Summary

Skin color is dependent on melanin pigment. Pigment-forming cells are called melanocytes. Abnormal hyperpigmentation (increased pigment) may result from alteration of the rate of melanin production, or uneven distribution of pigment, or both. Although rare, some pigmented skin diseases are genetically determined. Most pigmented disorders result from acquired factors such as UV light, skin trauma, pregnancy, hormones, drugs, or chemical compounds. The MSI team of medical professionals will thoroughly assess your condition before determining which energy-based technology is best to treat your disease. We use selective lasers, fractional lasers, fractional radiofrequency, and elos light technology. We mix and match different techniques to give the best possible results. Furthermore, physician skincare products with or without electroporation will help you to achieve the best results.

Do Dark Spot Need Treatment?

Many patients with various types of pigmented lesions present to a dermatologist for treatment primarily because of cosmetic concerns. Before treatment, and for treatment to be most effective, it is crucial to determine the depth of the pigmentation in the skin. Clinical judgment is not always helpful. Sometimes Wood’s Light gives conflicting results. 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.

What Are the Options in Treating Dark Spot?

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 pigmentation. Therefore, You should wear a photoprotective 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 lesion using chemical depigmenting agents such as hydroquinone, Arbutin, Licorice, or Kojic acid. Unfortunately, hydroquinone can help superficial (epidermal) pigmentation, and only 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 in addition to 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.

Other 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 hypopigmentation, hyperpigmentation, atrophy, scarring, and frequent recurrence. Treatment of dermal pigmented lesions by any destructive agent invariably causes scarring.

Why are Lasers Needed in 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 rate of melanin production, or uneven distribution of pigment, or both. Although rare, pigment 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, age spots, café au lait birthmarks, or are deep (dermal) such as tattoo pigments and nevus of Ota, or are mixed (dermo-epidermal) lesions such as melasma, post-inflammatory hyperpigmentation, nevus Spilus or Becker’s melanosis.

Because treatment of pigmented lesions (Dark Spot) is often done for cosmetic reasons, it should not only be helpful but as free from adverse reactions as possible. Treatment should, therefore, be directed toward selective destruction of pigment-containing cells in either the epidermis or dermis, without adverse effect on surrounding tissue, hence why only laser light is unique in obtaining desired results. When proper laser parameters are used, laser light behaves like a magic bullet, precisely clearing thousands of microscopic pigment-laden cells, including melanocytes, keratinocytes, nevus cells, and tattoos, without adverse effects on surrounding tissue. Lasers have been credited for clearing dermal pigmentation for the first time without scarring.

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?

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 combination of wavelength and rapidly pulsed light minimizes 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; Treatment; and Post-treatment Healing:

Pre-treatment Preparation: patients are advised to avoid aspirin or any non-steroidal anti-inflammatory agents such as ibuprofen to prevent the occurrence of bruising after treatment. Many patients benefit from topical anesthetic cream (EMLA) applied under an occlusive dressing 1-2 hours before laser treatment, removed just before the surgery. Bleaching cream specifically designed for each patient can be applied two weeks before laser session and continued for another two weeks to decrease any incidence of bruising should it occur.

Treatment: During the procedure, I will cover my eyes with protective eyewear. The skin is kept cool with a cold gel or a cooling device for the patient’s comfort. The laser procedure is quick; duration depends on the site treated. A topical antibiotic and dressing are placed on the treatment site following the laser session. Patients are given detailed instructions for care of the treated area by a member of our well-trained medical staff.

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 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. No specific wound care is needed after the treatment of epidermal lesions. A subtle eschar appearing as a darker version of the original lesion will form and peel off within 7–10 days. 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 1–2 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.

Freckles

appear as light brown pigmented macules on light sun-exposed skin. Initially 3mm in diameter, but increase in number, size, and depth of pigmentation during the summer months. More frequently seen in individuals with red or blonde hair and blue eyes.

Lentigines (age spots)

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)

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.

Cafe-Au-Lait Macules (coffee with milk birthmarks)

occurring in 14% of the population, ranging from 2-20cm in diameter. May appear at birth or soon after that, increasing in number over the first two decades of life. Lesions may be found in several genetically determined syndromes, including von Recklinghausen disease. Treatment sessions are spaced at least eight weeks apart, and clearance requires at least 2–4 treatment sessions.

Freckles and age spots respond most favorably, with virtual complete removal after 1-3 treatments. Café Au Lait responds less positively, not responding at all, and sometimes getting darker or ever-recurring after clearing.

Mixed (Dermal-Epidermal) Dark Spots Skin Lesions

Lesions in this category include Becker’s nevus, melasma, postinflammatory hyperpigmentation, drug-induced hyperpigmentation, and nevocellular nevi. The pigment is present at the dermo-epidermal junction and, in the case of a Becker’s nevus, in addition to the pigment, there are often terminal hairs in the lesion itself. Nevocellular, junctional, and compound melanocytic nevi should be treated with laser only if the operator in particular that they are benign.

Becker’s nevus.

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. Once present, Becker’s nevi stay indefinitely. It is usually first noticed during adolescence, more commonly in males than females.

Becker’s 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 generally incomplete and patchy. I can remove the terminal hairs with hair removal lasers.

Melasma (pregnancy mask)

Bilateral, symmetrical brownish hyper-melanosis affects the upper lip, cheeks, forehead, and chin, becoming more apparent following sun exposure. Frequently occurs during pregnancy, menopause, with certain topical medications, or when taking hormones or oral contraceptives. Condition is commonly seen in men of Middle Eastern or Asian descent.

Unfortunately, although lasers can improve the appearance 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. Although there is no definitive cure, the fractional CO2 laser has been reported as a treatment modality to improve melasma. 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 to not try correction of melasma during spring or summer as incidental sunlight exposure will likely 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.

Post-Inflammatory Hyperpigmentation (PIH)

PIH can occur on the face but can also result from hemosiderin deposition after sclerotherapy. Individuals with darker and yellow-toned skin show more pigmentary reactions following trauma and acute or chronic skin inflammation. Hyperpigmentation has various sizes and shapes and may affect large areas.

Cutaneous pigmentation commonly occurs following sclerotherapy of varicose and telangiectatic leg veins in 10%-30% of patients, mainly due to hemosiderin deposits. It is essential to use low fluences and ensure that the patient does not develop significant post-treatment erythema to provoke more PIH. For this reason, test spots are encouraged before treating large areas. The laser system currently used most often for PIH is the fractional photothermolysis system. All patients being treated for PIH on the face should use bleaching cream along with a broad-spectrum sunscreen before and after treatment. Before using a laser for facial PIH. At MSI, Prof Moawad recommends a series of MSI chemical peels and mesoderm to improve the discoloration with laser as the final step. Recurrence is frequently seen, especially after sun exposure.

Drug-induced hyperpigmentation

Minocycline, doxycycline, amiodarone, and zidovudine can cause hyperpigmentation of the skin that appears gray-brown to brown. Type II minocycline hyperpigmentation has been reported to clear after using the QS Nd: YAG laser. Discontinuation of the medication is essential. As in PIH, the use of bleaching, sunscreens, series of chemical peels, microdermabrasion, mesoderm should be tried first with laser as the final step.

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 congenital nevi who do not want surgical removal. Residual pigment and re-pigmentation are standard.

Dark Circles Treatment

Infraorbital discoloration results from various 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 circles with a selective pigment laser or a resurfacing technique using the CO2 laser or both.

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 Skin Lesions

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 10 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.

Congenital dermal melanocytosis

Mongolian spots typically appear as blue-gray macules of varying size on the body that resolves in childhood but occasionally persist into adulthood. These can be treated with the 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.

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.

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.

Conclusion

Several pigment-specific lasers can effectively treat epidermal and dermal pigmented lesions. Lasers are most effective in treating epidermal pigmented lesions (e.g., lentigines, ephelides). I expect variable responses in café au lait macules, Becker nevi, and melasma. Nevus of Ota is unique in that near-total clearance is often seen after laser treatment. New, long-pulsed, pigment-specific lasers may further enhance the clinical results obtained in resistant pigmented lesions and other conditions. Future lasers for pigmented lesion treatment may selectively target melanocytes rather than melanosomes. It will resolve the controversy over laser treatment of congenital nevi once thousands of treated lesions are watched for several years.

Warning

Birthmarks Treatment. Lasers should not be used for any melanoma, as melanoma recurrence rates are very high, even in situ. Similarly, Prof Moawad does not recommend the removal of dysplastic nevi with lasers.

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