We are very pleased to announce that we are now using our new Q-switched alexandrite laser for skin rejuvenation in our office. This laser is used to remove a wide variety of pigmented skin lesions. Sun spots, brown spots, freckles, and patchy areas on the face and body can all be removed with the "Q-switched Alex." The laser is extremely safe and highly effective. It is so easy to tolerate that the procedure does not require any numbing cream. Generally, only one or two sessions are needed to remove these skin lesions.

Because this is a non-ablative laser, no special skin care is needed after the treatment. Patients only need to take reasonable sun precautions, apply an ointment to the treated spots, and use sunscreen. There is absolutely no recovery downtime with the Q-switched alexandrite laser.

Any of our patients who have pigmented spots on their face or body that they would like to remove are invited to call our office and make an appointment with either Dr. Amerian or Dr. Anterasian.

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Many people have scars that they find unattractive. In addition, the presence of the scar may continue to remind the person of an experience from the past that was upsetting such as a cancer treatment, a traumatic injury, or a medically required surgery. Scars like these can occur on any part of the body. Other times, the scars are simply the result of an earlier childhood or teenage ailment such as acne or chicken pox.

Thanks to modern medicine, there are now many ways that scars can be cosmetically improved. In this month's newsletter, we will review the different types of scars and the methods available to improve the appearance of unfavorable or unsightly scars.

Scars come in several different types.

• Hypertrophic scars: Hypertrophic scars are raised, firm, thick, and red.
• Atrophic scars: Atrophic scars are depressions in the skin that result from the loss of collagen.
• Keloid scars: Keloid scars are raised reddish nodular scars that are quite firm and relatively large. With a keloid scar, the size of the keloid is actually larger than the size of the original surgery.
• Acne scars: Acne scars are very common. Although they may occasionally be hypertrophic or keloidal, they are usually atrophic. The most common type of atrophic acne scar is referred to as an "ice-pick" scar. Ice-pick scars are narrow with sharply demarcated tracts that can reach deep into the skin.

Options for improving the appearance of scars include the following:

• Steroid Injection – Steroid injections are often used to treat hypertrophic scars and keloid scars. With a series of steroid injections, the inflamed raised scar should flatten out and become less inflamed and less irritated. Although steroid injections may be used alone, combining steroid injection with laser treatment enhances scar treatment.
• Vbeam Laser – The Vbeam laser is an excellent choice for hypertrophic scars and keloids. In research studies, there has been significant improvement in scar redness and in reduction of bulk following Vbeam laser treatment. Generally, after three or four treatments, the scars are flatter and less red. The Vbeam laser procedure is very well tolerated, with patients only feeling a mild snapping sensation. There is no downtime after a Vbeam laser treatment.
• Fraxel Lasers – The two Fraxel lasers will improve all types of scars and they are the most commonly used lasers to improve the appearance of scars. The most common scars treated with the Fraxel lasers are atrophic acne scars and surgical scars. However, even traumatic scars resulting from injury to the skin can be improved with the Fraxel lasers. Often, Fraxel laser treatment is combined with steroid injection to provide optimum improvement of the scar.
  
  Patients undergoing Fraxel laser treatment of scars may choose between traditional Fraxel laser treatment and Fraxel Repair laser treatment. With traditional Fraxel laser treatment, patients undergo a series of 4 or 5 Fraxel laser procedures at monthly intervals, with no downtime, to improve the scar. The improvement in the scar results from the new collagen that is formed as a result of the laser treatment. This procedure is FDA approved for the treatment of acne scars and surgical scars, and it will also improve all other types of scars as well.
  
  With Fraxel Repair laser treatment, patients generally need only one or two treatments; however, depending on the size of the treated area, there may be a few days of downtime with Fraxel Repair laser treatment. The improvement in the scars following treatment with the Fraxel Repair laser results from immediate shrinkage of the scar tissue followed by new collagen growth. Like the traditional Fraxel laser, the Fraxel Repair will improve all types of scars, including acne scars, surgical scars, keloid scars, and atrophic scars.
• Surgical Scar Revision – Occasionally, a scar that healed poorly needs to be surgically removed and stitched using very precise and careful surgical technique. In properly selected patients, this will result in a much-improved scar. However, surgical scar revision is only rarely necessary, and nearly all patients can have their scars improved without surgery, using lasers and steroid injections.

Any of our patients who have a scar that they do not like are invited to call our office (1-866-811-7986) and make an appointment with either Dr. Amerian or Dr. Anterasian.

What is melasma?
Melasma is a skin condition most commonly characterized by the presence of brown irregular patches on the face of a woman. Quite often, both sides of the face are involved symmetrically, with the most common sites of involvement being the cheeks, bridge of nose, forehead, and upper lip.

Melasma is extremely common, and it affects five to six million American women annually. Over 90% of melasma cases occur in women, and it is especially common in darker skinned individuals, particularly Hispanics, Asians, and women of Middle Eastern ancestry.

What causes melasma?
Although the causes of melasma are not completely understood, several factors are known to play a role. Clearly genetics is a factor, as women with a family history of melasma are more likely to develop the condition. Also, hormonal factors play a role, as pregnancy and birth control pills may also cause melasma. In addition, sun exposure is an important contributing factor.

It is believed that melasma results from exposure to the hormones estrogen and progesterone combined with exposure to ultraviolet light from the sun. This results in an over-stimulation of the pigment producing cells in the skin, increased production of melanin pigment, and the characteristic brown patches of melasma.

How is melasma treated?
Several modalities are available to treat melasma. Melasma resulting from pregnancy frequently, but not always, disappears spontaneously over a period of several months after giving birth. If melasma develops after starting birth control pills, it may improve after discontinuing their use. However, melasma that results from the use of birth control pills usually persists even after the pills are stopped.

Melasma treatment always starts conservatively. If at all possible, it is preferable for women undergoing treatment of melasma to discontinue their use of birth control pills. Although melasma can be treated while continuing the use of birth control pills, this is not optimal.

Sunscreens, sun avoidance, and depigmenting creams are three of the mainstays of melasma treatment. The sunscreen must provide both UV-A and UV-B protection. Regardless of how melasma is treated, the treatment will fail if sunlight is not strictly avoided. Prudent measures to avoid sun exposure include hats and other forms of shade combined with the application of a broad-spectrum sunscreen. Sunscreens containing physical blockers, such as titanium dioxide and zinc oxide, are preferred over chemical blockers because of their broader protection.

Topical depigmenting creams should also be used. Hydroquinone is the most commonly used depigmenting agent; it works by decreasing the production of melanin pigment. Some physicians also add tretinoin (retinoic acid) and a steroid to the hydroquinone. The tretinoin acts by increasing cellular turnover, resulting in a quicker response to therapy. Tri-Luma cream conveniently combines hydroquinone, tretinoin, and a steroid in one medication, and is available by prescription. Other medications for melasma include azelaic acid, kojic acid, and peels containing alpha hydroxy acids such as glycolic acid.

Patients who have not responded to conservative treatment can consider laser treatment. The FDA has approved the use of the Fraxel laser for the treatment of melasma. At the Santa Monica Laser and Skincare Center, we have had good success in treating melasma by combining Fraxel laser treatment with hydroquinone, sun avoidance, and the regular use of sunscreen. Generally, an optimal result can be obtained after four or five Fraxel laser treatments given at four to six week intervals.

Melasma treatment is complex and should be managed by a dermatologist. Generally, several months of therapy are required to significantly improve melasma. Any of our patients who believe they may have melasma or who have abnormal pigmentation in their face are invited to make an appointment with Dr. Amerian.