Before treatment, and for treatment to be most effective, it is crucial to determine the depth of the dark spots. Patients with several dark spots are presented to a dermatologist for treatment primarily because of cosmetic concerns.
Clinical judgment is not always helpful. Your dermatologist may need to take a skin biopsy to confirm the diagnosis or determine the depth of the dark spot (at MSI, we find the Wood’s light and UV camera helpful in assessing the extent of pigmentation. Sometimes Wood’s Light gives conflicting results.
What Are the Options in Treating Dark Spots?
Sunscreen: individuals have greater sun exposure to UV rays than realized because even fluorescent lighting can be a source of UV light. In many cases, exposure to sunlight intensifies skin dark spots. Therefore, you should wear a photo-protective preparation (sunscreen) daily whether the person is outdoors little or often.
Bleaching Agents: blocks the creation of more pigment melanin, which continually feeds the dark spots while bleaching cream containing; hydroquinone, Arbutin, Licorice, or Kojic acid reverses the process. Unfortunately, hydroquinone can help superficial (epidermal) dark spots after a considerable time. Additionally, its lightning effect might not remain localized to the desired area.
Exfoliating Agents: to decrease the number of melanin granules present using tretinoin or glycolic acid, salicylic acid, or a combination of these peels and prescribed skincare products. Combined treatment with bleaching agents and exfoliants, sometimes with chemical peel sessions, can give the best results for lesions such as melasma, post-inflammatory hyperpigmentation, or freckles.
Surgical techniques: destructive modalities like cryosurgery or chemical peel with TCA have succeeded in treating epidermal pigmentation. However, these treatments are problematic due to possible resultant hyperpigmentation (increase), and hyperpigmentation (decrease in skin pigments). Removal of dermal pigmented lesions by any destructive agent invariably causes scarring.
Are Lasers Needed for Dark Spots Removal?
Dark spots that appear on the skin are dependent on melanin pigment. Pigment-forming cells are called melanocytes. Abnormal hyperpigmentation (increased pigment) may result from alteration of the melanin production rate, uneven pigment distribution, or both. Although rare, dark spots and skin diseases are genetically determined.
Seen pigment disorders usually result from acquired UV light, skin trauma, pregnancy, hormones, drugs, or chemical compounds. Lesions may be located superficially (epidermal) such as freckles or are deep (dermal) such as tattoo pigments or mixed (dermo-epidermal) lesions such as melasma.
Are All Lasers the Same in Removing Dark Spots?
No, Lasers differ in colors, power, and time the laser energy is delivered to the skin. These parameters determine the outcome of laser treatment. Non-selective lasers can destroy pigment-containing cells and damage the surrounding healthy skin. In simple terms, they work exactly like a cautery machine applied to the surface, with the same possibilities of scarring and pigment changes.
What Does MSI Offer Dark Spots Patients?
Dark Spots Consultation
• How long has the lesion(s) been present?
• Has a biopsy of the lesion been performed?
• Has it grown, bled without injury, or developed such symptoms as a changed color?
• Has the symptoms patient attempted to remove or alter the lesion previously? If so, how was this attempted?
• Is the patient currently taking an oral retinoid?
• Is there a personal history of herpes infection or cold sores in the proposed treatment area?
• Has the patient previously developed keloids or abnormal scars after surgery or injury?
• Does the patient currently actively pursue a tan or use a tanning bed or bronzer?
• Any history of gold treatment?
• What is the patient’s Fitzpatrick skin type?
At MSI, we use selective lasers to remove pigmented lesions, especially in patients with dark skin. Lasers provide different appropriate wavelengths of light for absorption by abnormal melanin depositions. We often mix and match specific lasers or different laser parameters in treating our patients. The wavelength and rapidly pulsed light minimize healthy skin damage while providing maximum abnormal melanin removal.
We are pleased to have the most advanced laser technology at MSI, Q-switched Nd: YAG 532nm,1064nm Lasers. Recently, fractional laser and fractional radiofrequency have been added to our weapons to treat pigmented conditions such as melasma, solar lentigines, nevus of Ota, post-inflammatory hyperpigmentation, and tattoo.
Do I need Preparation before Dark Spots Laser Removal?
Treatment sessions are divided into three phases:
Pre-treatment Preparation: patients are advised to avoid aspirin or any non-steroidal anti-inflammatory agents such as ibuprofen to prevent bruising. Bleaching cream specifically designed for each patient can be applied two weeks before the laser session and continued for another two weeks to decrease any incidence of bruising should it occur.
Treatment Session: Many patients benefit from topical anesthetic cream (EMLA) applied under an occlusive dressing 1-2 hours before laser treatment and removed just before the surgery. The skin is kept cool with a cold gel or a cooling device for the patient’s comfort. During the procedure, I will cover my eyes with protective eyewear.
The laser procedure is quick; the duration depends on the site treated. Patients are given detailed instructions for care of the treated area by a member of our well-trained medical staff. A topical antibiotic and dressing are placed on the treatment site following the laser session.
Postoperative Healing: treated area may develop a crust and a scab. I should handle it gently to minimize the potential for alterations in the skin’s texture. The treated area will heal over one to three weeks. You may apply for the prescribed topical cream for one week. As the area begins to heal, the site will gradually fade. Later treatment sessions should be scheduled 4-6 weeks apart.
The treatment area should improve within 5–14 days. A subtle eschar appearing as a darker version of the original lesion will form and peel off within 7–10 days. No specific wound care is needed after the treatment of epidermal lesions. If I used an IPL system for treatment, typically, only erythema is seen postoperatively.
What types of Dark Spot can be Removed with Lasers?
Epidermal Dark Spots (superficial)
Therefore, any laser system that damages the epidermis will improve 1–one to 2 treatment sessions. Conversely, if the epidermal damage is part of more profound destruction, there may be scarring or dyspigmentation afterward. Fractional laser can be considered for these conditions, especially if the lesions are widespread, but the mainstay laser is QS Nd: YAG (532 nm); long-pulsed lasers and IPL can also be helpful.
Initially 3mm in diameter, but increase in number, size, and depth of pigmentation during the summer months. Appear as light brown pigmented macules on light sun-exposed skin. More frequently seen in individuals with red or blonde hair and blue eyes.
Lentigines (age spots)
They appear as small, round-to-oval, and darker than freckle macules. They often arise in childhood without a preference for sun-exposed skin.
Labial melanotic macule (LMM)
Melanotic macules on the lip vermilion are a feature of several entities, including physiologic racial pigmentation, Laugier-Hunziker syndrome, and Peutz-Jeghers syndrome. It occurs in 3% of average persons in young women on the lower lip. In the case of syndromes, patients should be made aware that new macules will develop over time.
These can be treated using the QS ruby or frequency-doubled YAG lasers. In the case of the syndromes, patients should be made aware that new macules will develop over time.
Cafe-Au-Lait Macules (coffee with milk birthmarks)
Café au lait macules (CALMs) vary in color, size, and shape, but histologically the excess pigment is found at the basal layer. When darker macules exist with the CALM, it is referred to as a nevus spilus. Before treating CALMs, one should always take a careful history to rule out neurofibromatosis (if multiple macules exist).
Lasers that are usually used to treat these lesions include the QS Nd: YAG, QS ruby, and QS alexandrite lasers, and currently, the PS laser can be used. Patients with darker skin are at risk for hyperpigmentation and hypopigmentation.
Light-skinned patients are the ideal candidates for CALM removal, but recurrences, residual hyperpigmentation, and incomplete pigment removal are common. Treatment sessions are spaced at least 8 weeks apart, and clearance requires at least two to four treatment sessions
Mixed (Dermal-Epidermal) Dark Spots Skin Lesions
The pigment is present at the dermo-epidermal junction and, in the case of Becker’s nevus, in addition to the pigment, there are often terminal hairs in the lesion itself. Dark spots in this category include Becker’s nevus, melasma, post-inflammatory hyperpigmentation, drug-induced hyperpigmentation, and nevo-cellular nevi. Nevo-cellular, junctional, and compound melanocytic nevi should be treated with laser only if the operator is benign.
The lesion is a developmental anomaly and not a nevus. It consists of either a brown macule, a patch of hair, or both. Non-hair lesions may later develop hair. Becker’s nevus varies in size (2-40 cm) and may enlarge to cover the entire upper arm or shoulder. It is usually first noticed during adolescence, more commonly in males than females. Once present, Becker’s nevi stay indefinitely.
The dark spot areas of a Becker nevus have shown improvement when treated with the PS alexandrite, QS ruby, QS Nd: YAG, and 1550-nm fractional erbium-doped fiber laser.
Becker of the QS lasers’ nevus responds unpredictably to laser treatment. Becker’s nevus Treatment sessions should be spaced 8–12 weeks apart, and 3–5 treatment sessions are usually necessary. Fading is incomplete and patchy. I can remove the terminal hairs with hair removal lasers.
Melasma (pregnancy mask)
Bilateral, symmetrical brownish dark spots affect the upper lip, cheeks, forehead, and chin, becoming more apparent following sun exposure. It typically presents as patchy hyperpigmented areas on the face in women. Frequently occurs during pregnancy, menopause, with certain topical medications, or when taking hormones or oral contraceptives.
Unfortunately, although lasers can improve the appearance of melasma, this is usually short-lived as recurrences are common. Dark spots of melasma are commonly seen in men of Middle Eastern or Asian descent.
Although there is no definitive cure, the fractional CO2 laser has been reported as a treatment modality to improve melasma. Unfortunately, although lasers can improve the appearance of dark spots of melasma, this is usually short-lived as recurrences are frequent. Patients must always be counseled on the proper use of broad-spectrum sunscreen and be aware that treatment of melasma may result in post-inflammatory hyperpigmentation.
Worsening of the melasma and recurrence after ‘successful’ treatment is often seen. Treatment sessions are usually spaced 4–8 weeks apart, and 4–8 sessions are needed. It is essential not to try correction of melasma during spring or summer as incidental sunlight exposure will counteract any improvement made by the laser itself. As with PIH, pre-treatment with bleaching is mandatory and is likely to enhance results. Bleaching preparation should be continued as part of a maintenance regimen.
Patients must be counseled on the proper use of broad-spectrum sunscreen at all times and be aware that treatment of melasma may result in PIH.
The QS ruby, QS alexandrite, QS Nd: YAG, Er: YAG, 1550-nm fractionated erbium-doped fiber laser, and fractional CO2 laser have all been reported as treatment modalities to improve melasma, although there is no definitive cure. Kauvar has reported success using QS Nd: YAG at low fluences. Worsening of the melasma and recurrence after “successful” treatment is frequently seen.
Post-Inflammatory Hyperpigmentation (PIH)
Dark spots of hyperpigmented skin have many sizes and shapes and may affect large areas. Individuals with darker and yellow-toned skin show more pigmentary reactions following trauma and acute or chronic skin inflammation.
PIH can occur on the face but can also result from hemosiderin deposition after sclerotherapy. Dark spots commonly occur following sclerotherapy of varicose and telangiectatic leg veins in 10%-30% of patients due to hemosiderin deposits. It is essential to use low fluency and ensure that the patient does not develop significant post-treatment erythema to provoke more dark spots. For this reason, test spots are encouraged before treating large areas.
The laser system currently used most often for a dark spot of PIH is the fractional photo-thermolysis system. All patients treated for PIH on the face should use bleaching cream and a broad-spectrum sunscreen before and after treatment.
Before using a laser for facial PIH, recurrence is frequently seen, especially after sun exposure. t MSI, Prof Moawad recommends a series of MSI chemical peels and electroporation to improve the discoloration with laser as the last step.
Dark AFTER USING THE QS ND: YAG LASER, type II minocycline dark spots have been reported to clear. Spots due to minocycline, doxycycline, amiodarone, and zidovudine can cause hyperpigmentation of the skin that appears gray-brown to brown. AFTERntinuation of the medication is essential. As in dark spots of PIH, bleaching, sunscreens, chemical peels, microdermabrasion, and mesoderm should be tried first with a laser as the last step.
Dark Hairy Spots of Congenital Nevi
Congenital nevi that are too large for surgical removal may be considered for treatment with laser. Unfortunately, scarring is common, especially on the anterior torso, flanks, or arms. Prof Moawad combines ablative CO2 with QS Nd: YAG to treat patients with dark spots of congenital nevi who do not want surgical removal. Residual pigment and re-pigmentation are standard.
Recent studies have reported success with the PS alexandrite, Er: YAG, and the CO2, or a combination of the QS lasers with ablative resurfacing. It is important to note that most studies have evaluated children with congenital nevi rather than adults who desire removal, and, in general, the value of removing congenital nevi with any laser has not been substantiated because residual pigment and repigmentation
Eyes Dark Circles Treatment
Infraorbital dark skin darkening results from distinct reasons, including dermal melanin deposition, post-inflammatory hyperpigmentation, superficial plexus of blood vessels (dark purplish color), and shadowing from shadowing lax skin and infraorbital swelling.
These conditions respond variably, at best. Lasers are not considered the best option for lesions such as melasma or post-inflammatory hyperpigmentation, responding variable at best. I can clear dark spots of the eye circles with a selective pigment laser or a resurfacing technique using the CO2 laser.
Pigmented skin lesion with more epidermal part responds more reliably than pigmentation with active dermal ingredients. Dark-skinned patients with pigmented lesions are encouraged to use a combination of bleaching agents and exfoliants as part of their daily program up to 6 weeks before undergoing laser surgery and as soon as skin healing begins the following laser.
Such an approach will block the creation of new melanin that feeds existing pigmentation or prevent or lessen the development of unique pigmentation. Sun protection is, of course, mandatory all the time.
Dermal (deep) Dark Spots
Dermal lesions have more deep-seated pigment in the dermis, requiring devices with longer wavelengths. Examples of such lesions include nevi of Ota, Ito, and Hori, and congenital dermal melanocytosis, also known as Mongolian spots. Argyria is an added example of a dermal process that manifests due to the ingestion of silver and can be treated with a QS laser.
In darker-skinned (type IV-VI) patients, the QS Nd: YAG laser at 1064 nm is usually the safest laser to lighten a nevus of Ota, Ito, or Hori. Nevus of Ota presents on the face as a blue-black, brown, or gray patch that develops after birth or in adolescence with a unilateral distribution that may involve the sclera. Nevus of Ito is similar, but its location is usually on the shoulder. Hori’s nevus is typically bilateral and found in the malar region.
Recently, a fractionated 1440 nm Nd: YAG laser has been reported to clear the nevus of Ota. Treatments are usually spaced 3–4 months apart, with up to ten treatment sessions needed for clearance with QS lasers and 2–3 treatment sessions with the fractionated laser. Nevus of Ota patients should be made aware that the sclera part of the lesion is not amenable to treatment with current technology.
Dark Spots of Congenital dermal melanocytosis
The dark spot of Mongolian typically appears as blue-gray macules of varying size on the body that resolves in childhood but occasionally persist into adulthood. These can be treated with QS alexandrite, ruby, or Nd: YAG laser through PIH is a risk. Sacral spots tend to be more laser-resistant than extra-sacral Mongolian spots, and treatment in childhood portends better results.
Dark Spot of Argyria
Argyria is a rare skin disease caused by the ingestion of silver salt or silver particles used in traditional remedies. The granules that result in the blue-gray discoloration associated with argyria are usually found in the upper dermis. Treatment of argyria can be accomplished using the QS 1064 nm Nd: YAG at low fluences. I should give particular attention to anesthesia in this situation as treatment is very painful.
The dark spots of Tattoo’s Pigment (Black and Blue)
Tattoo lesion patient history
. Is it an amateur, professional, traumatic, cosmetic, or medical tattoo?
• How long has it been present?
• What colors of inks/dyes were used?
• Were inks mixed to make the colors?
• Is there any white or skin-colored ink in the tattoo, to the patient’s knowledge?
• Has the patient attempted to remove or alter the tattoo previously? If so, what technique was used?
• Is the patient currently taking a retinoid?
• Is there a history of herpes infection or cold sores in the proposed treatment area?
• Has the patient previously developed keloids or abnormal scars after prior surgery or injury?
• Does the patient currently actively pursue a tan or use a tanning bed or bronzer?
• Any history of gold treatment?
• What is the patient’s Fitzpatrick skin type?
Modern tattoo removal involves the use of Q-switched Nd: YAG laser 1064nm infra-red laser” and frequency-doubled 532nm green KTP laser to remove unwanted tattoos pigments or fade them to prepare the area for a different tattoo. This laser sends precise pulses of high-energy light into the skin, vaporizing some tattoo inks and fragmenting other inks into thousands of tiny particles, which are safely eliminated from your skin.
I should also consider testing spots for cosmetic, medical, traumatic, or decorative tattoos with light colors. After laser treatment of tattoos, skincare is quite similar to skincare after. Paradoxical darkening is likely to be encountered in these tattoos.
Gentle cleansing of the skin and applying an antibiotic ointment will help tattoos heal quickly after treatment. Protect the treated area from sun exposure until the skin is completely healed and the skin color has returned to normal.
Your tattoo usually fades over 4-6 weeks. Other
Dark Spots of Amalgam tattoos
Amalgam tattoos on the gingival or buccal mucosa result from silver fillings in the teeth. They can be of cosmetic concern, especially on the anterior gingival surface.
Dark Spots Laser Removal Conclusion
The most recent addition to the treatment of dark spots including tattoos is the picosecond
(PS) laser available as alexandrite (755 nm), Nd: YAG (532 nm), and Nd: YAG (1064 nm).
• Just as the placement of tattoos has gained popularity, so has the number of people interested in their removal.
• Dark spots of Black and blue tattoos are the easiest to fade with the most predictable results, whereas multicolored tattoos are the most difficult.
• Lentigines spots are the easiest to treat, whereas the most difficult is the nevi of Ota, Ito, and Hori.
• Dark spots magic bullet or specific lasers, such as the PS alexandrite (755 nm), PS Nd: YAG (532 nm), quality-switched (QS) ruby (694 nm), QS alexandrite (755 nm), and QS Nd: YAG (532 and 1064 nm) continue to be the workhorse systems for both tattoo and pigmented lesion removal.
• QS and PS lasers remove tattoo pigment through photoacoustic injury, breaking up the ink particles
and making them more available for macrophage phagocytosis and removal.
• Fractional photothermolysis has provided expanded options for dark spots removal in the past
decade, although generally treatment sessions are required, and the cost is higher.
• In general, patients with Fitzpatrick skin prototypes I to III have a better response than those with skin
phototypes IV to VI because the lasers used for pigment removal can also damage epidermal pigment.
• Topical anesthesia is helpful when treating dermal pigmented lesions and tattoos.
• Factors to consider prior to estimating the number of treatment sessions a patient will need for a tattoo
removal includes: Fitzpatrick skin phototype, location, color, amount of ink used in the tattoo, scarring or
tissue change, and ink layering.
• As with any procedure, patient selection and preparation are important to success, and
a photograph should be photographed of the lesions during each treatment session.
• Side effects of laser treatment for pigmented lesions include textural change, scarring, pruritus,
hypopigmentation or hyperpigmentation, and immediate pigment change.
• Tattoos with white or red ink carry an increased risk of paradoxical darkening after laser treatment, so test spots should occur during the first treatment session.
• Caution should be exercised prior to treatment of a tattoo with an allergic reaction because
the dispersed ink particles can elicit a systemic response.
• For dark spots such as melasma and postinflammatory hyperpigmentation, preoperative
and postoperative treatment should include hydroquinone and topical retinoids.
• Postoperative care includes gentle cleansing and a bland emollient while the skin heals.
Birthmark Treatment. Lasers should not be used for any melanoma, as melanoma recurrence rates are incredibly high, even in situ. Similarly, Prof Moawad does not recommend the removal of dysplastic nevi with lasers.