CO2 Laser is one of the key modalities used in a multimodality approach to treating pigmentation disorders.
Jenni Nagle, L+A CO-Founder had a CO2 laser treatment and kept an eight day diary of her recovery process!
Whether caused by sun exposure, hormonal fluctuations, post-inflammatory responses, or genetic factors, pigmentation can present unique challenges in clinical practice. For estheticians and skincare professionals, addressing pigmentation involves understanding and applying a multimodality treatment approach, which combines various techniques to tackle pigmentation through multiple mechanisms. This article provides an overview of key treatment modalities, layering strategies, and the importance of collaborative care in achieving optimal results.
Dr. Krystal Briglia, L+A Medical + Wellness Editor
Dr. Krystal Briglia of Triada Integrative Medicine + Wellness is a board-certified nurse practitioner specializing in aesthetic dermatology, integrative medicine, and wellness. She has an extensive and diverse background in healthcare, with over a decade of experience working in emergency, critical care, trauma, aesthetics, healthcare administration, and healthcare education. Krystal holds multiple board certifications, including family practice, emergency, and critical care. Her educational background includes two undergraduate degrees, a degree in health sciences, and a bachelor’s degree in nursing from the University of Delaware. She holds three graduate-level degrees, including a master’s degree in nursing leadership, a master’s degree in business administration, and completed her nurse practitioner education at the University of Massachusetts. In 2016, Krystal completed her clinical doctorate in nursing practice. Dr. Briglia is an entrepreneur and specializes in organizational process improvement. She is a Lean Six Sigma master black belt, a certified Six Sigma champion, and a certified Kaizen facilitator. She also has a passion for education and spent 6 years teaching health profession graduate-level courses. During that time, she held a lead faculty position and helped the university develop a family nurse practitioner program from inception to credentialing and first graduates. Read Full Bio
Why a Multimodality Approach?
A multimodality treatment plan offers a multifaceted approach to pigmentation by targeting different layers and pathways within the skin. Research shows that combining treatments improves efficacy, reduces recurrence rates, and minimizes side effects, particularly in addressing conditions like melasma, sunspots, and post-inflammatory hyperpigmentation (Anderson & Anderson, 2020). This approach can also be adapted to other skin concerns, such as acne scarring and signs of aging, which share overlapping pathways with pigmentation.
Understanding and offering guidance on multimodal treatments—even if certain techniques are beyond the scope of an esthetician’s licensure—allows skincare professionals to be more effective patient educators and fosters collaboration with other licensed providers. Cross-collaboration is essential for delivering the most effective and comprehensive care possible.
Core Treatment Modalities for Skin Pigmentation
1. CO2 Laser and Other Laser Treatments: Ablative and Non-Ablative
Laser technology targets pigmentation by concentrating on melanin within the skin. The main types of lasers used are:
Ablative Lasers: CO2 and erbium lasers remove layers of skin, reducing pigmentation through controlled injury and subsequent skin regeneration. Ablative lasers are best suited for patients with deeper pigmentation concerns but require longer recovery times.
Non-Ablative Lasers: These lasers, including fractional lasers, target melanin without disrupting the skin’s surface, making them suitable for patients with minimal downtime preferences. Research suggests they are safer for darker skin tones when used with careful consideration of settings (Lee et al., 2020).
Non-ablative lasers are ideal for superficial pigmentation and safer across various skin types, while ablative lasers are effective for stubborn pigmentation, but may pose higher risks in darker skin.
2. Intense Pulsed Light (IPL)
While not a laser, IPL uses broad-spectrum light to treat pigmentation by targeting the chromophore melanin within the dermis. IPL is effective for sun-induced hyperpigmentation, freckles, and general photodamage in lighter skin tones (Sarkar et al., 2021). It is, however, less suitable for darker skin types due to the risk of post-inflammatory hyperpigmentation (PIH).
3. Chemical Peels: Light to Deep Depth
Chemical peels exfoliate the outer skin layers, helping reduce superficial pigmentation and improve skin texture.
Light Peels: These include alpha-hydroxy acids (AHAs) and beta-hydroxy acids (BHAs), which are effective for mild pigmentation and patients with sensitive skin.
Medium Depth Peels: Peels with trichloroacetic acid (TCA) penetrate deeper, providing a more significant exfoliation. Studies suggest that medium-depth peels can be effective for moderate hyperpigmentation, especially when used in conjunction with other modalities (Kong et al., 2022).
Deep Peels: Phenol-based or high-concentration TCA peels address severe pigmentation but require extended recovery time and increased caution for darker skin tones.
Layering chemical peels with other modalities can produce synergistic results, helping reduce pigmentation through progressive, controlled exfoliation and renewal.
4. Facial Machines and Microneedling
Devices like radiofrequency and microneedling machines enhance skin rejuvenation by stimulating collagen production, which helps with overall skin health and can indirectly support pigmentation treatments. Microneedling creates micro-injuries in the skin that encourage healing and the absorption of topical brightening agents. When combined, these techniques can improve the skin’s overall appearance and reduce pigmentation with minimal downtime (Park et al., 2020).
5. Active Ingredients in Pigmentation Therapy
In-office treatments are complemented by topical agents that help maintain results and prevent new pigmentation. Notable actives include:
Vitamin C: Known for its antioxidant properties, vitamin C helps inhibit melanin production, protecting skin from oxidative stress that can worsen pigmentation.
Kojic Acid: Derived from mushrooms, kojic acid inhibits tyrosinase, an enzyme necessary for melanin production. It is especially useful when paired with other brightening agents.
Hexylresorcinol: This gentle tyrosinase inhibitor also has antioxidant properties and can be used safely in a variety of skin types.
Tranexamic Acid: Known for its efficacy in melasma treatment, tranexamic acid works by reducing inflammation and vascular component-related pigmentation (Wu et al., 2020).
Hydroquinone: Hydroquinone remains a gold standard for melasma, but its use should be monitored to avoid potential side effects like ochronosis. It can be layered with other actives and light peels for controlled results.
These are some topical agents to enhance in-office treatments, maintaining and prolonging results through consistent home care.
Designing a Customized Home Care Regimen
A home care regimen reinforces the effects of in-office treatments and guards against new pigmentation. Products containing the active ingredients above support ongoing skin brightening and prevent melanin synthesis. Additionally, protecting the skin from UV radiation is fundamental to preventing pigmentation recurrence. Tinted sunscreens, which contain iron oxides, offer an additional layer of protection against visible light—a significant contributor to pigmentation in conditions such as melasma. Research indicates that tinted sunscreens provide superior protection for pigmentation-prone individuals, particularly those with melasma, by blocking both UV and visible light rays (Drealos et al., 2021). Home care, including sun protection, is essential in any pigmentation treatment regimen.
Layering Modalities for Optimal Results
Combining modalities allows for comprehensive pigmentation treatment. For example, a treatment plan for a patient with moderate hyperpigmentation could include a light chemical peel, followed by an IPL session, and be supported with a home care regimen containing tranexamic acid and vitamin C. When layering treatments, it’s essential to:
Consider Skin Type: Certain lasers and peels can pose risks for darker skin tones, making gentler treatments like non-ablative lasers or certain light peels more suitable.
Sequence Treatments for Safety: Estheticians can schedule less invasive treatments first and reserve higher-intensity therapies for later sessions to reduce skin sensitization.
Collaborate for Advanced Care: For modalities outside an esthetician’s scope, understanding and recommending these treatments to patients allows them to make informed decisions. Partnering with other licensed providers can facilitate a well-rounded care plan, ensuring each patient receives the most effective and tailored treatment.
Applying a Multimodality Approach Beyond Pigmentation
While pigmentation is a complex concern, the multimodality approach is equally valuable for other skin issues, such as acne scarring, rosacea, and general skin rejuvenation to name a few. For instance, combining microneedling with chemical peels and a collagen-stimulating serum regimen offers notable results for acne scars, while layering IPL with vascular lasers can significantly improve rosacea.
Conclusion
A multimodality approach to treating pigmentation empowers estheticians to provide patients with comprehensive, customized care plans that address pigmentation on multiple levels. By combining various modalities—from lasers to topicals and peels—skincare professionals can achieve improved results and greater patient satisfaction. Cross-collaboration and continuing education allow estheticians to deliver the best in patient-centered care, creating pathways for optimal outcomes in pigmentation treatment and beyond.
References
Anderson, R. R., & Parrish, J. A. (2019). New Developments in Laser Treatment for Hyperpigmentation Disorders. Journal of Dermatological Science.
Draelos, Z., et al. (2021). Benefits of iron oxide-tinted sunscreen for pigmentation-prone patients. Journal of the American Academy of Dermatology.
Farris, P. K., et al. (2021). Tranexamic Acid in Dermatology: Current Perspectives and Clinical Outcomes. Dermatologic Therapy.
Goldberg, D. J., et al. (2021). Optimizing IPL Treatment for Sun-Induced Pigmentation: An Updated Review. Aesthetic Surgery Journal.
Kong, Y., et al. (2022). Comparative Efficacy of Chemical Peels in Pigmentation Management. Dermatology Research.
Lee, S., et al. (2020). Comparing ablative and non-ablative laser treatments for skin pigmentation. Aesthetic Surgery Journal.
Rigel, D. S., & Rivers, J. K. (2022). The Role of Tinted Sunscreens in Protecting Against Visible Light-Induced Hyperpigmentation. Journal of the American Academy of Dermatology.
Rigopoulos, D., et al. (2022). The efficacy of multimodal treatments in pigmentation disorders: A clinical review. Journal of Dermatologic Therapy
Wu, D., et al. (2020). Tranexamic acid as an emerging treatment for melasma: Mechanisms and efficacy. International Journal of Dermatology.