"Before I address your aesthetic questions, I'll need to make sure that none of your dark spots are potentially cancerous. The vast majority of skin discolorations are harmless, but in some cases, I might have to do a biopsy. Once I've given you a clean bill of health, I can determine the cause of the discoloration. It is likely one of three things: melasma (relatively symmetrical discoloration on the temples, forehead, chin, and bridge of the nose, most often triggered by hormonal changes), sun damage (usually a more diffuse speckling, brought on by years of UV exposure), or post-inflammatory hyperpigmentation (concentrated areas of darkness that form after the skin is injured, most common in dark skin).
"If you've noticed discoloration only recently, the pigment is probably confined to the most superficial layers of the skin; exfoliating products can fade it. Try cleansers and moisturizers that contain glycolic or lactic acid. If you have light skin, you can also use physical exfoliants, which buff off dead skin with tiny beads; I tell dark-skinned patients to avoid them, though, because they can produce inflammation that could lead to more dark spots. Over-the-counter exfoliators (ideally combined with a couple of monthly in-office chemical peels) make a big difference within six to eight weeks. I might also suggest a hydroquinone lotion, which inhibits the pigment-forming enzyme tyrosinase. You can get a 2 percent concentration over-the-counter, but it takes many months to yield results. I prescribe 4 percent or more; women with darker skin have darker spots and can tolerate up to 12 percent. (I would rather prescribe a higher strength that you will need to use for only three to six weeks.)
"If a dark patch has been present for a year or more, the pigment is probably pretty deep beneath the skin; a laser is the best option to get rid of it. On light skin, I use the Q-switched or KTP laser, which feels like rubber-band snaps; you'll have a few scabs afterward that fall away after about two weeks. One or two treatments are usually enough to vaporize specific dark spots. Lighter-skinned patients with more diffuse pigmentation do beautifully with four or five monthly intense pulsed light (IPL) treatments. IPL minimizes discoloration and other symptoms of sun damage, like broken blood vessels and enlarged pores; it's painless and doesn't involve downtime. For darker-skinned patients, I usually recommend fractional nonablative lasers, like the Fraxel Re:store. I turn down the energy on the machine so patients don't leave the office red or swollen, and there's no risk of causing post-inflammatory hyperpigmentation. These less-intense treatments do necessitate four to six sessions, though.
"And use sunscreen daily. If you don't, you're just chasing your tail—and wasting your money—by coming to me for treatment. The sun causes discoloration in any skin tone—creating new dark patches, as well as exacerbating melasma and post-inflammatory hyperpigmentation."
Reliable weapons in the war against unattractive dark spots: laser treatments. One or two can easily vaporize them.
- A.M.: Sunscreen
- A.M./P.M.: Glycolic or lactic acid cleanser and moisturizer
- Hydroquinone cream, OTC (like Ambi Fade Cream, $6), or prescription, $50, three to 24 weeks
- Two or three monthly chemical peels, $100 to $150 each
- For lighter skin: One or two KTP or Q-switched laser treatments, $250 to $500 each, or four to six monthly IPL treatments, $250 to $350 each
- For darker skin: Four to six monthly fractional nonablative laser treatments, $750 to $1,500 each