IntroductionMelasma is the utmost common hyperpigmentation ailment in Asians, and is difficult to treat. Treatment for this mutilating condition accounts for quite 50% of aesthetic consultations in Asian countries. The pathogesis of melasma is complex and associated with genetics and hormonal factors also on photodamage. The lesions occur mainly on sun-exposed areas of the face, especially on the cheeks, forehead and upper lip. Lesions begin as a brownish asymptomatic irregular border of macules that slowly spreads out, forming brownish patches.Hyperpigmentary disorders, especially melasma and post-inflammatory hyperpigmentation (PIH), cause significant social and emotional stress to the patients. Although many treatment modalities are developed for melasma and PIH, its management still remains a challenge thanks to its recurrent and refractory nature. With the arrival of laser technology, the treatment options have increased especially for dermal or mixed melasma.Case ReportA 50-year-old Asian female with refractory dermal melasma and severe PIH received 10 weekly laser treatments combined with 7% alpha arbutin and a broad-spectrum sunscreen.The patient came with refractory melasma on the face which persisted for quite six months and had did not answer conventional treatment. Exclusion criteria included photosensitive conditions or sensitivity to hydroquinone or arbutin, treatment with laser or Intense Pulsed Light (IPL) within 1 month, and/or inability to suits the 6 month follow-up visit schedule.On the primary day of treatment, the subject’s face was thoroughly cleansed. Laser pulses were delivered perpendicular to the surface with 10% linear overlapping during a small treatment plot (approximately 3x3cm2) for 10 passes. The direction of the beam was then changed and delivered perpendicularly to the previous line of treatment for an additional 10 passes. After each small treatment plot was completed, the treatment was extended to adjacent areas to hide the whole face. Immediately after the treatment of every area the subsequent clinical endpoints were observed: 1. Lightening of epidermal hyperpigmentation 2. Whitening of fine hair 3. Grayish darkening of dermal hyperpigmented lesions 4. Perilesional erythemaShe was asked to use a topical 7% alpha arbutin solution twice daily with a broad-spectrum sunscreen of SPF 50 and PFA +++ after treatment. She was also advised to avoid sunlight. After completion of the primary ten laser treatments, the patient showed a discount of hyperpigmentation beginning with the primary treatment.Clinical improvement continued even after the conclusion of the intensive weekly treatment phase.ConclusionCombination therapy, laser treatments combined with 7% alpha arbutin and a broad-spectrum sunscreen is an efficient and well-tolerated treatment for refractory melisma.

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