Post fractional CO2 laser hypopigmentation

[HypoCO2]

Dear Sarah,

I have type IV (Asian), combination skin. I had a course of Accutane last year for acne.

I underwent ablative fractional CO2 laser for facial acne scarring in November 2012.

Since then, I’ve presented with persistent redness at the sites treated most aggressively (forehead, temples and cheeks).

Two months ago, however, as these areas of redness slowly began to resolve, it revealed areas of delayed onset hypopigmentation (3 months post-op). The hypopigmentation (lighter skin) presents in the size and shape of the laser head/area treated (2-3cm).

As of today (2 months since the hypopigmentation presented and 5 months post-op) the hypopigmentation has not improved and, perhaps, as the transient pinkness resolved, has become slightly whiter. I have strictly avoided sun expose since the treatment.

I have tried Protopic for the past 4 weeks with no results. I have also recently purchased a NB-UVB lamp.

The hypopigmentation is very distressing for me and I am desperate for your help.

I have been a frequent visitor to your forums for the past few months and I would now like to attempt needling.

I want to treat myself correctly, therefore please kindly advise me on the following:-

1. What rollers, stamps, single needles should I purchase?
2. What needle lengths should I choose?
3. What is the most efficacious treatment method/plan? For example:-

1. Single needling with (x) needle at the hypopigmented edges at a 15 degree angle towards the hypopigmentation to promote peripheral melanocytes migration.
2. Stamp hypopigmentation using (x) dermastamp to prepare area for melanocytes transfer.
3. Attempt melanocytes transfer using (x) dermastamp/dermaroller from (x) donor region.
4. Cover the area in an occlusive dressing using (x) for (x) duration to promote melanocyte bedding.
5. After (x) length of healing time, cover around the hypopigmentation with sunscreen SPF (x) to avoid unwanted hyperpigmentation.
6. Expose needled area to NB-UVB lamp (safer and more efficacious wavelength than the sun and avoids UVA hyperpigmentation) to promote new melanocyte proliferation for (x) seconds.
7. Cover area with Protopic to suppress melanocyte death.
8. Use NB-UVB light and Protopic everyday.
9. Repeat the above needling every (x) days.

Yours faithfully,

[SarahVaughter]

We sometimes get emails stating that laser- or IPL treatment left people with hyperpigmentation, hypopigmentation or even scars.  It doesn’t happen very often but it happens.

Intense Pulse Light (IPL) or lasers work on the same principle. They heat up the skin. The tissue absorbs light from the laser and that heats it up.

Everything in the skin absorbs laser light but some parts (for example dark colored parts) absorb it quicker, especially if specific wavelengths of light are used.

Thus, you can target hemoglobin in the blood and seal spider veins through heat. In laser epilation, you target the melanin pigment in the hairs and the heat will temporarily weaken the hair bulb. You can target tattoo pigment and the heat disperses it. You can stimulate collagen production by slightly heating up the water molecules in the skin or use more energy and actually evaporate a layer of skin or just fractions of skin (Fraxel). You can even cut steel with sufficiently powerful laser light and that works on the same principle.

However, because everything in the skin absorbs laser light to a certain degree, this technique is prone to "collateral damage".
 
Not only hairs but the skin itself contains melanin. It is a pigment that makes up the color of the skin. It is our natural UV filter. The darker the skin the more melanin it contains and the more prone it is to collateral damage. In some unfortunate cases, the heat destroys for example melanocytes (pigment producing cells) and you end up with hypopigmented spots.

I am not sure it was a good idea to undergo laser treatment just a few months after using Accutane because Accutane potentially makes skin more prone to scarring and unpredictable healing and it is generally recommended to wait at least six months.

I also do not quite understand why you used Protopic because it is an immune-suppressant. It can effectively suppress (chronic) inflammation (present in certain eczemas and skin rashes) because inflammation is an immune reaction. It can reduce redness (hyperpigmentation) if the redness is caused by inflammation but it cannot help hypopigmentation.

I will post another reply later concerning suggested treatment.

[HypoCO2]

Thank you for your response.

My course of Accutane lasted approximately 5 months and I reached the standard cumulative dose of 110mg/kg.

Seven weeks after cessation of Accutane, my dermatologist was of the opinion that sebaceous function had returned to sufficient levels and it would be safe to perform ablative fractional CO2 laser for my facial acne scarring. Re-epithelisation occurred as normal within 7 days, indicative of normal healing. I did present with prolonged and persistent redness, however.

It is my understanding that Protopic (tacrolimus) is a common topical treatment for vitiligo, particularly on the face because it has a better side effect profile than typical first line therapy of corticosteroids. Please kindly see the following:-

https://http://www.ncbi.nlm.nih.gov/pubmed/16120133
https://http://www.ncbi.nlm.nih.gov/pubmed/17034537
https://http://dermatologyandlasersurgery.com/wp-content/uploads/2011/12/2003-Cutis-Tacrolimus-Ointment-Produces-Repigmentation.pdf
https://http://archderm.jamanetwork.com/article.aspx?articleid=479293

I am very distressed by the hypopigmentation. I would be grateful to receive your comments on this and look forward to receiving your recommendations.

Best wishes,

[SarahVaughter]

Oh I see, I am sorry, I did not know that tacrolimus was found to improve melanin concentration.

If your hypopigmentation is more or less on just several spots, buy a 1 mm dermastamp. Stamp the white patch (every week) and also a little over the edges of the white patch to facilitate the migration of melanocytes from the surrounding normal skin into the white patch.

You can attempt melanocyte harvesting:

Stamp normally pigmented skin several times to try to "harvest" some melanocytes and then stamp the hypopigmentation. Melanocytes are at the bottom of the epidermis, whose thickness is 0.1 - 0.3 mm. (Try it with and without occlusive dressing).

Apply your Protopic cream right after stamping and continue applying it every day.

When the skin is healed from microneedling, expose your spots to your NB-UVB lamp.

Basically you have to improvise a little and try various approaches. Unfortunately, there is no one single approach that always works for everybody.

You can try some of the substances for repigmentation that are discussed here but I cannot attest to their efficacy:

https://http://forums.owndoc.com/dermarolling-microneedling/melanocytes-transfer-for-white-scars-and-hypopigmentation/