If there is one thing my patients hate more than wrinkles, it would have to be dyspigmentation. Dyspigmentation is a fancy term for uneven skin color. Hyperpigmentation is a condition of having too much pigment, and includes such problems as freckles, brown spots, melasma ("mask of pregnancy",) and post-inflammatory hyperpigmentation (those pesky brown spots that remain after a pimple or skin irritation has healed.) Hypopigmentation is a disorder of having too little pigment, such as white spots and vitiligo. For the purpose of this article, I am going to concentrate on one of the more common hyperpigmentation problems I encounter in my practice: sun freckles.
Freckles are familiar to all of us and frequently occur in children, especially blondes and redheads. They occur on sun exposed skin (mainly nose and cheeks) and fade in the winter months. We think they're cute. But as we get into our 40's and beyond, a different kind of freckling starts to appear on our faces, neck, chest and hands. These spots are larger than childhood freckles, more permanent, and definitely not as cute. The medical term is solar lentigo, though most people refer to them as "age spots" or "liver spots." I prefer to use the term "sun freckle." Calling them "age spots" wouldn't make me very popular!
These spots are the source of much distress. Why do we hate them so much? Well, because a smooth even skin tone is associated with youth. In fact, a recent study showed that skin color uniformity was a significant factor in the estimation of a person's age.
So, if you have sun freckles, what can be done? Here are some options:
1. Sunscreens. Actually, this is not an option; this is mandatory. No lightening treatment will stand a chance of working if you allow your pigment cells to continue to be stimulated by sun exposure. Interestingly, some freckles can darken even with visible light exposure, so you might think about wearing a sunscreen indoors if you work under fluorescent lights. (make sure it has good UVA protection; it should contain zinc oxide, titanium dioxide, avobenzone, Mexoryl, or Tinosorb.) Also, remember that UVA, which stimulates pigmentation, is not filtered by glass; therefore, use your sunscreen when you're in the car!
2. Cryotherapy. Individual freckles can be treated by your dermatologist with liquid nitrogen. This is an effective treatment; however, it can occasionally leave white spots, and it is not practical when there are hundreds of lesions.
3. Bleaching agents. The gold standard for bleaching agents is hydroquinone, which has been used for many years in prescription and non-prescription forms. Non-prescription hydroquinone products include Ambi Even and Clear and Alpha Hydrox Spot Light Targeted Skin Lightener. Hydroquinone can be prescribed in concentrations of 3% or more and can result in significant lightening in 70-80% of patients. It works by interfering with the enzyme necessary for pigment formation and usually takes several months to achieve noticeable results. (As the existing pigment is shed over time, less new pigment is being formed.) Hydroquinone can cause skin irritation in some patients. It can be compounded with other lightening agents and with anti-irritants for better effect and tolerance. It should not be used during pregnancy or breastfeeding.
For those who cannot or do not want to use hydroquinone, there are several non-prescription natural lightening agents, including Kojic acid, licorice extract, soy, arbutin, bearberry, vitamin C and glycolic acid. A few examples of some over the counter skin lighteners include the Aveeno Positively Radiant and Neutrogena Visibly Even lines, which contain soy, and Skinlogics Platinum Plus Brightening Day Creme by Beauticontrol, which contains arbutin, soy and licorice. In the past two years, several new non-hydroquinone products such as Elure, Perle, and Lumixyl have been developed and are promising additions to our therapeutic armamentarium.
4. Chemical Peels. Chemical peeling with mild acids can be helpful in treating sunspots, especially on the face. They can also improve texture. Peels usually involve a small amount of downtime (redness and peeling for several days,) depending on the strength of the peel solution. They may not be the best option for patients with sensitive skin.
5. Lasers and light sources. Laser and light treatments can provide excellent and rapid improvement in skin pigmentation. Intense Pulsed Light (IPL) is an effective treatment for brown and red discoloration. The term "photofacial" refers to a treatment with IPL, though other areas such as the neck, chest and hands can also be treated. Downtime is minimal. Finally, laser resurfacing is a more aggressive treatment that is mainly used to treat wrinkles, but will also improve pigmentation irregularities. Much more downtime can be expected with this treatment.
If you suffer from unwanted sun freckles, there are good treatment options available! Just talk to your dermatologist.
Katherine Farady is a board certified dermatologist with a special interest in skin care and cosmetic dermatology in Austin, TX.