Chronic solar lentigines on the lower extremities present a unique clinical challenge due to delayed healing, repeated mechanical stress, and an unpredictable response to standard aesthetic therapies. This report details a two-year clinical evaluation of a 69-year-old female patient presenting with a recalcitrant, 20-year history of lower limb solar lentigines that showed minimal improvement with conservative measures. To address the complexities of this anatomical region, we implemented a sequential combination approach utilizing a distinct “break and build” methodology.

The treatment protocol was divided into two main phases. The initial “break” phase utilized Q-switched Nd:YAG Laser (QSNYL) therapy over six sessions to selectively target and fragment the melanin burden without inducing excessive thermal injury. The subsequent “build” phase integrated alternating sessions of QSNYL with Polynucleotide Highly Purified Technology (PN-HPT). While the laser continued to address residual pigmentation, the PN-HPT acted as a regenerative adjunct to stimulate tissue recovery, enhance dermal repair, and improve overall skin quality.

Over the 26-month treatment duration, the patient exhibited progressive and sustained lightening of hyperpigmentation. Clinical assessments at the two-year follow-up revealed marked aesthetic outcomes, achieving both a patient-reported and clinician-assessed Global Aesthetic Improvement Scale (GAIS) score of 1 (very much improved). Notably, the sequential therapy was well-tolerated, with no significant adverse events such as scarring or post-inflammatory hyperpigmentation. This case demonstrates that a sequential combination approach, integrating pigment-fragmentation with regenerative bio-stimulation and offers a highly effective and safe strategy for the management of challenging lower limb pigmentary disorders.

Cheah Phei Chuin (Cheryl) is a dedicated aesthetic physician currently practicing at UR Klinik Greenlane in Penang, Malaysia. She earned her MBBS from AIMST University and holds a postgraduation certification in aesthetic medicine (PGCert. Aesthetic Medicine). Furthermore, she is a recognized medical aesthetic Letter of Credentialing and Privileging (LCP) holder in Malaysia. In addition to her clinical practice, she takes on significant educational and leadership roles. She serves as a doctor trainer and leads of UR Community Service. She is also an active contributor to the international aesthetic medicine community, having previously shared her expertise as an invited speaker at the Scientex 2024 conference in Bangkok, Thailand. Her clinical research focuses on optimizing laser therapies and combination treatments for challenging pigmentary disorders. She has published a case report titled "Therapeutic Efficacy of RuVY Touch (Ruby-like Versatile YAG) Q-switched 660nm Wavelength Treatment on Ephelides (Freckles)" in JAPA. She is currently authoring her second case report, which explores a novel "break and build" combination approach using sequential Q-switched Nd:YAG laser and polynucleotide therapy for recalcitrant lower limb solar lentigines.