (16–19).
524 D. B. Lee et al.
We therefore investigated whether Jessner’s solution provide
additional effect when combined with 1064-nm QSNYL, and
assessed the clinical efficacy and safety of this method.
Furthermore, we analyzed which type of melasma responded
well to this treatment.
Subjects and methods
This study was performed in accordance with the Declaration of
Helsinki (1975) and was approved by the institutional review
board of Ulsan University Hospital. Before enrollment, patients
were informed of the study procedure, possible risks, benefits and
complications. All patients provided written informed consent and
fully understood the purpose of this study.
Study design and subjects
This was a single-center, randomized, controlled, double-blinded
study comparing a combination of 1064-nm QSNYL plus
Jessner’s peel with 1064-nm QSNYL plus placebo in patients
with melasma.
Inclusion criteria required a diagnosis of melasma by two
dermatologists and confirmed by Wood lamp examination.
Exclusion criteria included underlying skin diseases or other
skin lesions on the treatment area; pregnancy or breast-feeding;
history of poor wound healing; recurrent herpes simplex infection;
use of oral medication; hormone replacement therapy; use of
topical bleaching agents within 1 month before enrollment; and
use of chemical peels, laser therapy or IPL within 6 months before
enrollment.
Fifty-two patients participated in this study from September
2011 to August 2012. Patients’ ages ranged from 29 to 53 (mean,
41.7); all were female. Twenty-six patients were each randomly
distributed into either group A (1064-nm QSNYL plus placebo)
or group B (1064-nm QSNYL followed by Jessner’s peel). All
patients were healthy, and none had any dermatologic, endocri-
nologic, hepatic or any other disorder except for melasma.
Patients were instructed not to use any other form of treatment or
functional cosmetics during the study period. Wood lamp
examination was used to determine which type of melasma is
present in each patient.
Treatment methods
Laser treatments were performed for 10 sessions at 2-week
intervals, using low-fluence Q-switched Nd:YAG laser (Cosjet
TR, Won Technology, Korea) (7-mm spot size, collimated
homogenous flat-top beam profile, energy fluence 1.0-1. 7J/cm2
at 10 Hz). A single physician performed all the treatments using a
collimation hand piece and two passes were done per each
treatment session.
Chemical peeling using Jessner’s solution (salicylic acid 14 g,
resorcinol 14 g and lactic acid 14 g dissolved in 95% ethanol) or
placebo (normal saline) was also performed immediately after
laser treatment at a 2-week interval for 10 sessions. First, one pass
of skin priming was done with alcohol gauze. Then, 1–2 ml of
Jessner’s solution or placebo was evenly applied onto melasma
lesion using cotton-tipped applicator. The contact time was 2–3
minutes average, until mild frosting developed. Cooling with ice
gauze was done after the procedure. A sunscreen with sun
protection factor of 50 and moisturizer were provided. Avoidance
of direct facial exposure to the sun was recommended.
Efficacy and safety assessments
Responses to treatments and adverse effects were evaluated at a 4-
week interval throughout the 20-week treatment period. Standard
photographs of both the front and sides of the face were taken
J Dermatolog Treat, 2014; 25(6): 523–528
Table 1. Demographic data of group A and group B. There was no
significant difference between the two groups. Patients of group A
received 1064-nm QSNYL alone and patients of group B received 1064-
nm QSNYL followed by Jessner’s peel.
Group A (n ¼ 26) Group B (n ¼ 26)
Age 42.086.56 40.85  7.48
Duration (yrs) 12.04  6.92 10.77  5.67
Clinical type
Centrofacial 6 (23.08%) 7 (26.92%)
Malar 18 (69.23%) 16 (61.54%)
Mandibular 2 (7.69%) 3 (11.54%)
Histologic type
Epidermal 8 (30.77%) 7 (26.92%)
Dermal 3 (11.54%) 4 (15.39%)
Mixed 15 (57.69%) 15 (57.69%)
using a digital camera (Nikon D7000, Tokyo, Japan), under the
same conditions at baseline and at each subsequent follow-up
visit. Two blinded independent dermatologists reviewed the
photographs to determine the score. The Melasma Area and
Severity Index (MASI) scoring system was used to evaluate the
severity of melasma, according to the measurements used in
previous studies (20).
Physician’s global assessment (PGA) was performed using
a five-point scale. In comparing the two photographs taken at
baseline and after 10 sessions of treatments, degree of improve-
ments were graded (1: none, 0%, 2: slight, 0–25%, 3: average,
26–50%, 4: good, 51–75%, 5: very good, 76–100%).
In addition, all patients were requested to complete a
questionnaire about the perceptions of their overall improvement.
Responses were graded in a seven-point scale (3: gravely
worsen, 2: worsen, 1: slightly worsen, 0: no change, 1: slightly
improved, 2: improved, 3: much improved).
Adverse events, including any possible complications
(erythema, edema, burning sensation, acute urticaria, post-
inflammatory hyperpigmentation and hypopigmentation) were
recorded at each visit.
Statistical analysis
Statistical Package for Social Sciences (SPSS version 19.0, SPSS
Inc, Chicago, IL) was used to all of statistical analysis. Student
t-tests were used to evaluate pretreatment homogeneity, mean
MASI score, and reduction of MASI score according to melasma
types. Significance level was set at 0.05.
Results
Demographics
All 52 patients completed the study. There were no significant
difference between the patients of group A and group B.
Clinically, malar type was the most common type in both
groups, and histologically, mixed type was the most common type
in both groups (Table 1).
Melasma Area and Severity Index
The mean MASI score of both groups decreased significantly in
a 20-week study period. In group A, the mean MASI score
reduced from 8.68  4.06 to 6.22  2.54 (p50.001) at completion
of treatment, achieving a 28.3% reduction from baseline MASI.
In group B, the mean MASI score reduced from 8.98  3.72 to
6.05  2.66 (p50.001), achieving 32.6% reduction (Table 2,
Figure 1).
Comparison of the MASI score reduction from the baseline of
the two groups at 8 weeks and 20 weeks were done. At 8 weeks,
DOI: 10.3109/09546634.2013.848261 1064nm QSNYL and Jessner’s peel for melasma patients 525
Table 2. Effect of low-fluence 1064-nm QSNYL vs. low-fluence 1064-nm QSNYL plus Jessner’s peel on the mean MASI score in melasma patients.
The mean MASI score gradually decreased in a 20-week study period.

Baseline 4 weeks 8 weeks 12 weeks 16 weeks 20 weeks

Mean MASI Group A 8.68  4.06 8.88  4.05 8.60  3.88 7.48  3.69 6.70  3.06 6.22  2.54
Group B 8.98  3.72 8.89  3.80 7.13  2.57 7.01  2.90 6.53  2.64 6.05  2.66

Group A ¼ 1064-nm QSNYL alone; Group B ¼ 1064-nm QSNYL plus Jessner’s peel; MASI ¼ Melasma Area and Severity Index.

none in one patient, slight in four patients, average in eight

patients, good in eight patients and very good in five patients.
Number of patients who had more than average improvement was
73% in group A and 80% in group B, the combined therapy group,
but this difference was not significant (Figure 3).

Figure 1. Effect of low-fluence 1064-nm QSNYL vs. low-fluence 1064-
nm QSNYL plus Jessner’s peel on the mean MASI score (the y-axis)
in melasma patients. The mean MASI score gradually decreased in a
20-week study period. At 8 weeks, after four sessions of treatment, group
B patients showed a significant decrease of mean MASI score than group
A patients.
Subjective assessment
After 20 weeks of treatment, the patients were asked to assess the
treatment results. There were no patients who reported gravely
worsen or worsen in both groups. In group A, 2 patients reported
slightly worsen, 3 reported no change, 4 reported slightly
improved, 11 reported improved and 6 reported much improved.
In group B, none of the patients reported slightly worsen,
2 reported no change, 7 reported slightly improved, 10 reported
improved and 7 reported much improved. Overall, patients’
subjective satisfaction was similar in both groups, but the
percentage of patients who reported better than slightly improved
was insignificantly bigger in group B, the combined therapy
group (Figure 4).

Table 3. Reduction of MASI score in two treatment groups at 8 weeks Recurrence and adverse effects
and 20 weeks are shown. The reduction of MASI score at 8 weeks was
significantly bigger in group B than in group A (p50.001). In terms of Jessner’s solution application, four patients experi-
enced burning sensation during and after Jessner’s solution
Mean Std. p Value application, which subsided within the following week. No other
complications occurred. The adverse events that occurred after
Reduction of MASI At 8 weeks Group A –0.08 0.88 0.000
Group B –1.85 1.96
laser treatments were mild pain and erythema. Punctate
At 20 weeks Group A –2.46 2.58 0.477 leukoedema, post-inflammatory hyperpigmentation or hypopig-
Group B –2.93 2.16 mentation did not occur in any patient.

Group A ¼ 1064-nm QSNYL alone; Group B ¼ 1064-nm QSNYL plus

Jessner’s peel; Std.: standard deviation.
after four sessions of treatment, group B showed a significantly
bigger reduction of MASI score (–0.08 in group A vs. 1.85 in
group B) (p50.001). However, at 20 weeks, the slightly greater
reduction of MASI score in group B (–2.46 in group A vs. 2.93
in group B) was not statistically significant (p40.05) (Table 3,
Figure 1). Clinical photographs demonstrating improvement of
melasma are seen in Figure 2.
Reduction of MASI scores were analyzed according to each
clinical and histological type. Of the clinical types, the dermal
type achieved the biggest reduction in both groups (–2.89  2.04
in group A, 3.77  2.59 in group B). Of the histologic types, the
malar type achieved the biggest reduction in both groups
(–2.87  2.95 in group A, 3.43  2.03 in group B). However,
these differences among the three clinical and histologic types
were not statistically significant (p40.05) (Table 4).
Physician’s global assessment
Two independent dermatologists, who were not involved in the
study, examined the serial photos and rated the overall improve-
ments compared to baseline. In group A, the clinical improve-
ments were evaluated as none in two patients, slight in five
patients, average in seven patients, good in six patients and very
good in six patients. In group B, the improvements were rated as
Discussion
Many therapeutic approaches have been used to treat melasma,
including hypopigmenting agents, chemical peels, dermabrasion
and laser treatments. Of these, chemical peels are used to create
injury at a specific skin depth with the goal of stimulating new
epidermal growth and collagen with more evenly distributed
melanin (8,9). Chemical peels are classified by the depth of action
into superficial, medium and deep peels. Specific peeling agents
should be selected based on the disorder to be treated and used
with an appropriate peel depth, determined by the histological
level or severity of skin pathology to maximize success (9).
The most frequently used peeling agents for melasma are
glycolic acid, trichloroacetic acid (TCA) and Jessner’s solution
(lactic acid, salicylic acid, resorcinol and ethanol), and the
reported efficacy of these agents are variable (21–24). Among
these agents, Jessner’s solution, a superficial chemical peeling
agent, induces desquamation of epidermis which has melanin and
atypical melanophages. It has been used in mild dyschromasias,
acne, post-inflammatory hyperpigmentation and actinic keratosis,
and is known to cosmetically increase brightness and radiance of
skin. Re-epithelization occurs after 3–5 days after desquamation
and the scales are minimal. The procedure itself is relatively
simple, and it does not require sodium bicarbonate for counter-
action, as is the case in glycolic acid peeling. A recent interest
in Jessner’s solution is as a combination medium-depth peel along
with other agents like GA and TCA (25,26). But the adequate
526 D. B. Lee et al. J Dermatolog Treat, 2014; 25(6): 523–528

Figure 2. Serial photographs of representative melasma patients treated with 1064-nm Q-switched Nd:YAG laser plus and Jessner’s peel (upper) with
1064-nm Q-switched Nd:YAG laser alone (lower). Relatively rapid clearing of melasma was seen in the combined therapy group.

Table 4. Reduction of MASI score at 20 weeks according to each clinical and histologic types of both groups. The differences between
the types were not significant (p40.05).

Clinical type Group A Group B Histologic type Group A Group B

Reduction Epidermal –1.60  3.03 –2.18  2.01 Centrofacial –1.50  1.29 –2.61  2.50
of MASI Dermal –2.89  2.04 –3.77  2.59 Malar –2.87  2.95 –3.43  2.03
Mixed –2.40  2.86 –2.74  2.02 Mandibular –1.65  0.21 –1.00  0.92
p Value 0.770 0.454 p Value 0.496 0.187

Group A ¼ 1064-nm QSNYL alone; Group B ¼ 1064-nm QSNYL plus Jessner’s peel.

Figure 4. Subjective self-assessments of combined treatment (1064-nm

Figure 3. Overall evaluation of the efficacy of combined treatment
(1064-nm QSNYL plus Jessner’s peel) vs. monotherapy with 1064-nm
QSNYL alone by Physician’s global assessment. The y-axis represents
the percentage of patients, and efficacy of treatment is expressed in a five
grade (from none to very good). The numbers of patients within each
grade are shown.
QSNYL plus Jessner’s peel) vs. monotherapy with 1064-nm QSNYL
alone by melasma patients. The y-axis represents the percentage of
patients, and efficacy of treatment is expressed in a five grade (from
slightly worsen to much improved). The numbers of patients within each
grade are shown.
DOI: 10.3109/09546634.2013.848261
number of sessions and intervals of chemical peeling procedures
are not determined.
On the other hand, ‘‘laser toning’’, which uses a collimated
low-fluence, 1064-nm Q-switched Nd:YAG laser has recently
been used for melasma in Asian practice (13–15). Although it is
frequently used in the cosmetic market, the reported efficacy is
variable, and it requires prolonged downtime in everyday practice.
This laser is known to minimize thermal damage by selectively
destroying abundant melanin pigments. These pigments are
removed by epidermal desquamation, hence superficial chemical
peeling after laser treatment may accelerate desquamation of
melanin, enhancing the efficacy of laser treatment alone. Prior
study which compared glycolic acid peeling before 1064-nm
QSNYL and laser alone suggested that the combination therapy
was more effective due to deeper penetration depth (18).
In this study, we compared the efficacy of 1064-nm QSNYL
followed by Jessner’s peel versus laser treatment followed by
placebo application (normal saline). Both treatments were effect-
ive after 10 sessions of treatment but the final difference between
the two groups were not significant.
The most notable finding of this study was that the mean
MASI score was significantly reduced from 8.98  3.72 to
7.13  2.57, showing 23% improvement after four sessions
of treatment in the combined therapy group, whereas in mono-
therapy group, the score reduced from 8.68  4.06 to 8.60  3.88.
From this data, we can postulate that Jessner’s solution had an
early additive effect to laser treatment, but this effect was not
consistent after four sessions of treatment (Table 2, Figure 1).
The epidermal turnover time, which is the sum of the turnover
time of proliferative compartment, differentiated compartment
and stratum corneum is reported to be 47–48 days (27). The
marked improvement after four sessions of Jessner’s peel might
be explained in the context that epidermis containing melanin
pigment was replaced in an 8-week period. Afterwards, additional
Jessner’s peel could not yield clinical effect due to newly replaced
epithelium.
Although chemical peels including Jessner’s solution has
extensively been used in melasma, the reasonable number of
treatment sessions and intervals are not precisely determined.
From this data, we may suggest that four to six sessions of
Jessner’s peel is adequate and further treatment might be of no
benefit in melasma patients.
In the treatment of melasma, the type and extent of the
pigment deposits determine the type and invasiveness of the
necessary treatment. The main factor to consider in determining
the prognosis and therapeutic approach is the location and extent
of the abnormal pigment deposits (2–4). Epidermal types usually
respond well to topical treatment, whereas dermal and mixed
types respond poorly and have high recurrence rates, and thus,
treatment methods should be tailored to the melasma type (4).
However, the majority of patients with melasma are of the mixed
type, as in this study group, therefore, combined modalities are
recommended.
With a relatively large group of melasma patients, we
investigated which type of melasma responded better and faster
to either combination therapy or monotherapy. Although the
reduction of mean MASI score was the biggest in malar and
dermal types, the degree of improvements between the clinical
and histological types was not statistically significant (Table 4).
It has been reported that repetitive chemical peeling cause
adverse effects, such as irritation and post-inflammatory hyper-
pigmentation, a serious cosmetic problem, but we found no
significant adverse effects. Variable reported clinical response and
recurrence are probably due to factors such as skin sensitivity,
telangiectasia, inflammation and erythema after chemical peel.
Especially in dark-skinned patients (Fitzpatrick skin type IV–V),
1064nm QSNYL and Jessner’s peel for melasma patients 527
medium-to-deep chemical peel is used with caution due to the risk
of prolonged hyperpigmentation. In this study, Jessner’s solution
proved to be safe, simple and effective method in combination
with 1064-nm Nd:YAG laser.
In conclusion, our results indicate that laser treatment using
a collimated low-fluence 1064-nm Q-switched Nd:YAG laser
with or without Jessner’s peeling is a safe and effective method
for melasma treatment. The combination treatment for four
sessions at a 2-week interval promises to be most effective and
further sessions of chemical peeling may not be necessary.
Furthermore, our findings showed that repetitive Jessner’s peeling
can be considered as safe, simple and effective method in
melasma cases that are resistant to laser treatment alone, or in
patients who expect to see earlier outcome.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
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