5.8 Pigmented Spots/black spots

Various types of pigmentation problems:

Photodamage & photoaging changes: Due to stronger sunlight Indians tend to develop slowly progressing damage in the skin. Such damage often remains unnoticeable or untreated. Those use cosmetics & fairness creams without concurrent sun protection & medical skin care tend to develop such damage.

Dark colour tone of the skin/loss of fairness:

This is most common problem in Indian skin.

Decease in fairness or increase in dark colour tone of the skin is medical problem. It may recur or may increase further in future at any time due to multiple factors. Due to self-medication and incomplete follow up treatmentperson fails to achieve enough results. Even though most of them know these factors which provoke failure in achieving results, they hardly make changes in them to make treatment effective. Multiple treatment modalities are available to keep skin fair & glowing. Laser facial skin rejuvenation is most commonly preferred, scientific and most effective treatment to improve dark colour tone of the skin. One needs to keep follow up treatment at certain intervals which varies from 2-6 months to maintain quality of results. As age increases most of us also need additional medical treatment to prevent aging changes.

Disorder of epidermal melanocytes:

a) Freckles (Ephelides):

Solar lentigos are seen generally after 50 years of age & so are called senile lentigos. 90% persons above age of 65 years have some solar lentigos. Face & back of the hands are mainly affected sites. These do not occur in sun protected area. Sunlight is the culprit. Clinically, it is difficult to distinguish freckles, (ephelides), solar lentigos & lentigos simplex. These can cause risk factor for melasma & basal cell carcinoma. These have elevated levels of melanocytes.

Treatment: Top flat beam of Q-Switch Nd: YAG laser & Ultra-Pulse® Co2 laser and radiofrequency can be used effectively for good results. When as Nd: YAG laser is used, it take 2-6 months to reduce satisfactionly & without harm when treated with Ultra-Pulse® Co2 laser or RF is used most of these spots vanish after siting. Use of medicine may partially reduce freckles.

b) Lentigo/Lentigens Lentigens are dark brown macules. Develop on exposed area (sun lentigo) or non-exposed area and on palm, plantor surface and mucus membrane. Lentigo simplex is common form of lentigo which has no predilection for sun exposed skin. Lesions are light brown to black. Lentigen is more common in women and scheborrhoic keratosis is more common in males.

For lentigens &freckles (ephelides), Top Flat beam & Gaussian beam Q.S. Nd YAG 532 and 1064 is used. One may need 4 to 6 sittings. Those who can-not come again or those who want to eradicate these spots earlier can undergo ablative Ultra-Pulse® Co2 laser treatment.

c) Cafe-au-lait macules: Appear as light brown macules or flat lesions 1-20 cm in size. Treatment with Q switch Nd: YAG laser is done In some person it tends to recur after treatment.

d) Senile lentigens: Ultra-Pulse®Co2 laser is used for treatment. It also improves skin tightness in that area as additional benefit.

e) Epidermal nevus: There are Linearly arranged papillomatous keratosis papules. There is hyperkeratosis and epidermal hyperplasia in basal layer. Ultra-Pulse®Co2 laser skin resurfacing and surgical excision are useful techniques.

f) Seborrhoeic keratosis: There is hyperkeratosis, acanthosis and papillomatosis. Smooth macules or verrucuous pigmented papules or plaque seen. Seborrhoeic keratosis is due to excess keratocytes and melanocytes. These are common epidermal proliferations. These can be effective treated with Ultra-Pulse®Co2 laser skin resurfacing.

Disorder of Dermal melanocytes:

Ephilides, lentigens, seborrhoic keratosis, nevi spilus and junctional nevi.

Melanocyte nevi are treated only when they cause cosmetic problem. These nevi can be congenital, acquired, compound, intradermal.

(g) Mangolian spot:Ill defined patch in sacro coccygeal area at birth which usually disappears after 4 years. Melanin granules are present in wavy dendrite cells present in dermis Laser treatment is helpful.

(h) Nevus of Ota:

Bluish gray macules on periorbital facial skin and in ipsilateral sclera of the eye (dark dissaturation). Some patients respond better with energy between 6-20 J/sq. cm with Top Flat beam of QSW Nd : YAG 1064 and QSW 532. Pigmentation in ABNOM occurs adultahard is symmetric and bilateral. It is more resistant to treatment than nevus of Ota. One need to take laser treatment 6 to 15 times for good results.

Dark skinned patients have less wrinkling.

(i) Nevus of Ito:

It is similar to nevus of ota but situated in supraclavicular, scapular or detoid area. Some respond better if treated as mentioned in nevus of ota.

(j) Blue nevus:

It is solitary lesion having dome shaped and blue black papules. Epidermis is not involved. It is treated like nevus of Ota.

(k) Dermal-epidermal pigmented lesion:

Melasma, post inflammation and post traumatic pigmentation compound nevi, Becker's nevi.

Those who are obese are most susceptible to develop such changes. Forehead, areas near outer aspect of eyes, below lower lip, around mouth, by the side of nose thickness can be reduced by Ultra-Pulse® Co2 laser resurfacing in 2-3 sittings at interval. The remaining darker shade can be reduced further or eradicated with Q Switch Nd: YAG laser (1064nm) in 4-10 sittings at interval of 4 to 6 weeks. Low fluence is used.

(l) Backer's Naevus:

The affected area is darker, hairy & sometime surface is thickened. These are large, hyperpigmented spots on the trunks of size, 2-40 cm lesion has coarse hairs and variable keratosis. Epidermal pigmentation is more common. Use protecting sunscreen during treatment period. Hairs are treated with LP Nd:YAG laser. This treatment helps to reduce pigmentation also. Simultaneously one can take treatment for improving dark colour of lesion with Q Switch laser 1064 and 532 in combination is used.

(m) Nevus spilus:

Within a tan brown patch, histologically, it is like neromelanocytic nevi. It is histologic polymer of lentigo simplex. It may become malignant. It responds to Long Pulse Nd: YAG. QSW.

Treatment of pigmented lesions:

Pigmented lesions like solar lentigens nevi of Oti and Ito, cafe-au-lait-macules (CALMS) and tattoos can be effectively treated. Melasma, nevocellular, nevi, lentigo, are partially treated by Laser. Invasive melanoma may be treated with deep laser surgery.

(n) Polikiloderma of Civattee:

Affects the side of the neck and lower lateral cheek. Atrophy eradicate the problem pigmentation and reticulate telangiectasis are present. Q-switch Nd: YAG selectively damages melanosomes in the cell wall.

(o) Polikiloderma of Civattee:

Affects the side of the neck and lower lateral cheek. Atrophy eradicate the problem pigmentation and reticulate telangiectasis are present.Q-switch Nd: YAG selectively damages melanosomes in the cell wall.

(p) Dark eye circle:

In India it is the most common complaint in both men and women. Its exact cause is not known. Skin in this area is thin. So, any inflammation or vasodilatation or skin damage due to ultraviolet rays, eye strain, non-compatible cosmetics may manifest as darkening of the area. Most of person think that skin on eye lid & around eyes is just a darker skin & nothing else. But these are early aging changes, Silent photo damage aggravate problem of dark circle. Thus often skin in this area is not normal but it is subnormally diseased. It causes looseness of the skin, wrinkling of the skin, & pigmentation.

Causes of under eyes dark circle: Allergies, Atopic Dermatitis (eczema), Heredity- Dark under- eye circles can run in families, Lifestyle factors, such as physical or emotional stress, smoking or chronic alcohol use can take a toll on you appearance. Nasal congestion (which can dilate and darken the veins that drain from your eyes to your nose). Pigmentation irregularities- These are a particular concern for people of colour, especially blacks and Asians. Rubbing or scratching your eyes. Sun exposure, which prompt your body to produce more melanin, the pigment that give skin its colour. Thinning skin and loss of fat and collagen- common as you age- can make the redness-blue blood vessels under your eyes more obvious. Shadowing due to skin laxity. Dermal melanin deposition.

Dark circles under the eyes has often been referred to as the tear trough deformity. The tear trough is sign of more advanced facial aging and is seen as a depression running below the eye from it's inner angle towards lateral side below the eyes.

Pigmentation is in the form of increase in dark colour tone on the skin, & formation of dark thick layers on the surface. All these factors play role in increasing darkness on the skin.

Dark Circles has two elements for which person should see improvement.

a) Wrinkles ( thick dark layer in some cases): Wrinkles and looseness of the skin aggravate dark colour tone of the skin around eyes. So stretching of this skin shows reduction of darkness.

b) Over all dark colour of local skin: Increase on pigment granules (melanin) in the cells of the skin leads to dark colour. Pigmentation can be partially treated with non-ablative Q Swich laser.

Most of person approach late for laser treatment. Such delay makes it more resistant to treatment. So these persons should keep optimum expectation about results. Some of these persons need to keep follow up at 3-6 months interval to preserve quality of the skin.

Treatment: Many cosmetics & medical preparations are valuable to treat these elements but they have their limitations. These creams need to be applied for long period. Sometimes signs of chemical irritation may develop in some person. Cosmetics available for dark circles are expected to be used for few years or lifelong-These provide temporary and partial solution to lifelong problem.

Ultra-Pulse® fractional Co2 laser skin resurfacing is most effective treatment to reduce looseness of the skin & excess wrinkles. It can be done in 1-3 sittings. Those who have excess loose skin can be reduced wrinkles by blepheroplasty surgery. Part of loose skin is excised to improve texture & wrinkles of the skin.

Those who have just mild dark circles can be treated with non-ablative laser treatment. Dark colour tone of skin can be improved gradually by 6-10 treatment session with Q-Switch Nd: YAG laser. Laser treatment for dark circle are quite safe. There is no danger to vision or eye sight. Use sunscreen regularly & take enough sleep. Ultra-Pulse® fractional Co2 laser skin resurfacing is ablative but very effective treatment to reduce looseness of skin, fine wrinkles, dark thick layers on the skin. The scabs fall of in 6-8 days. Improvement is dramatic in most of the cases. Remaining darkness of the skin is treated by Q Switch Nd: YAG laser. In 6 -10 sittings. Each sitting is gives at interval of 4-6 weeks.

(q) Xanthelesma:

Xanthelesma as small whitish yellowish lesion around eyes due to deposition of fatly substances on & under the skin.

It is present near the eye. It is seen as depigmented lesion. In 50% patients, no abnormality is seen in blood lipid level. Triglycerol level is raised such patient is asked to have cardiologist opinion. Ultra-Pulse® fractional Co2 laser can be used to treat xanthelasma cases effectively. Some persons need 2-3 sitting to eradicate it completely.

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