Pigmentation Problems

Freckles, Lentiges, Melasma and Pigments
Pigmentary changes on our skin is something nobody wishes to have. But unfortunately in our Asian population, hyperpigmentation (increase in pigment in our skin) is a common and sometimes distressing problem.

Much of the root of the problem comes from our tendency to sun exposure (UV radiation), and when coupled with factors like genetic predisposition, drugs and pregnancy, we can develop a variety of skin pigmentary changes.

In order to have optimal treatment, it is important to ascertain if the pigmentary lesions are epidermal or dermal. Many patients have a combination of both types of pigmentation. Examination under a Wood’s lamp can help in our clinical assessment.

Freckles and Lentiges
These are by definition, epidermal lesions on skin. (The epidermis is the outermost layer of our skin, as opposed to the layer beneath the epidermis which is called the dermis)

What are freckles and lentiges?
Freckles (or Ephelides) are very common and can be easily treated. They are small brown macules (flat lesions) on the face or other sun-exposed areas.

Lentiges are similar to freckles but are a different entity. They tend to be a darker shade than freckles. Solar lentiges can be found on the back of the hands, and face. There are usually associated sun related changes like wrinkling and dryness, and in combination are sometimes referred to as signs of photoaging.

How can freckles and lentiges be treated?
We can use VPL (a variation of IPL) to treat freckles and lentiges . Post procedure, the pigmentation will darken and eventually fall off in a few days to a week’s time. Sometimes, a second session may be required for complete clearance. The use of IPL or VPL in darker skinned individuals with higher epidermal melanin can pose challenges (increased risk of pigmentation worsening), hence the importance of skin conditioning.

At times, we can also use Q-switched Nd:YAG at 532nm to treat these epidermal lesions. This laser targets epidermal melanin via the concept of selective photothermolysis.

With a tighter spot size, we can avoid stimulating normal skin and hence manage the risks of new pigmentation occurring post treatment. The only downside of 532nm settings is the small risk of post treatment hypopigmentation (less pigment) which may be transient and improve by itself. This risk can be minimized by keeping energy levels (or fluence) at moderate levels, avoiding unnecessary sun exposure post treatment, and adhering to our prescribed post treatment skin and wound care.

Chemical peels and topical lightening agents can also be used in combination with light and laser treatment.

Is there downtime?
No. There may be slight redness over the treated areas post laser but this will subside within a day. We may prescribe some mild steroids and antibiotics to speed up healing and prevent infection.

Melasma
Melasma has been historically referred to as the “mask of pregnancy” because it was thought to occur as a result of pregnancy. However, we now know that it can happen to sun-exposed skin of both males and females. We still do not know the exact cause of Melasma but use of the oral contraceptive pills, hormone replacement therapy and other drugs have been associated with the condition. There may be a mixture of epidermal and dermal components in Melasma. Based on present evidence, epidermal melasma can be treated with a combination of topical creams and chemical peels. The dermal component of Melasma is more difficult to treat.

Acquired Bilateral Nevus of Ota-like Macules (ABNOM)
ABNOM are also know as Hori’s macules (brownish or grayish in colour) and usually occur symmetrically over the upper cheek regions (what we call the malar region), just below and around the lower eyelids. Many people mistake this as freckles but they should not be confused with each other as the treatment is different.

These predominantly dermal pigmentation is best treated with a Q-switched Nd:YAG laser at 1064nm. This longer wavelength allows heat from the laser to penetrate deeper into the dermis (which IPL or a 532nm wavelength cannot effectively reach), and via selective photothermolysis, breaks up melanin.

We like to combine laser treatments with a series of PCA chemical peels as well as topical treatment of hydroquinone and Retin A for optimal results. Combination therapy is particularly effective because many times, there is a mix of epidermal and dermal components.

How effective is treatment and how many sessions are required?
Some patients can get very good clearance while some may see reasonably significant lightening. Multiple sessions are usually needed.

As much as no doctor can guarantee 100% removal, we always try our best within safety limits.

It is very important to follow a strict home care treatment and the use of sunblock, lightening agents and moisturizers are absolutely essential.

With discipline and patience, good results are possible.