Journal of Aesthetic & Reconstructive SurgeryISSN 2472-1905

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DOI: 10.36648/2472-1905.6.3.59

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Priscila Fernanda Campos Menezes1,2*, Nahdia Jackeline Souza Caixeta1 and Vanderlei Salvador Bagnato2

1 BellelaPelleClinicadeEstética&CursosProfissionalizantes–Araras-SaoPaulo,Brazil

2 InstitutodeFísicadeSãoCarlos(IFSC)–UniversityofSãoPaulo(USP),Av.TrabalhadorSãoCarlense,Brazil

*Corresponding author: Dr.PriscilaFernandaCamposMenezes

priscilamene2015@gmail.com

Tel:551633739672

Instituto de Física de Sao Carlos (IFSC),UniversityofSaoPaulo(USP),Av.TrabalhadorSaoCarlense,400-CEP:13560-970;SaoCarlos-SaoPaulo,Brazil.

Citation:MenezesPFC,CaixetaNJS,BagnatoVS(2020)PhotodynamicCosmeticTherapyonMelasmaManagement-MelanReduxxProgram.JAesthetReconstrSurgVol.6No.3:10

Photodynamic Cosmetic Therapy on Melasma Management - Melan Reduxx Program

AbstractThemelasmahasamultifactorialpathogenesisandalotofstrategiesontreatmentareproposed.Howevermelasmahasnoafinaltreatmentbecausedependingofhormonalalteration,UVexpositionfrequentlyandothercauses,thepigmentationcomesagainandinmanycasesstrongerthanbeforetreatment.Theaimofthisstudy is to demonstrate that the management of melasma proposed in themelan reduxx program is possible by associating different treatment strategiesas:professionalproceduresonclinicalusing lowlevel lightprofessionaltherapywithlaserandLEDs,indifferentvisiblewavelengthsinthepresenceofchemicalandphotoactivedpeels (professional cosmeticsproducts)aswellashomecareprocedures using topical and oral cosmetics products. The management ofmelasmacanberealizedfrom3to4months,decreasingtheskinpigmentationgradually.Themelanreduxxprogramisproposedtobeperformedfrom5to15sessionswithintervalsfromfifteentothirtydaysbetweensessions.InagreementwiththeresultsitispossibletoperformthePhotodynamicCosmeticTherapyonmelasmamanagementonmelanreduxxprogramusingchemicalandphotoactivedpeelswithsafetyandeffectivityassociatingvisiblelightandalotofcosmetology.

Keywords: Photodynamic cosmetic therapy; Melasma; Laser; Chemical peel;Photoactivatedpeel

Received: July11,2020; Accepted: August05,2020; Published: August12,2020

IntroductionOne of the most frequently asked questions from patients toaesthetichealthprofessionalsisabouttheeffectivetreatmentofmelasma.Theanswertothisquestionis"No,"becausemelasmahasnotreatmentbutmanagement.Thismeansthatmelasmamaybecontrolled,butatsomepointeitherbyhormonalfluctuation,sunexposureandsomekindofaggressionintheskinthattriggersaninflammatoryreaction,itmaycomebackmorestrongerwithalotofamountofmelaninformedintheregion(pigmentreboundeffect)[1-3].Thenwecansaythatthemanagementofmelasmacanbedefinedasatreatmentforalllife.

Melasma has a multifactorial pathogenesis that envolves theGeneticpredisposition,hormonal factors,pregnancy,ultraviolet(UV) radiation exposure frequentely, farmaceutical drugs andcosmeticsonskin,thatplayimportantroleonincreaseinmelanindeposition in theepidermisanddermis (epidermalanddermalmelasma)[1,3-6].

Duringpregnancy,increasedlevelsofestrogenandprogesterone,thatstimulatesthealfaMSHreceptor,increasesthepigmentation

on skin. The oral contraceptives also have been linked to skinhyperpigmentation since that increases the levels of estrogensstimulatingtheactivityofmelanocytes.Onpostmenopausalthelevels of estrogen also increase by aromatase enzyme activityalsostimulatingthepigmentationsonskinmelasma.Thepatientswithmelasmashowsinallstituationanincreasedexpressionofestrogen receptorsat skin andmanystrategieshasbeendonetoactonselectiveestrogenreceptormodulators–SERMs[7,8].

In this sense, some depigmenting active principles, even bydifferentmechanisms,haveastheirfinalobjectivethedecreaseof spots andmelasma on skin acting by differentmechanismsas: promoting the degradation of superficial melanin on skin(peelings effect); inhibition of melanin production on skin bytyrosinase enzyme (melanogenese modulation); destruction ofmelanocytesbyautophagymechanisms;andalsointerferingon

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using minimally invasive professional aesthetic treatments, ie,thosethathavemodulationoftheinflammatoryresponseaswellastheuseoftopicalandoralhomecarecosmeticproductssuchasnutraceuticals[3,16-18].

Therapyofphotobiomodulation(PBM)isthebesttechnicaltermforLowLevelLaserTherapy(LLLT).ItisalighttherapyusinglasersorLEDsto improvetissuerepair, reducepainand inflammationinthemostfrequentlyapplications.Manyclinicalstudiesonpainwith Photobiomodulation applications have been published.Photobiomodulation has been used for many years on sportsinjuries, arthritic joints, neuropathic pain syndromes, back andneck pain. Nowadays the photobiomodulation in dermatologyis increasing since thatPBMaccelerates thehealingofwounds(traumatic,surgical,acute,andchronic)aswellascanbeusefuloncutaneouswoundsandacceleratinghealingafteraggressiveaesthetic treatments (high power laser therapy and chemicalpeels procedures). also the pbm has a lot of application onaestheticanddermatologicalapproachforagingtreatment,acne,spots,alopeciaandotherapplications[6,18,19].

Low level light professional therapy using lasers and LEDs forprofessional uses can be useful to practitioners to performingvariousskintreatmentsforaestheticanddermatologicalpurposes[5,6,18-20].

In our previous paper we defined photodynamic cosmetictherapy (PDT) as amixture between Phototherapy (now calledPhotobiomodulation Therapy) and Photodynamic Therapybehaviorsincethatuseslowpowerlightradiation(mW)andlow-mediumlightirradiationdoseorfluences(J/cm2)inthepresenceofphotoactives[3,18,21].

Also we defined photocosmetic as products that presentchromophores photostable on its formulations capable toinducephotophysicalandphotochemicalmechanismtopromotephotobiologicaleffectsonthetissue[18,21].Thephotocosmeticproduct contains photoactivated actives associated with othercosmetic components on formulation depending on cosmeticgoal[3,18,21].

PhotoactivatedPeels,ontheotherhand,isdefinedasacosmeticcompositioncontendchemicalpeels(suchasglycolicacid,salicylicacid, lacticacid,mandelicacid) in lowconcentrations (cosmeticproposes)associatedwithactivesthat increase lightabsorptionintheskincalledasphotoactives,promotethePeelingeffectinacontrolledmannerwithoutdistancingpatient’sfromprofessionalandsociallife[3,18,21].Thisphotoactivesusedasmethyleneblue(absorbslighton630nm-redregion),curcumin(whichabsorbslighton450nm–blueregion),hypericin(whichabsorbslightintheregionof590nm-yellow/amber-region)increasethelightinteractionof skin.Othersphotoactivesorphotosensitizers canbefoundontheliteratureonPhotodynamicTherapyapplicationsoncanceranddermatologyskindiseases[3,18,21].

Finally,thePhotoactivatedPeelscanbedefinedaslessaggressiveandnon-invasivecosmetic formulations,andcanbeperformedby non-medical aesthetic professionals with safe and effectiveresults.Chemicalpeelsassociatedwithvisiblelightonprocedurecanbeappliedalsowithsafety[18].

transportationofmelaninfrommelanosomestokeratinocytes.

In this sense, some depigmenting cosmetics actives, even bydifferentmechanisms,haveastheirfinalobjectivethedecreaseofspotsandmelasmaonskinactingbydifferentmechanismsas:degradation of superficial melanin (peelings effect), inhibitionof the melanin production through melanogenesis pathwayscontrol (tyrosinase enzyme activity inhibition), destructionof the melanocytes by autophagy mechanism; decreasingof the melanin granules transportation from melanocytes tokeratinocytes,reductionofproinflammatoryeffects(antioxidantagents),decreasesofthenumberofvesselsonskinandfinallybyhormonalmodulationofestradiolhormone[1,9-11].

Professionalproceduresformelasmatreatmentaresummarizedas: chemical (acid) peels, mechanical (abrasive) peels, electricpeels, High-power laser therapy, intense pulsed light (IPL)andmore recently the Low-level light therapy, using laser andLEDs, both therapies associated with professional and homecare cosmetics [5,6]. Chemical peels act by accelerating therenewal of cells on surface and deep layers of the skin. HighPower Laser Therapy and intensepulsed light acts by selectivephotothermolysismechanism.Mainly Chemical peels and HighPowerLaserTherapyarewidelyusedinclinicalpractice,buthaveahighrateofreboundpigmentationeffectastheyleadtopostinflammatory hyperpigmentation (HPI) common to extremelysensitiveskinwithmelasma[3,11-13].

Inadealwiththeliteraturethereareagreatnumberofcosmeticsactives (topical and oral) that acts onmelanogenesis pathwayscontrol. The best topical cosmetic actives found to melasmatreatment can be described as: vitamin C, alpha arbutin,arbutin, kojic dipalmitate, kojic acid, curcumin, resveratrol,epidermalgrowthfactor,fibroblastgrowthfactor,TGP-2,retinolmicrospheres (cosmetic retinol like),mandelic acid, tranexamicacid,niacinamide,Hexylresorcinol,arbutin,belides,alphaarbutin,ferulicacid,phyticacid,prodizia,amongothers[14-17].

Oneofthelatesttechnologicaldevelopmentsintopicalmelasmatreatment is the cysteamine active. Cysteamine is a reducingmolecule,endogenousantioxidant,andthismolecule isabletoactontheenzymesresponsiblefortheformationofmelaninbymodulatingmelanogenesis.TyrosinaseandperoxidasesequesterironandcopperdoesnotletthefreeH202pre-radicalreactwithiron and form the Fenton reaction, a reactive oxygen speciesgenerator that stimulates the entire melanogenesis pathway[14,15].

For oral cosmeticdefined as nutraceuticalswe summarized as:Pycnogenol,hydroxytyrosol,polypodiumleucotomos,resveratrol,panaxginseng,nicotinamide,vitaminc,curcumin,panaxginseng,greentea,zincchelate,melatonin,tranexamicacid,amongothers[16-18].

Themost common strategies onmelasmaManagement are tomodulateinflammation,vascularizationthat"nourish"melasma,formationandtransferofmelaninformedintheskinaswellascosmetic-likehormonalmodulation.Forthistooccursafelyandeffectively the combination of low power light with laser andLEDsisnecessary.Managementofmelasmashouldbeperformed

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with age from 30 to 40 years old, healthy (without anyconcomitant disease), skin phototype III and IV,withmelasmaonface,characterizedbyelevatedpigmentation.Thevolunteerswereclarifiedaboutthestudyandreadandsignedtheinformedconsent, authorizing the accomplishment of the procedures.The patients report years of problems with many tries withconventionaltherapywithoutsatisfactoryresults.

Melan Redux Program - Melasma managementThemelanreduxxprogram;onmelasmamanagementispossibleby associating different treatment strategies as: professionalproceduresonclinicalusinglowlevellightprofessionaltherapy,withlaserandLEDs,indifferentvisiblelightwavelengthsinthepresence of chemical and photoactivated peels (professionalcosmeticsproducts)aswellashomecareproceduresusingtopicalandoralcosmeticsproducts.Themanagementofmelasmacanbe realized from3 to4monthsuntil5months,decreasing theskinpigmentationgradually.

The professional treatment using chemical and photoactivatedpeels is proposed tobeperformed from5 to 15 sessionswithintervalsfromfifteentothirtydaysentersessions.Howeverthespots on skin beginning decreasewith onemonth aftermelanreduxxprograminitiation.Thisprogramcanbeusedonepidermal

Managing melasma with light consists of applying differentlaser/LED wavelengths (colors) acting on all signalingpathways of melanin formation in the skin. Then Amber ledlight acts: stimulating the degradation on superficial to deepmelanin on skin; stimulate melanin autophagy; generate localvasoconstrictiondecreasedvascularization;aswellasmodulatingthe inflammatory process; main responsible for the “reboundeffect”;increasesofspotsaftertreatment[22-27].

AlsotheRedlightdecreasethemelanogenesisprocesssincethatdecreasesthetyrosinaseenzymeactivityaswellascontributestomodulatingtheagingondermis, inducedbysun(photoagedskin), that have impaction on several inflammatory mediatorssuchasendothelin-1,stemcell factor,c-kit,GM-CSF, iNOS,andVEGF,besideshavingagreaternumberofinflammatorycellsandvessels, have been described asmore highly expressed in skinwithmelasma,whencomparedtonormaladjacentskin.Theredlighthasagreaterinfluenceondermisstructurationstimulatingproliferation of fibroblast that increases collagen and otherproteins on dermis layers modulating also the inflammatoryresponseofdamagedskin[28-30].

BlueLEDlightinlowfluencesactsalsodecreasingthepigmentationbydifferentmechanismas:inhibitsmelaninsynthesis,promotingdegradation on superficial melanin and also improves of thehydrationofskinoptimizingthereversionofagingonskin[31,32].Theinfraredlightactsmodulatingalsodeinflammatoryresponsecorroborating to melasma treatment. The Microneedlingtechniqueisapromisingtechniquefortransdermaldrugdeliveryand on melasma treatment acts optimizing the permeationof cosmeticactivesonskinandalso improves the liberationofgrowthfactorsdecreasingtheagingprocess[33].

The aimof this study is to demonstrate that themanagementofmelasmaproposed in themelan reduxxprogram ispossibleby associating different treatment strategies as: (1) applicationof Low level light professional therapy, using laser or LED, ondifferent visible light wavelengths, (2) professional cosmetics,including chemical and photoactived peels and (3) topical andoralcosmetics(nutraceuticals)forhomecareaplications.So,itis possible toperform thePhotodynamicCosmeticTherapyonmelasma treatment using chemical and photoactived peels onaesthetical procedures with safety and effectivity associatingvisiblelightandalotofcosmetology.

Materials and Methods EquipmentThe laser and LED light treatmentwas done using commercialequipment called Venus (MM Optics - São Carlos-Brazil). Theequipmentshowsredandinfraredlaserlighton630nmand850nmrespectivelyandblueandAmbarLEDlighton450nmand590nm.InFigure 1theirradiationprocedureatskincanbeobservedusingdifferentwavelengthsandintheFigure 2wecanobservethemelasmadiagnosis.

Volunteers Thecasereportformelasmawascarriedwithfemalevolunteers

Figure 1 Photobiomodulationprofessional sessiononMelasmamanagement. The equipment used on study is calledVenus(MMOptics–SãoCarlos-Brazil).

Figure 2 MelasmadiagnosisusingcommercialequipmentcalledEVINCE(MMOptics–SãoCarlos-Brazil).

called Venus (MMOp�cs – São Carlos- Brazil).

A B

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and dermal melasma. In case of dermal melasma is possibleto associate collagen biostimulation technics invasive (PDOTHREADS, calcium hydroxyapatite, Poly-L-lactic acid (Sculptra)and non-invasive (microneedling, deep and medium peelings)associatedtomelanreduxxprogram.

Melasma resistant in most of case with hormonal causes andmelasma resistant to hydroquinone must be evaluated inrelationtogoodprofessionalpractice.onfirstcaseisimportanttoevaluate theestrogen inhormonalexamesandperformthehormonalmodulationwithnutraceuticalsasmelatonin,chrysinandothers. and in the secondcase trying toworkwith topicalcysteamine(epidermalmelasma)andtopicalandoralcosmeticsformulations(nutraceutical)withelevatedantioxidantproposal.

Itisimportanttomentionthathormonalfluctuations,excessivesolar radiation, photosensitizing medications can lead toincreasedskinpigmentation.Andeachcaseshouldbediscussedwith the aesthetic health professional to evaluate the beststrategiesthatminimizethereboundeffectofpigmentationonmelasma[14,17].

The melan reduxx program can be carried out for 3 until 5months throughout the year with annual maintenance or asneeded. However topical and oral cosmetics should be keptundercontinuoususe;sincethesearenutraceuticalsthataimtomodulateantioxidantstressduetoexternalfactors(UVradiationamongothers),inflammationaswellasexcessivevascularizationof the skin and the hormonal factors present (estrogenmodulationduetodifferentcauseswithherbalmedicines).Themelan reduxx program can be performed inmen and womenwhohavemelasmabothepidermalanddermalmelasma.

Melan Reduxx Program - Professional procedureThemelanreduxxprograminvolvestheapplicationofchemicaland photoactiveated peels and application of low level lightprofessional therapy using amber LED (25 J/cm2) and infraredlaser light (5 J/cm2) associated on irradiation procedure (totaldose= 30 J/cm2). The applicationof bothwavelengths at sametime is useful modulating mainly the inflammatory response[34].NotforgettingthebenefitsofamberLEDlightondecreaseofvascularizationanddegradationofmelanin.

Onmelanreduxprocedurefirstlytoopenskinwecanusetoolsas microneedling and chemical peels. This first step (FASE 1)increase the permeation of the photoactivated peels thoughtskinonFASE2.

Onthesecondstep(FASE2)thephotoactivatedpeel,commercialprofessionalcosmeticcalledmelanreduxxpeel(PriscilaMenezescompany–Araras-Brazil)wasappliedonskinandimmediatelyafter;startedthelightirradiationprocedure,usinglaserandLED,atskin.

ThemelanreduxxPeelcosmetic(photoactivatedpeel)presentsonitscompositionablendofAHAs(mandelicacid,lactic,glycolicacid)andBHAs(salicylicacid)atlowconcentrations,photoactives(chromophores)ashypericin(0.5-1%),methyleneblue(0.05-1%)andcurcumin(0.5-1.5%),thatabsorbsamber,redandbluelightrespectively,associatedwithtranexamicacid(2-8%)andothers

principalactivesthatactsondepigmentingskinasarbutin,alphaarbutin,kojicacid,resveratrol,vitaminc,dipalmitate,kojicacid,niacinamide, Hexylresorcinol, belides, ferulic acid, phytic acid,prodiziaandothers.

Afterirradiationprocedurethephotoactivatedpeelwasremovedfromskinandathirdcosmeticproduct, in the formofamask,was added at skin. Thismask contains a blend of actives andcosmeticretinol.Thismaskmustremainontheskinuntil8hoursonskin.Alltheseproductsareusedintheprofessionalprocedureonclinical[14-17].

Oral and topical home care cosmetic productsFor topical cosmeticproposalsof themelan reduxprogramonhomecaremelasmamanagement;wedevelopmentcommercialcosmeticsproducts (PriscilaMenezescompany–Araras-Brazil)and them can be described as nutri skin Advanced cream(anti-aging cream), melan clean cream (depigmenting cream),Irradianceeyes cream (depigmenting creamofeyes) andhidrabalanceAdvancedcream(Highmoisturizingandinertcream).Themelasmacosmetickit(PriscilaMenezescompany–Araras-Brazil)proposedherecontainsthefollowcreams:nutriskinadvanced,melan clean and hidra balance advanced. the application ofproductsmustbedone in the follow sequence;1)onmorningmustbeappliedonskinfirstlynutriskinadvancedcreamonfaceandafteronesunscreenand2)atnightmustbeappliedonskinfirstlythemelancleancreamonallface.thetopicalcommercialformulationscontainstheprincipalcosmeticactivesasmentionedbefore,thatactsonmelanogenesispathwayscontrolaswellason aging process, on hydration and restoring the skin barrier(protectionofskin)[15,17].oneanothernocturnalformulationcontaining acid can be prescribed to be added after melancleancreamonlyoverspots.Thisformulationcanbesimilartokligmanformulationcontainingretinoicacid,hydrocortisoneandactives as kojic acid,mandelic acid and arbutin in theplaceofhydroquinone.

Theoralcosmeticsubstancesusedonmelanreduxxprogramcanbedescribedas :Picnogenol (50-100mg),hydroxytyrosol (100-300mg),polypodiumleucotomos(100-200mg),resveratrol(20-100mg),panaxginseng(50-200mg),nicotinamide(50-200mg),vitaminC(50-200mg),curcumin(50-250mg),greentea(50-200mg), zinc chelate (10-50mg), chrysin (100-500mg), bioperine(5-10mg)amongothers.Alsomelatonin (medicalprescription:3-10mg)andoraltranexamicacidforpatientswithoutthromboproblems (medical prescription 250 mg) can be prescribed bydoctors[3,16,17].

Both topical and oral cosmetic products on Themelan reduxxprogram has intention to controlling skin pigmentation bydifferent strategies and modulating the inflammatory processavoiding the rebound effect due to hyperpigmentation posinflammatorysocommononmelasmatreatment.

DiscussionIn Figure 1lightapplicationonskinusinglaserandLEDssystemsondifferentwavelengthswasperformedonmelasmapatient.

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In Figure 2themelasmadiagnosisisperformedusingequipmentcalled Evince. The evince equipment has violet visible light on405 nm (visible light wavelength) differently fromwood lamp,which presents black light (ultraviolet light wavelength) whichisadisadvantage;canbeusefulondiagnosisofepidermalanddermalmelasma.

ThevolunteerinFigure 3wassubmittedtophotobiomodulationprofessional session using only amber LED light associated toinfraredlaserlightonlyinasideofface(leftside).AswecanseethePBMproceduredecreasesthepigmentationonskin(C-D).

TheirradiationwithamberLEDlightdecreasesthepigmentationonskinsincethatdecreasestheinflammationandvascularizationof skin aswell as increases thedegradationofmelanin at skin[27,35-38].Howeverisimportanttomentionthatmanyauthorsmentionaboutthephotooxidationeffectsofmelaninonskinbyvisible light increasing either oxygen reactive species than skinpigmentation[35-38].

In case after visible light irradiation procedure the skinpigmentation decreases by bleaching from amber LED light(visible light). But themelanin production after oneweek canbe increased as protection mechanism [37,38]. Knowing this,the application of ideal home care after the melan reduxxprogramprocedureisveryimportantavoidingthemelanogeneseactivationandasconsequenceincreaseofskinpigmentation.InthiswayinourstudiesweassociateamberLEDlighttoinfraredlaserlightmodulatingtheinflammatoryresponse.

The association of the infrared laser light to amber Led lighton irradiation procedure; avoids the post inflammatoryhyperpigmentation after procedure; since that amber led lightdegradedthemelaninonskinandwhenassociatedwithinfraredlight; the modulation of inflammation occurs avoiding thefeedback negative In the Figure 4 both patients used only thecosmetichomecareduring90daysof treatment.HoweverthePatientonFigures 4A and 4Busedtopical(MelasmaKit-PriscilaMenezes Company – Araras- Brazil) and oral (nutraceuticals)homecare cosmetics.OnFigures 4C and 4D thepatientsusedonlytopical(MelasmaKit-PriscilaMenezesCompany–Araras-Brazil)homecarecosmetics.Aswecanseethetreatmentusingonly home care cosmetic products show good results on skindepigmentation. But the association between oral and topicalcosmeticsonhomecareapplications;improvetheresultsonskinagingandonpigmentationcontrol(Figures 4A and 4B).

In Figure 5 thepatientwassubmittedtoonesessionofMelanReduxx procedure using laser and LEDs in the presence ofchemical and photoactivated peels (PriscilaMenezes company– Araras- Brazil) associatedwith topical home care cosmetics(MelasmaKit-PriscilaMenezescompany–Araras-Brazil)around90 days of treatment. This patient was diagnosticated withdermalmelasmaby equipment EVINCE (MMOptics-SaoCarlos-Brasil)andthehormonaldysfunctionsinfluenceswasevaluatedontheanamnesisform.Theresultsshowsthatthepigmentationofskindecreasesveryslowly,butforonlyonetreatmentsession,usingonlythetopicalhomecarecosmeticsaround90days,theresultswereexcellent.

Already on Figures 6, 7 and 8 the Patient was submitted tofour session ofmelan reduxx procedure using laser and LEDsin the presence of chemical and photoactivated peels (PriscilaMenezes company – Araras- Brazil), associated with topical(MelasmaKit - PriscilaMenezes company–Araras- Brazil) andoral (nutraceuticals) home care cosmetics treatment. Thetreatmentwasdoneonfoursessionswithanintervalfrom15to30daysbetweenthesessions(from3to5monthsofcompletetreatment).

Figure 3 Patient submitted to one Photobiomodulationprofessional session using only amber LED lightassociatedto infrared laser lightonly inasideof face(left side). The fluency applied on skin was 30J/cm2.Beforetreatment(A-B)andaftertreatment(C-D).

Figure 4 Patient submitted to topical and oral home carecosmetics. Patient on Figure 4A and 4B used topical(Melasma Kit - Priscila Menezes company – Araras-Brazil) andoral (nutraceuticals) home care cosmetics.OnFigures4Cand4Dthepatientsusedonlythetopical(Melasma Kit - Priscila Menezes company – Araras -Brazil) home care cosmetics. Before treatment (A-C)andaftertreatment(B-D).

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Figure 5 Patientwassubmittedtoonesessionofmelanreduxxprocedure using laser and LEDs in the presence ofchemical and photoactivated peels (Priscila Menezescompany–Araras-Brazil)associatedwithtopicalhomecarecosmetics(MelasmaKit-PriscilaMenezescompany–Araras-Brazil).Thefluencyappliedonskinwas30J/cm2.Beforetreatment(A-C)andaftertreatment(B-D).

Figure 6 Patientwassubmittedtofoursessionsofmelanreduxxprocedure using laser and LEDs in the presence ofchemical and photoactivated peels (Priscila Menezescompany – Araras- Brazil) associated with topical(Melasma Kit - Priscila Menezes company – Araras-Brazil) and oral (nutraceuticals) home care cosmeticstreatment. The four sessions were performed withan interval of 15 days between sessions. The fluencyapplied on skin was 30J/cm2 using amber LED lightassociatedtoinfraredlaserlight.Beforetreatment(A)andaftertreatment(B).

InadealwithresultspresentedonmelasmamanagementwhenweappliedonlylightirradiationusingLEDandLASERonprocedure

Figure 7 Patientwassubmittedtofoursessionsofmelanreduxxprocedure using laser and LEDs in the presence ofchemical and photoactivated peels (Priscila Menezescompany – Araras- Brazil) associated with topical(Melasma Kit - Priscila Menezes company – Araras-Brazil) and oral home care cosmetics treatment. Thefour sessions were performed with an interval of 15daysbetweensessions.Thefluencyappliedonskinwas30J/cm2 using amber LED light associated to infraredlaserlight.Beforetreatment(A)andaftertreatment(B).

Figure 8 Patientwassubmittedtofoursessionsofmelanreduxxprocedure using laser and LEDs in the presence ofchemical and photoactivated peels (Priscila Menezescompany – Araras- Brazil) associated with topical(Melasma Kit - Priscila Menezes company – Araras-Brazil) and oral (nutraceuticals) home care cosmeticstreatment. The four sessions were performed withan interval of 15 days between sessions. The fluencyappliedonskin.

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(Figure 3),onlyhomecarecosmeticsproducts(Figure 4)aswellasjustoneprofessionalsessionevenassociatedwithhomecarecosmetology (Figure 5) thedepigmentationofmelasmaoccursslowlywhencomparedwithalltheresultsshowedontheFigures 6, 7 and 8wherethemelanreduxxprogramwasperformed.Itisimportanttoemphasizethatthemelanreduxprogrammustbeperformed considering at least 5 sessionofprocedureuntil 10or15 session tokeeping thepigmentationonmelasmaat skinundercontrol.Wealsohighlightthatthereisagreatimportanceofmaintaininghomecaretreatmentaftertreatmentintheclinicsothattheresultsarelongerlasting.

Conclusion In agreement with the results it is possible to perform thephotodynamic cosmetic therapy on melasma management

proposedhereinthemelanreduxxprogramassociatingdifferenttreatmentstrategiesas:applicationoflowlevellightprofessionaltherapyusinglaserorLEDlight,indifferentvisiblewavelengths,professional cosmetics, including chemical and photoactivedpeelsandtopicalandoral(nutraceuticals)homecarecosmetics.Wealsohighlightthatthereisagreatimportanceofmaintaininghome care treatment after treatment in the clinic so that theresultsarelongerlasting.

Disclosure StatementTheauthorsinformthatthereisnotconflictofinterest.

AcknowledgementsThe authors would like to thanks to FAPESP for the financialsupportforthisresearch.

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