Shedding Light on Dark Spots

“Why do I have so many brown spots! My face used to be so clear.” I usually hear that multiple times a day. There are many different skin lesions that can look like “brown spots.” Two common causes of brown spots are freckles (known medically as solar lentigines) and melasma. These can occur in any skin type, Caucasian, African American, Asian – any ethnicity, any skin type.

Freckles (known medically as solar lentigines) are caused by the sun (UV radiation) over a period of years (even decades). The UV radiation causes the cells that produce the pigment in the skin to increase in number, as well as increase the pigment they are making.

Melasma is a chronic skin condition that causes blotchy, brown pigmentation on the face (especially the cheeks). Melasma can be caused by both the sun (UV radiation) but also there is a strong hormonal component (can start/worsen with certain birth control pills, pregnancy, hormonal fluctuations).

OVER THE COUNTER TREATMENTS

The best treatment for both freckles and melasma is PREVENTION! Use sunscreen (At least with an SPF of 30 but it would be best to do SPF 50+). Even if it is cloudy outside, there are UV rays that are still touching your skin. Make it a routine to wear sunscreen everyday before you put your make up on. Sunscreen will not only prevent the new lesions but can improve the cosmetic appearance of current lesions. If there was only one treatment for “anti-aging,” my answer would be SUNSCREEN, SUNSCREEN, SUNSCREEN. You don’t need to buy an expensive sunscreen either. They all work about the same in terms of efficacy when the SPF is the same. It depends more on what you like on your skin (barely there feel vs tinted vs moisturizing). I will post some of my favorite sunscreens soon.

Bleaching creams (contain hydroquinone) can also improve the appearance of melasma and freckles but have to be done very carefully. Most over the counter “skin lightening” or “skin brightening” therapies contain a retinoid and hydroquinone. Ambi Fade Cream contains 2% hydroquinone and can work well for mild cases. Differin cream is a retinoid that has solid science backing it for both acne and hyperpigmentation (brown spots). It was a prescription only treatment until a few months ago. There are hundreds of “skin lightening” or “skin brightening” on the market that are just as efficacious as these two but will cost you unnecessary money. Read the back of the products and don’t be duped. Most of these products have hydroquinone + an extra ingredient that do have strong scientific data (studies were done by the company, not clinically significant results). In other words, the products may work, but it is just the hydroquinone doing the work, not the other stuff that they added so they could market the product as “something different.”

DERMATOLOGY PEARLS (TIPS)

1. Use sunscreen with SPF 30-50+ EVERY DAY. Sunscreen in make up does not count (will blog about this soon).

2. Whenever starting a cosmetic regimen, start slow. Test the product, use it every other day. If you see any redness (WHICH IS A SIGN OF INFLAMMATION), STOP. Inflammation can leave behind a dark spot or scar (post inflammatory hyperpigmentation).

3. After applying the medication at night, follow with a moisturizer to lessen the incidence of dry skin.

4. It will take at least 6-8 weeks before you notice a difference. So if you do it for 2 weeks, don’t notice a difference, and stop, that may not be a treatment failure. You just didn’t use it long enough for the pigment in your skin to change.

5. Be very, very, very careful with hydroquinone. Using too much of it, for too long, or sometimes just because your skin doesn’t like it, you can have paradoxical DARKENING (ochronosis) which is very hard to reverse

The over the counter treatments only work for mild pigmentation and do not work well for moderate-severe cases. The concentration and therefore the power of the over the counter therapies are limited. In addition, there is a delicate balance between being effective and causing too much inflammation that it leaves dark spots.

STRONGER OPTIONS

Your dermatologist may be able to give you a stronger prescription strength hydroquinone, often combined with a prescription strength retinoid and anti-inflammatory agent. The stronger medication works faster and has been cosmetic results, especially if you have moderate to severe freckles or melasma. They can also monitor you for side effects, including the paradoxical darkening (ochronosis) that I talked about above.

Other in office treatments with good success include certain chemical peels. In my expertise, glycolic acid does not help with pigmentation (it is more an exfoliative agent). Salicylic acid, Jessner’s, TCA, and hydroquinone peels do have solid scientific evidence to help with pigmentation. If done correctly, the results can be seen as quickly as 2-4 weeks. A dermatologist can assess your skin and skin type (some cannot be used on skin of color) and suggest the correct treatment for you.

Other in office treatments include a cold spray of liquid nitrogen (cryotherapy) or laser surgery, but the important thing to note is that these both can leave a permanent dark or white spot. Often times, the lesions only disappear temporarily. Again, it is important that if you are considering these, that you see a trained dermatologist who can assess your skin and discus the treatment options best for you given that delicate balance between being effective and causing too much inflammation that it leaves dark spots.

There are many emerging treatment options but the studies have been limited. Oral tranexamic acid (TA) is a medication has been used for uterine fibroids and has promising scientific data for being a treatment for refractory melasma. However, there are side effects to the medication including blood clots, and the medication should only be given after a detailed consultation, including screening for risk factors and evaluation, with a physician.

BE CAREFUL

Lastly, there are many other skin conditions that you can look like freckles and melasma but are not. They range from chronic conditions (like erythema dyschromicum perstans) to life threatening conditions including melanoma and especially a type known as lentigo maligna. Remember, if you have any skin concerns, you should consult a board certified dermatologist.

Happy reading!

Dr. Z

Remember, this blog just provides general information and is not intended and should not be construed as medical advice. If the you or any other person has a medical concern, he or she should consult with an appropriately licensed physician or other health care worker. Never disregard professional medical advice or delay in seeking it because of something you have read on this blog or in any linked materials. Full Disclaimer.