Hyperpigmentation

Age spots and freckles

Freckles
Freckles are small flat brown marks arising on the face and other sun exposed areas. They are most often seen in fair skinned people, especially those with red hair, but they are an inherited characteristic that sometimes affects darker skin types as well.
The medical term for this type of freckle is ephilis (plural ephilides). The color is due to pigment accumulating in the skin cells (keratinocytes).

Skin pigment (melanin) is made by cells called melanocytes. They don't produce much melanin during the winter months, but produce more when exposed to the sun. The melanin is diffused into the surrounding skin cells, called keratinocytes. The color of ephilides is due to localized accumulation of melanin in keratinocytes.

Ephilides are more prominent in summer but fade considerably or disappear in winter as the keratinocytes are replaced by new cells.

As the person ages this type of freckle generally become less noticeable. Apart from sun protection, no particular treatment is necessary.

Lentigines or Age Spots

Larger flat brown spots on the face and hands arising in middle age also result from sun damage exposure. Unlike freckles they tend to persist for long periods and don't disappear in the winter (though they may fade). Commonly known as age spots or liver spots, the correct term for a single lesion is solar lentigo (plural lentigines).

Lentigines are common in those with fair skin but are also frequently seen in those who tan easily or have naturally dark skin. Lentigines are due to localised proliferation of melanocytes.

It is important to distinguish the harmless solar lentigo from an early malignant melanoma, the lentigo maligna. If the freckle has arisen recently, is made up of more than one colour or has irregular borders or if you have any doubts, see our dermatologist for advice.

Other brown marks

If the brown marks are scaly, they may be solar keratoses (sun damage) or seborrhoeic keratoses (senile warts). In this case there is a proliferation of keratinocytes.

Treatment of brown marks
Brown marks may fade with careful sun protection, broad spectrum sunscreen applied daily for 9 months of the year. Regular applications of anti-aging or fading creams may also help. These may contain hydroquinone, or antioxidants such as:
· alpha hydroxy acids
· vitamin-C
· retinoids
· azelaic acid.
However, brown marks may be removed more rapidly and effectively by chemical peels, cryotherapy or Solar Genesis IPL that target melanin in the skin.

Melasma
Melasma, also known as chloasma, appears as a blotchy, brownish pigmentation on the face that develops slowly and fades with time.

Clinical features
Chloasma usually affects women but occasionally is seen in young men who use after-shave lotions, scented soaps, and other toiletries.

Chloasma is especially common in women aged 20-40. It affects the forehead, cheeks and upper lips. It occurs frequently during pregnancy and is more common in dark skins than in fair skins. Often called "the mask of pregnancy", chloasma is more pronounced during the summer months as a result of sun exposure. It usually fades a few months after delivery. Repeated pregnancies, however, can intensify the pigmentation.

Chloasma also occurs as a side-effect of taking contraceptive pills and injected depot contraceptive preparations. It may also be noticed in apparently healthy, normal, non-pregnant women where it is presumed to be due to some mild and harmless hormonal imbalance.

Sun exposure, following the use of deodorant soaps, scented toiletries, and various cosmetics can also produce this mottled pigmentation. This is called a phototoxic reaction and is due to ultraviolet radiation being absorbed by the chemical substance (perfume, cologne and other types of fragrance) on the skin. This pigmentation often extends down to the sun-exposed areas of the neck and may be more pronounced on the right side of the forehead, face and neck due to sun exposure while driving a car (or the left side - if you drive on the right).

Treatment
· Discontinue birth control pill
If you are on hormonal contraception, consider stopping this. However any benefit from changing hormonal preparations is usually slow to become apparent.
· Sun protection
It is very important to minimise sun exposure on the face. Use a broad-spectrum very high protection factor sunscreen of reflectant type and apply it to the whole face. Alternatively, use a make-up with a sunscreen in it.
· Avoid irritating the facial skin
No strong soaps or abrasive cleaners - use only a mild soap or cleanser for washing.
· Bleaching creams
Bleaching creams contain hydroquinone, which inhibits formation of new pigment. Bleaching creams take 3 to 6 months to obtain a worthwhile lightening of pigmentation. Even then, just a "whiff" of summer sun can darken the pigment again and spoil months of hard work. Follow the instructions in the packet insert carefully. Apply a small amount of cream daily to a small test area of chloasma on the side of the face then, if there is no redness, itching or scaling, after, say, 5 days, apply the cream twice a day to the area. If still well tolerated, apply the cream accurately to all the pigmented areas twice a day. Avoid applying bleaching cream to normal skin as this will lighten as well. When using a sun screen, apply the bleaching cream first then the sunscreen on top. Stop daily bleaching cream after six months or so, or at least reduce to twice weekly applications.
· Topical alpha hydroxyacids
A face cream containing a fruit acid or alpha hydoxyacid (glycolic acid, lactic acid, Kojic acid).
· Tretinoin cream
If progress is slow using a hydroquinone cream alone, tretinoin cream (a prescription medicine) may be used. Tretinoin always causes a degree of pinkness and peeling of the facial skin which can be controlled by starting with a little then building up. It may fade freckles, improve acne and smooth wrinkles. A sun screen must be applied as well. Tretinoin should not be used in pregnancy.
· Azelaic acid cream
Azelaic acid inhibits formation of pigment and is also effective against acne. Try it first on a small test area of the chloasma as described above for bleaching creams. There can be mild stinging after putting it on, followed by a little peeling. This will settle with continued use of the cream. As with the bleaching creams, it takes several months to see worthwhile lightening of the pigment.
· Superficial peels
Repeated superficial chemical peels (glycolic acid or Jessner solution) may be helpful. Deeper chemical peels run the risk of increasing pigmentation and causing uneven results, but may be recommended in severe cases.
· Laser peel
IPL Photo Genesis is sometimes worthwhile but should be performed cautiously as it can aggravate pigmentation. It is very important to follow up with careful sun avoidance and it may also be necessary to use hydroquinone.
· Make-up
Cosmetic camouflage
Another approach to chloasma is to use special camouflage cosmetics.

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