Aesth Plast Surg
https://doi.org/10.1007/s00266-020-01637-x
REVIEW
A Meta-analysis-Based Assessment of Intense Pulsed Light
for Treatment of Melasma
Jiarong Yi1 • Tao Hong2 • Hanling Zeng1 • Peiwen Li1 • Pinglu Li1
Shaohua Wang1 • Jia Chen1 • Ping Li1 • Jianda Zhou1
Received: 20 November 2019 / Accepted: 30 January 2020
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Abstract
Background A safe and effective treatment for melasma,
an acquired refractory pigmented skin disease, remains a
problem, although numerous clinical trials have explored
the possibility of combined therapy involving intense
pulsed light. To date, little is known regarding the efficacy
of this treatment. The current study, therefore, sought to
explore the effectiveness of intense pulsed light.
Methods We used published studies from literature data-
bases, based on established inclusion criteria, to calculate
standardized mean differences (SMDs) and risk ratio
(RRs), and evaluated the effectiveness of combined therapy
with intense pulsed light in melasma patients. We per-
formed data analysis using the Review Manager 5.3 soft-
ware at 95% confidence interval.
Results We obtained a total of 8 studies, involving 215
patients, from the databases and found a significant effect
on efficacy following combined therapy with intense
pulsed light. Specifically, the melasma area and severity
index (MASI) score was significantly low (SMD = 0.61,
CI [0.42, 0.80] P \ 0.0001 for a fixed-effects model),
while a four-point scoring scale self-assessment by patients
was significantly high (RR = 1.44, CI [1.17, 1.76]
P = 0.0004 for a fixed-effects model).
Jiarong Yi and Tao Hong have contributed equally to this work.
& Jianda Zhou
doctorzhoujianda@163.com
1 Conventional melasma treatment therapies include the
Department of Plastic Surgery, The Third Xiangya Hospital,
Central South University, Tongzipo Road 138, Yuelu
District, Changsha 410013, China
2
Department of Urology, The Third Xiangya Hospital, Central
South University, Changsha 410013, China
NON-SURGICAL AESTHETIC
•
Conclusion Our meta-analysis showed that IPL-based
combination therapy for melasma can effectively reduce
the MASI score and result in higher satisfaction among
patients, indicating an effective method for treatment of the
condition.
Level of Evidence III This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Intense pulsed light
Melasma
Meta-analysis
Introduction
Melasma, an acquired refractory pigmented skin disease,
mainly occurs on exposed body parts such as the face and
neck [1]. Approximately 90% of patients diagnosed are
female, with the condition commonly seen in Fitzpatrick
IV-VI types of skin among the crowd [2]. Dermatological
treatment of melasma is a challenge, owing to a low cure
rate and high recurrence in patients [3]. Based on the
degree of skin lesions and position of the pigment observed
under the wood lamp, melasma can be categorized into
epidermis, dermis and the mixed type. The incidence of
melasma has recently increased, owing to changes in life-
styles, thereby becoming a major problem for contempo-
rary women. Consequently, this has seriously affected their
beauty [4].
use of laser, broad-spectrum sunscreens and bleaches, such
as hydroquinone, tranexamic acid, platelet-rich plasma and
chemical peeling [5–7]. However, most of these treatment
options are ineffective due to relatively frequent failures
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and are prone to high chances of recurrence. However,
intense pulsed light (IPL) is a therapy that has emerged in
recent years. It involves use of a strong light, focused by a
concentrating mirror and emitted by a specific wavelength
of intense light, generated by filtering through the filter
system on the treatment head [8]. It is essentially an
incoherent ordinary light and not a laser. This light pene-
trates the skin, through a specific wavelength, until it
contacts the illuminant and is then converted into heat to
solidify it including hair follicles or capillaries in the der-
mis [9]. As a broad-spectrum light source, IPL acts
extensively on melanin in skin tissues and also destroys
proliferating blood vessels, thereby achieving therapeutic
effects but with mild adverse reactions [10, 11]. However,
the efficacy of IPL on melasma is dependent on the type of
the disease. In addition, the treatment of erythema is not
effective and the complications are particularly high.
In view of the refractory nature of melasma, many
clinicians have proposed the concept of combination ther-
apy. Specifically, IPL treatment is the core, but it is com-
bined with other forms of treatment to achieve higher
results, such as light-emitting diodes, topical 5% magne-
sium ascorbyl phosphate and low-fluence Q-switched
Nd:YAG 1064-nm laser. Numerous experiments have been
conducted, although the specific effects remain elusive.
The current study aimed to explore the effect of IPL
therapy on melasma treatment.
Methods
Search Strategy
We included relevant studies published between Jan 1,
2000, and Oct 1, 2019, by searching English databases,
including PubMed, Web of Science, Embase and
Cochrane. The keywords used were melasma, intense
pulsed light and therapy. We modified the following
PubMed search strategy, to suit the other Library database,
for use in the study: (Melanoses OR Melanism OR Freckles
OR Freckle OR Chloasma OR Chloasmas OR Melasma
OR Melasmas) AND (intense pulse light).
Inclusion and Exclusion Criteria
The inclusion criteria were as follows: (1) The studies were
designed as case–control; (2) the cases in the study were
melasma patients; (3) the studies were all related with IPL-
based treatment or other types of treatment; and (4) all the
data in identified studies were real and proved by standard
institution. The exclusion criteria included: (1) reviews and
abstracts; (2) studies not relevant to melasma; and (3) if
multiple studies from the same series were available, the
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Aesth Plast Surg
one with most individuals was included in the analysis.
When included articles had the same patient cohort, only
that article with the longest follow-up period was selected.
Data Extraction and Quality Assessment
All tittles and abstracts of the selected papers were
reviewed by two authors (Tao Hong and Jiarong Yi). For
each of the included papers, we carefully extracted the
following details; first author, year of publication, study
design, events in laser treatment group and control group,
average, and standard deviation in a standardized form.
The quality of evidence in the outcomes was judged
according to the Cochrane Scale [12], where scores ranged
from 0 to 7, with higher scores indicating better quality.
Statistical Analysis
To assess the effects of study, we calculated the stan-
dardized mean differences (SMD) in continuous outcomes
and risk ratios (RR) in dichotomous variables using a 95%
CI. During meta-analysis, SMD is applied as aggregate
statistics when all trials evaluate the same outcome, but are
assessed with many kinds of methods (such as different
rating scales) [13]. We used the inverse variance method,
in continuous variables with random-effects model and/or
fixed-effects model, to combine data and generate the
overall effect estimate according to the degree of hetero-
geneity. This degree was assessed by a v2 test combined
with the I2 method (I2 \ 25% representing low hetero-
geneity, and I2 [ 75% representing high heterogeneity).
Data with high heterogeneity were analyzed using the
random-effects model, and data with low heterogeneity
were analyzed with the fixed-effects model. The analysis
was performed using RevMan version 5.1. with P \ 0.05
representing statistical significance [14]. Funnel plotting
and Begg’s test, performed in RevMan version 5.3 and
Stata version 12.0, were used to assess publication bias.
Results
Literature Selection
A total of 185 related articles were obtained following a
search through various databases. Of these, 63 were re-
listed. After scanning the remaining 122 articles, we
excluded documents that did not meet our inclusion crite-
ria. We conducted a further assessment of the remaining 73
articles, and excluded 65 studies due to the following
reasons: They were not an English article, had no useful
data and represented other types of treatment. Eventually, 8
Aesth Plast Surg
studies that included 215 patients were eligible for inclu-
sion. The procedures are outlined in Fig. 1.
Study Characteristics
Study characteristics are shown in Table 1.
Assessment of Study Quality
The quality of all 8 studies was assessed using the
Cochrane Scale, and the results are as shown in Fig. 2. The
green, red and yellow points denote low, high and unclear
risks, respectively. All studies resulted in a score between 3
and 6, indicating a low or middle risk. No study attained a
score of 7 because double blinding was not observed in the
clinical research.
Detection of Heterogeneity and Pooled Analysis
Melasma Area and Severity Index (MASI) Score
The effect of IPL therapy was evaluated using the MASI
evaluation scale. All the 8 studies showed a value of MASI,
and a fixed-effects model was therefore applied. We
observed a significantly lower MASI with IPL-based
combination therapy compared to the other single treat-
ment group (SMD = 0.61, CI [0.42, 0.80] P \ 0.0001)
(Fig. 3).
Fig. 1 Literature selection
Self-assessment
Self-evaluation is a feedback based on the satisfaction of
patients. We found useful information in 7 of the studies,
and as a result, we applied the fixed-effects model for
further assessment. We observed a significant increase in
the four-point scoring scale in IPL-based combination
therapy relative to other single treatment groups (RR =
1.44, CI [1.17, 1,76] P = 0.0004) (Fig. 4).
Sensitivity Analysis
To determine the contribution of individual studies, we
pooled the results using a sensitivity analysis. We removed
each study from the analysis, in turn, and determined
pooled RRs. We found no significant changes between
each of these analyses and the overall results after meta-
analysis, indicating that none of the included studies sig-
nificantly altered the overall results. This, therefore, con-
firmed that our meta-analysis results are stable and reliable.
Publication Bias
Publication bias was assessed by generating and analyzing
a funnel plot, as shown in Fig. 5. The shapes of the funnel
plots did not reveal any evidence of obvious asymmetry.
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 Aesth Plast Surg

Table 1 Study characteristics

Authors Year of Study Patients Mean age Mean duration of Area Methodology Number of
publication design melasma (years) sessions

Vachiramon 2014 RCT 18 47.5 ± 6.9 8.8 ± 2.7 Asian Subjective and 5
et al. [15] females objective
Bae et al. 2015 RCT 12 46.1 ± 5.4 None Asian Subjective and 6
[16] females objective
8 males
CHIA et al. 2004 RCT 31 45.0 ± 4.9 47.3 ± 6.7 10.1 ± 5.8 Asian Subjective and 4
[17] females 10.7 ± 7.0 objective
Shaikh et al. 2014 PCS 47 27 ± 8.5 18 ± 9.2 Asian Subjective and 3
[18] females objective
18 males
Yun et al. 2014 RCT 24 43.4 ± 2.0 – Asian Subjective and 6
[19] females objective
Figueiredo 2012 RCT 58 43.8 ± 7.2 8.9 ± 4.2 American Subjective and 1
et al. [20] females 45.1 ± 4.3 9.4 ± 4.8 objective
4 males
CHIA et al. 2006 RCT 32 45.9 ± 5.6 4 ± 5.6 Asian Subjective and 2
[21] females objective
Ilgen Ertam 2019 RCT 47 39.56 ± 7.25 7.150 ± 4.5322 Asian Subjective 3
et al. [22] females
3 males

Fig. 2 Risk of bias summary

Discussion this method as a more objective indicator for evaluation of

We performed a meta-analysis on eight articles, comprising
215 patients and found two major indicators for evaluation.
These were a MASI score and patient’s self-evaluation of
efficacy. The MASI score is considered a relatively simple
and objective evaluation method in clinical applications,
and an effective tool for patients with melasma [23]. In our
results, MASI scores significantly decreased after com-
prehensive treatment with intense pulsed light. For the
treatment of melasma, the color and area of skin pigment
plaques are mainly resolved, indicating the effectiveness of
efficacy in patients [24]. In this study, the combined
number of documents enabled us to conclude that a com-
prehensive treatment for patients with intense pulsed light
brings better results than other single-form treatments.
The biggest advantage of IPL is that it has a wide range
of applications and it is economical compared to conven-
tional treatments. Particularly, IPL covers a wider range of
lesions than single treatment therapies. Controlled trials
have shown that IPL is similar to laser treatment when
dealing with melasma [25]. However, IPL has an advan-
tage to laser therapy, in that it uses a wavelength spectrum

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Aesth Plast Surg

Fig. 3 Forest plot of MASI score

Fig. 4 Forest plot of self-assessment

the treatment of melasma has been affirmed, care needs to

be taken when selecting the amount of energy because if
the energy is too strong, then the risk of pigmentation
increases. On the other hand, weak energy does not gen-
erate effective outcomes. Pigmented cells in the skin
lesions of the melasma are very active. Functionally, if
light-mediated stimulation is too strong, it induces tyrosi-
nase activity and causes stains that increase pigmentation.
Therefore, clinicians focus on a strong pulse of low energy,
supplemented by other treatment methods to avoid the
possibility of aggravation of the stain. In general, the IPL-
Fig. 5 Funnel plot of publication bias
based combination therapy has fewer side effects or com-
plications. The common side effects include mild erythema
that can penetrate various levels of skin and simultaneously
and mild tingling, but this symptom usually disappears in
target epidermis and dermal melasma. In addition, its pulse
about a day. A small number of patients may experience
duration is in the millisecond range, which enables greater
mild skin exfoliation due to higher energy infusion, which
heat spread and reduces the chance of heat-related post-
will heal without scarring in about a week [15, 20]. This, in
inflammatory pigmentation. This is because the size of an
turn, generates a comprehensive melasma treatment with
IPL head is larger than that of most laser spots, which
good effects and relatively small side effects.
ensures rapid processing of large areas [5, 26]. Further-
Despite the limitations of the current study, including
more, IPL therapy is even more pronounced than laser
few patients involved in the clinical trials in the selected
during treatment of some vascular diseases, such as vas-
articles, and a shorter follow-up time, the findings still
cular malformations [27]. Although the efficacy of IPL in
provide strong evidence for future clinical trials.

123

Conclusions
Our meta-analysis shows that IPL-based combination
therapy for melasma can effectively reduce MASI scores
and result in higher satisfaction among patients. IPL and
IPL-based therapy for melasma will therefore be the
mainstream in the near future.
Acknowledgements All the co-authors performed analysis proce-
dures and participated in writing of the manuscript.
Funding This work was supported by the Special Foundation of
Basic Science and Technology Resources Survey of Ministry of
Science and Technology of China (2017FY101204) and the Scientific
Research Fund Project of Hunan Provincial Health Commission
(B2015-040).
Compliance with Ethical Standards
Conflict of interest The authors have no conflicts of interest to
disclose.
Ethical Approval This article does not contain any studies with
human participants or animals performed by any of the authors.
Informed Consent Informed consent was not required for this study.
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