The efficacy of energy-based devices combination therapy for melasma

Melasma is a recalcitrant pigmentary disease with a complex pathogenesis. Monotherapy often results in unsatisfactory results with high recurrence rate. In this review article, we evaluate efficacy of energy-based devices combination therapy for melasma. We reviewed published literature since 2010 up to November 2020 regarding adjuvant therapy of energy-based devices with other treatment modalities in the treatment of melasma. After final selection, we assessed 49 articles. Energy-based devices include lasers, non-coherent lights, radiofrequency, iontophoresis, sonophoresis, microneedling, and microdermabrasion. Adjuvant therapies other than energy-based devices were lightening agents, chemical peels, platelet rich plasma (PRP) and mesotherapy. Combination of Q-switched neodymium-doped: yttrium, aluminum, and garnet (QSNY) with either intense pulsed light therapy (IPL) or pulsed-dye laser (PDL) are recommended in recalcitrant melasma in patients with light skin photo types and with dilated skin vessels (especially with PDL). Combination of fractional microneedling radiofrequency or microneedling with QSNY leads to promising results and is a safe treatment modality, especially in darker skin types. Application of topical lightening agents in combination with laser therapy leads to higher efficacy with less adverse effects (post-inflammatory hyperpigmentation) and rebound of melasma. Combination of ablative techniques with QSNY is not recommended, due to the high risk of permanent adverse effects such as guttate hypopigmentation and exacerbation of melasma.