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Original Contribution

Beneficial effects of spraying low mineral content thermal spring water after fractional photothermolysis in patients with dermal melasma D Barolet, MD,1,2 I Lussier, PhD,1 S Mery, PharmD,3 & C Merial-Kieny, PhD3 1

RoseLab Skin Optics Research Laboratory, Montreal, QC, Canada Department of Medicine, McGill University, Montreal, QC, Canada 3 Laboratoires Dermatologiques Ave`ne, Lavaur, France 2

Summary

Introduction Melasma is a common dermatological skin disease that can now be treated by fractional photothermolysis (fractional resurfacing). Past studies have shown that thermal spring water (TSW) spray can reduce local inflammatory symptoms after dermatological surgery, laser surgery or chemical peelings. The aim of this study was to evaluate the clinical efficacy and safety of spraying TSW post-fractional resurfacing treatment in patients with dermal melasma. Methods Twenty patients with bilateral dermal melasma were included in this split-face comparative study. Patients were treated by fractional resurfacing laser and then TSW was sprayed generously unilaterally. For the next 48 h, patients were instructed to spray thermal water at least six times a day on one side. Patient’s self-assessment conducted 10 min and 2 days after TSW spraying (stinging, pain, skin dryness, swelling, and redness) and investigator’s 48-h post-treatment evaluation (purpura, skin dryness, erythema, swelling, scars, hyper- or hypopigmentation) were recorded for the treated and control sides using visual analogue scales. Results Pain, dryness, and redness were significantly lower 10 min after spraying on the TSW-treated side in comparison with the untreated side, as assessed by the patients (P < 0.05). Two days after fractional resurfacing, dryness and redness were still improved on the TSW-treated side. The investigator’s evaluation revealed that erythema, the only perceivable sign following irradiation, was significantly reduced by TSW spraying (P < 0.01). Conclusion This split-face comparative study conducted in patients with dermal melasma showed that spraying TSW after fractional laser resurfacing significantly reduced shortterm adverse effects associated with the procedure. Keywords: fractional resurfacing, side effects, spring water, melasma

Introduction Correspondence: Daniel Barolet, MD, RoseLab Skin Optics Research Laboratory, 3333 Graham Blvd (suite 206), Mont-Royal, QC, Canada H3R 3L5. E-mail: [email protected] Accepted for publication November 23, 2008

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Melasma (also known as chloasma or mask of pregnancy) is a common dermatological skin disease.1 It is an acquired hypermelanosis of sun-exposed areas. Melasma is much more common in women than in men. While causes of melasma are unknown, risk factors are well

2009 Wiley Periodicals, Inc. • Journal of Cosmetic Dermatology, 8, 114–118

Benefit of TSW spray after fractional laser

identified. They include sun exposure, hormonal disturbances, genetic predisposition and phototoxic drugs. Different treatment options are currently available for treating melasma.2 Topical agents remain the first-line treatment for epidermal and mixed type of melasma.3 However, despite the large number of depigmenting agents, the treatment of such hypermelanosis is often unsuccessful. For refractory lesions, fractional photothermolysis represents a new therapeutic option.4 The efficacy of fractional laser resurfacing in treating melasma has been reported by several authors.5,6 This technique involves the use of an infrared laser (1450 or 1540 nm) to create microcolumns of thermal injury surrounded by uninjured tissue. These columns of thermal injury are called microscopic treatment zones (MTZs). The density of MTZs may vary for a given energy level. Zones of collagen denaturation in the dermis cause upregulation of the inflammatory cascade, which leads to collagen remodelling and new collagen formation. The treatment by itself is not very painful. Reported side effects are sunburn-like erythema that last 1–3 days, skin discomfort, and swelling. Several comparative clinical studies have shown that the use of a particular thermal spring water (TSW) after superficial procedures such as photodynamic therapy,7 and more aggressive laser resurfacing and medium ⁄ deep chemical peel procedures, decreases inflammation, reduces irritation, and improves patient discomfort. The therapeutic properties of the water involve the reduction in sensitivity of cells thereby reducing the reactivity threshold.8 It also exhibits anti-inflammatory properties by modulation of the body’s natural immune defense mechanism. This water has indeed an inhibiting activity on basophil degranulation, as well as antiinflammatory properties in the sodium lauryl sulfate model.9,10 The aim of this study was to evaluate the clinical efficacy and safety of spraying TSW after fractional resurfacing treatment in reducing post-laser short-term side effects in patients with dermal melasma.

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active infection, immunosuppression, coagulation problem, peripheral arterial disease, hematologic abnormalities, vasculitis and history of epilepsy), and current use of cortisone or anticoagulant therapy or drugs known to cause photo-sensitivity reactions. In addition, during the 12 months preceding the study, subjects could not have taken isotretinoin. The use of corticosteroids on the face within 2 weeks of the first treatment and topical tretinoin for at least 1 month prior to enrollment were also disallowed. Study design

This was a split-face comparative study. The fractional laser was performed on the full face with one side randomly assigned for TSW spraying (Ave`ne Thermal Spring Water; Laboratoires Dermatologiques Ave`ne), and the other, as the control side by the investigator (T0). No anesthetic method was used prior to the treatment by fractional laser (Starlux 500 Platform; Palomar Inc., Burlington, MA, USA). Using a 10-mm lens, 20 mJ energy was delivered for 15 ms (per pulse) with two consecutive passes performed on the melasma lesions on both sides of the face. The treatment lasted about 30 min. Immediately after the laser treatment (T1), the TSW was sprayed generously unilaterally, at a rate of 10 s spray per min for 10 min. Ten minutes later (T2), after removing excess water at the surface, a topical moisturizer (Cre`me pour Peaux Intole´rantes, or CPI; Laboratoires Dermatologiques Ave`ne, Lavaur, France) was applied. Before returning home, subjects were instructed on posttreatment, which included topical skin care continuation sun avoidance and the use of sun protection. For the next 2 days, patients were instructed to apply only a standardized moisturizing cream on one side (control side) and the standardized cream and TSW spraying on the other side (treated side). The experimental group had to spray TSW at least six times a day. Patient’s self-assessment

Materials and methods Patients

Twenty patients with bilateral dermal melasma were included in this IRB-approved study with relevant informed consent. Inclusion criteria comprised healthy subjects aged ‡30 years with bilateral dermal melasma diagnosed by a Wood’s lamp and a minimal surface area to be treated (more than 5 cm2). Exclusion criteria included phototype ‡V, pregnancy, known diseases (vitiligo, psoriasis, severe eczema, poor skin healing,


Thermal spring water efficacy was assessed by means of evaluating side effects (stinging, pain, skin dryness, swelling, and redness) using the Visual Analogue Scale (0–10 cm). The evaluation was performed 10 min after spraying the TSW (T2) and 2 days post-treatment (T4) for both sides of the face. Investigator’s evaluation

Objective clinical signs (purpura, skin dryness, erythema, swelling, scars, hyper- or hypopigmentation) on

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both sides of the face were rated by the investigator before the first spraying (T1) and 2 days post-treatment (T4) using a Visual Analogue Scale (0–10 cm). Dermaspectrometer (Cortex Technology, Hadsund, Danemark) measurements were performed for erythema and melanin indexes at T0, T1, T2, and T4. Patient satisfaction

The subjects were asked to rate their satisfaction level of the TSW 24 h (T3) and 48 h (T4) after treatment and prior to the clinic visit. Improved comfort, tolerance, ease of use ⁄ comfort, global appreciation, and improvement in appearance were assessed using a five-point scale (1 = not satisfied; 2 = little satisfaction; 3 = somewhat satisfied; 4 = satisfied; 5 = very satisfied).

those on the untreated side, as assessed by the patients (P < 0.05; Figure 1). Two days after fractional resurfacing, dryness and redness were still improved on the TSW-treated side (P < 0.05). There were no differences between sides for stinging and swelling at T2 and T4. The investigator’s evaluation revealed that erythema, the only perceivable sign following irradiation, was significantly reduced by TSW spraying (P < 0.01). Furthermore, the erythema index measured with a dermaspectrometer at T2 showed significantly less redness (P < 0.05) on the TSW-treated side vs. the control side (Figure 2). Melanin index was essentially the same on both sides. TSW was deemed acceptable by patients at T3 and T4 (Figure 3). Overall, TSW applications were highly tolerated.

Discussion Thermal spring water

Ave`ne TSW is a low mineral content water (dry residue close to 207 mg ⁄ L). It is clear, limpid, and odorless, with a pH of 7.5. This water also contains bicarbonates and presents a stable ratio of calcium and magnesium content (2 ⁄ 1 in mg ⁄ L). Statistical analysis

Data sets were analyzed with paired one-tailed t-tests. Results were considered statistically significant at an alpha level of 0.05.

Results Patient’s self-assessment values for pain, dryness and redness were significantly lower 10 min (T2) after spraying on the TSW-treated side in comparison with

Fractional laser photothermolysis has been recently introduced as a new concept in dermatological laser medicine. It has been used to treat a variety of skin conditions including dyschromia, lentigines, wrinkles, melasma, and acne scars with minimal downtime.11 Fractional laser is described as a thermal procedure. The treatment by itself is not very painful. However, in the minutes following this procedure, it can produce acute skin discomfort, as laser energy (heat diffusion) accumulates in the skin. Post-treatment erythema and swelling are usually seen consequent to such thermal heat diffusion. In the present study, we observed a significant reduction in pain, cutaneous dryness, and redness ⁄ erythema in the TSW-treated side of the face following fractional laser irradiation. These results are in line with previous studies showing the soothing and anti-irritant properties of TSW in various skin conditions such as

Figure 1 Patient’s self-assessment of side effects for the treated and control sides as a function of post-treatment assessment times (T2: 10 min; T4: 48 h).

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Figure 2 A typical patient 10 min (T2) after fractional photothermolysis showing significantly less erythema on the thermal spring watertreated side.

Figure 3 Patient satisfaction of thermal spring water as a function of post-treatment assessment times (T3: 24 h; T4: 48 h).

irritation secondary to topical retinoı¨c acid, and after specific procedures like ALA-PDT.7,12,13 TSW has also been shown to decrease local skin temperature, as measured by thermography after vascular laser treatment in patients suffering from rosacea.14 This decrease in skin temperature correlated with the soothing effect of the water reflected by a significant improvement in erythema, pain, and burning sensations. These effects are believed to be associated with the low mineral content of this water. A sensory analysis has revealed that global parameters of skin comfort depend on the mineral concentrations.15,16 The lower the mineral content, the greater is the patient comfort sensation. The hypothesis is that low mineral content water tends to spread to a lesser extent over the skin surface and evaporates slowly, resulting in less


stinging sensation with increased suppleness and softness.16 Overall, this split-face comparative study conducted in patients with dermal melasma showed that spraying TSW after fractional laser significantly reduced short-term adverse effects associated with the procedure. These findings support the complementary use of TSW in the treatment of patients with bilateral dermal melasma.

References 1 Nicolaidou E, Antoniou C, Katsambas AD. Origin, clinical presentation, and diagnosis of facial hypermelanoses. Dermatol Clin 2007; 25: 321–6. 2 Rigopoulos D, Gregoriou S, Katsambas A. Hyperpigmentation and melasma. J Cosmet Dermatol 2007; 6: 195–202.

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3 Lynde CB, Kraft JN, Lynde CW. Topical treatments for melasma and post-inflammatory hyperpigmentation. Skin Therapy Lett 2006; 11: 1–6. 4 Rahman Z, Alam M, Dover JS. Fractional Laser treatment for pigmentation and texture improvement. Skin Therapy Lett 2006; 11: 7–11. 5 Tannous ZS, Astner S. Utilizing fractional resurfacing in the treatment of therapy-resistant melasma. J Cosmet Laser Ther 2005; 7: 39–43. 6 Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional photothermolysis: a pilot study. Dermatol Surg 2005; 31: 1645–50. 7 Goldman MP, Merial-Kieny C, Nocera T, Mery S. Comparative benefit of two thermal spring waters after photodynamic therapy procedure. J Cosmet Dermatol 2007; 6: 31–5. 8 Sulimovic L, Licu D, Ledo E, Naeyaert JM, Pigatto P, Tzermias C, Vasquez Doval J, Dupuy P. Efficacy and safety of Ave`ne Thermal Spring water in the healing of facial skin after laser resurfacing. Dermatol Surg 2002; 5: 415–8. 9 Sainte-Laudy J, Sambucy JL. Inhibition of basophil degranulation by Ave`ne Spring Water. Int Immunother 1987; 4: 307–12.

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10 Sainte-Laudy J, Gall Y, Soto P. Inhibition of human basophil and rat mast cell activation by Ave`ne Spring Water. Agents Action 1993; 38: 228–30. 11 Tannous Z. Fractional resurfacing. Clin Dermatol 2007; 25: 480–6. 12 Poelman MC, Cosson C, Duval C. Sodium lauryl sulfate contact dermatitis: in vivo assessment of the anti-irritant activity of a spring water. Dermatol Prat 1993; S120: 1–4. 13 Alirezai M, Vie K, Humbert P, Valensi P, Cambon L, Dupuy P. A low-salt medial water reduces irritancy of retinoı¨c acid in facial acne. Eur J Dermatol 2000; 10: 370–2. 14 Bensafi Benouda A, Goerge J, Lagarde JM, Degouy A, Dahan S, Loche F, Schmitt AM. Evaluation of the soothing effect of Ave`ne thermal water in post laser therapy using clinical thermography. From Hippocrates to modern dermatology. 15th EADV Congress, 2006; 567–71. 15 Bacle I, Meges C, Lauze C, Mac Leod P, Dupuy P. Sensory analysis of four medical spa spring waters containing various mineral concentrations. Int J Dermatol 1999; 38: 784–6. 16 Mavon A. Ave`ne thermal spring water and skin sweetness. Oral Communication, Fourth International Academy of Cosmetic Dermatology World Congress, Paris, July 2005.
