Pico toning: why does melasma pigmentation return?

Pico toning (a procedure that uses short pulses of laser to break up pigment) works by delivering a high level of energy for a very short period, effectively fragmenting melanin particles within the skin.

The key principle is to selectively break down pigment before heat spreads to surrounding tissue.

Pigmented spots and melasma can respond differently to the same pico-toning treatment.

Epidermal pigmentation, such as solar lentigines and freckles, often shows noticeable improvement over a relatively short period.

Conversely, melasma is classified as a complex pigmentation disorder because it involves blood vessels and inflammatory factors in the deeper layers of the skin, and is sensitive to external stimuli such as hormones and ultraviolet radiation.

Comparative studies following various treatments have also reported that the degree of melasma improvement varies between individuals, with some treatment courses ending without substantial change.

The primary reason for the recurrence of melasma is that it is a chronic skin condition characterized by a tendency to reappear.

Even if the existing pigments have been broken down, if the cells responsible for producing pigments remain active, they can react to stimuli such as UV radiation, friction, and inflammation, and produce pigments again.

Some studies have observed a temporary worsening of the lesion during treatment, which is attributed to the pigment cells becoming more active in response to stimulation.

In such cases, the interval between treatments needs to be extended rather than increasing treatment intensity.

If post-treatment sun exposure is not adequately managed, it can lead to a vicious cycle where the faded pigment darkens again.

Therefore, recurrence is more closely related to the inherent characteristics of melasma itself, rather than being solely due to the failure of the treatment.

After Pico toning, the most fundamental aspect of aftercare is sun protection.

In melasma, ultraviolet exposure tends to reactivate pigment-producing cells, so applying sunscreen consistently is important for maintaining results.

While pico-toning is generally reported to have a lower incidence of post-inflammatory pigmentation compared to nanosecond lasers, this does not mean that it is completely free of this side effect.

Occasionally, pigmentation or hypopigmentation, along with redness, may occur.

If redness persists for more than a few days or if irritation continues, it is important to seek professional medical attention rather than attempting to self-treat.

Ignoring the condition can actually increase the risk of developing pigmentation.

While the temporary darkening of the treated area with pigment may be normal, it is important to adjust the treatment plan if the discoloration persists.

Darker skin tones or rapidly spreading melasma are associated with a relatively higher risk of adverse effects, so a more cautious approach is needed.

I recommend pico toning for people concerned about mainly epidermal pigmented spots or solar lentigines, or for those whose melasma is stable and not spreading rapidly.

In such cases, relatively predictable improvements can be expected.

However, if the melasma has recently become significantly larger or if there has been a significant change in hormone levels or pregnancy, which has led to increased pigmentation, it may be better to prioritize stabilization before undergoing treatment.

From the hospital's perspective, procedures can contribute to revenue, but prioritizing the patient's well-being may sometimes mean delaying the procedure.