Expert Doctor Specializing in Treating Melasma and Dark Spots in Bangkok 

Darks spots, moles, or hyperpigmentation are conditions where certain areas of the skin become darker than usual or develop excess pigmentation in those areas, resulting in an uneven complexion with dark patches that are difficult to conceal. While not necessarily severe, these conditions can significantly impact confidence and self-image, often requiring constant cosmetic coverage. Both internal hormonal factors and external environmental conditions contribute to the onset of these conditions. Therefore, understanding the causes and treatment options can help individuals make better decisions in self-care and prevention. 

What are melasma? Melasma are a common dermatological condition caused by the overactivity of melanocytes, the cells responsible for producing pigment in the skin. This leads to an increase in localized pigment production (hyperpigmentation), resulting in darker patches, especially prominent on the face and sometimes on the neck, chest, and arms. Freckles are most prevalent among individuals with Fitzpatrick skin types III-IV, commonly found in Asian populations. They appear as light to dark brown spots or patches and are more frequently observed in women than in men, with a ratio of 9:1. 

The exact cause of melasma remains unclear, but it is believed to be associated with the overactivity of melanocytes beneath the skin’s surface. Freckles occur due to an increased melanin production, with melanocytes in affected areas having longer dendrites and a higher concentration of melanosomes in stages III and IV, both in epidermal and dermal melanocytes. Factors that increase the likelihood of freckles include Asian ethnicity, particularly Fitzpatrick skin types III-IV, female gender, sun exposure, hormonal changes such as during pregnancy or with contraceptive use, genetics, thyroid disorders, and low levels of testosterone. 

In summary, understanding the factors contributing to the development of freckles can help individuals take proactive measures to manage and prevent these conditions, thereby improving their self-care and confidence. 

Periorbital hyperpigmentation, also known as dark circles under the eyes, occurs due to the thinness of the periorbital skin, leading to the visibility of blood vessels, hollows, and shadows. Accumulation of melanin in the dermis, post-inflammatory hyperpigmentation (PIH) resulting from conditions like allergic contact dermatitis, etc., can contribute to its formation. Treatment options for periorbital hyperpigmentation include topical medications such as hydroquinone, kojic acid, azelaic acid, etc., as well as various procedures like chemical peels, radiofrequency, fractional laser, picosecond laser, filler injections, fat injections, etc. 

Freckles, also known as ephelides, are small, flat, brown spots that appear on the skin due to increased melanin production. They are commonly found on sun-exposed areas of the skin and are usually harmless. Freckles may be treated with topical creams containing ingredients such as hydroquinone, retinoids, or azelaic acid, or through procedures like chemical peels, laser therapy, or cryotherapy, depending on the individual’s preference and severity of the freckles. 

Ephelides, freckles 

(Ephelides (Freckles) — Dermatology Advisor, n.d.) 

These are light brown patches with distinct borders, typically larger than 5 millimeters in size, commonly found in areas exposed to sunlight such as the face, back of the hands, and arms. This condition is more prevalent in individuals with fair skin compared to those with darker skin tones. Prolonged sun exposure tends to darken these spots and may contribute to their increased occurrence. 

Solar lentigo, actinic lentigo, sun spot, senile lentigo 

(Solar Lentigines — Dermoscopedia, n.d.) 

Due to sun exposure, freckles are commonly found on sun-exposed areas such as the face, upper chest, back of the hands, and arms, often seen under shaded areas of clothing exposed to sunlight. Initially, freckles tend to be smaller than 5 millimeters in size, with a light brown color that may darken over time. Freckles usually increase in number gradually and may enlarge in size, with small spots merging to form larger ones. Treatment can involve targeted laser therapy aimed at specific pigmented spots, causing them to peel off gradually within about 7 days. Typically, 1–5 treatment sessions are needed, with freckles often responding well to laser treatment. 

Hori’s nevus 

(Tian, 2015) 

Hori’s nevus typically appear as dark brown or grayish round spots. They are often found in clusters on both sides of the cheeks and both temples, commonly starting around the ages of 20–30. Genetics play a role, with a higher prevalence in females at a ratio of 21:1 compared to males. They resemble freckles but tend to have a more grayish hue, hence the name “Hori’s nevus” 

These spots do not fade away on their own and often darken over time. Treatment typically involves targeted laser therapy to remove both epidermal (top layer) and dermal (deeper layer) pigmentation. Picosecond laser is effective, with a minimum of 5 sessions required due to the deep-seated nature of lentigines. Topical treatments or superficial laser therapy targeting only the epidermal layer are ineffective in eliminating lentigines since the melanin deposits are deep within the dermis or inner layers of the skin. Laser treatment may cause transient hyperpigmentation, which typically fades after using whitening agents. 

Red and Dark spots from acne 

Post-inflammatory erythema (PIE) and post-inflammatory hyperpigmentation (PIH) are residual marks that occur after the inflammation of acne. PIE appears as red marks resulting from inflammation of the underlying tissue combined with the expansion of blood vessels. On the other hand, if inflammation persists over a prolonged period, it stimulates melanocytes to produce excess melanin, resulting in post-inflammatory hyperpigmentation or dark spots after the acne heals. Therefore, gradual and consistent care of inflamed acne can help reduce the severity of acne marks. 

Melanocytes are cells that produce melanin, the natural pigment that determines skin color, hair color, eye color, and post-acne dark spots. These dark spots occur due to excessive melanin production or the release of excessive melanin produced by melanocytes, making the dark spots darker than other areas. Thus, individuals with fair skin tend to have a faster fading of dark spots and red marks compared to those with darker skin, as dark spots may linger longer in the latter. 

Basic treatment for dark spots usually involves skincare products containing ingredients such as niacinamide, vitamin C, retinol, etc. However, noticeable improvement may take some time and patience. 

Currently, the most effective and fastest method for removing dark spots and post-acne marks is Picosecond Laser, the latest innovation in laser technology. It directly affects and destroys melanin granules within seconds, using energy at 1/1,000th of the nanometer level of the traditional Q-switched laser system. Treatment typically requires about 3–5 sessions, depending on the severity of the individual’s condition. 

Treatment options for mild to moderate hyperpigmentation, such as post-inflammatory erythema (PIE) and post-inflammatory hyperpigmentation (PIH), include: 

Skin exfoliation: 

• Chemical peels: Chemicals are applied to the skin to exfoliate the top layer, revealing new, healthier skin underneath. 
• Microdermabrasion: A minimally invasive procedure that uses a diamond-tipped wand to gently exfoliate the skin, promoting cell turnover. 

Stimulating skin cell turnover in the dermis: 

• Vitamin A acid: Also known as retinoids, these compounds promote skin cell turnover and help fade pigmentation. 
• Glycolic acid: A type of alpha hydroxy acid (AHA) that exfoliates the skin and encourages the growth of new, evenly pigmented skin cells. 
• Salicylic acid: A beta hydroxy acid (BHA) that penetrates deep into the pores to unclog them and improve skin texture 

Inhibiting melanin synthesis: 

• Hydroquinone: A popular skin-lightening agent that inhibits melanin production. 

• Arbutin, kojic acid, licorice extract, tranexamic acid: Other skin-lightening agents that may be effective but are less commonly used due to lower efficacy and higher cost. 

Reducing melanin transfer from melanocytes to keratinocytes: 

• Laser treatments: Q-switched laser, fractional laser, and picosecond laser are popular options that can target melanin deposits within the skin. 

It’s important to note that prolonged use of hydroquinone can lead to rebound hyperpigmentation, where the skin becomes darker than before. Therefore, treatment goals should focus on reducing existing pigmentation, inhibiting the formation of new pigmentation, and preventing future pigmentation by avoiding UV radiation exposure. 

While there is no definitive cure for hyperpigmentation, laser treatments have become increasingly popular due to their ability to target melanin deposits effectively. These lasers should ideally have: 

• Short pulse width in the nanosecond or picosecond range. 
• Adjustable energy levels. 
• Wavelengths in the visible to near-infrared range (approximately 1,100 nm). 

Studies on ablative laser resurfacing for treating hyperpigmentation have shown that it can cause discomfort, prolonged downtime, and potential uneven skin tone afterwards. Severe side effects such as scarring may also occur. Therefore, to ensure effective treatment, laser penetration into the dermis is necessary to target the root cause of pigmentation. Skin resurfacing with lasers that induce skin peeling (e.g., CO2 or Erbium YAG laser) may provide better results, although they come with longer downtime and a higher risk of side effects. 

In the treatment of pigmentation abnormalities, lasers based on the principles of Selective Photothermolysis, which generate heat at the targeted area, have been explored. However, outcomes using lasers such as 532 nm frequency-doubled Q-switched Nd: YAG, 694 nm Q-Switched ruby, or 755 nm Q-switched alexandrite have been unsatisfactory. Similarly, the use of Intense Pulsed Light (IPL), which has a broad spectrum ranging from 515 to 1,200 nm, has been widely employed. Unlike lasers, IPL does not require specific targeting. Its light waves can penetrate both the superficial and deep layers of the skin, with a pulse duration in the millisecond range, allowing for effective heat dispersion and reduced risk of side effects from excessive heat. However, IPL treatment for pigmentation abnormalities should be combined with topical therapy, such as hydroquinone creams, especially for treating superficial and mixed pigmentation types, to achieve better outcomes compared to deep or mixed pigmentation types. 

Q-switched laser technology is considered Minimally Selective Photothermolysis due to its extremely short pulse durations, which are shorter than those of IPL by approximately one million times. Q-switched NdYAG lasers have been in use since around 1990 and include ruby (694 nm), alexandrite (755 nm), and neodymium-doped yttrium aluminum garnet (Nd:YAG; 532 nm or 1064 nm) lasers. These lasers have been used for tattoo removal, pigmented lesions, and even freckles, leading to the expectation that they could effectively treat hyperpigmentation. However, due to their limitations in targeting only the epidermal layer of the skin, the results in treating hyperpigmentation have not met expectations. 

Studies on using Q-switched ruby lasers for treating hyperpigmentation have not shown significant improvements, with some patients returning to their original skin tone several months after treatment. Similarly, studies on Q-switched alexandrite laser and combined carbon dioxide (CO2) and Q-switched alexandrite laser therapy have also yielded unsatisfactory results, with reported side effects from the treatment. Subsequently, low fluence or subthermolytic Q-switched lasers have been developed in an attempt to mitigate side effects and improve treatment 

Q-switched Nd:YAG laser has gained significant popularity as it can effectively address pigmentary concerns such as freckles, lentigines, melasma, and post-inflammatory hyperpigmentation with deeper penetration into the skin compared to traditional treatments like chemical peels or topical treatments. The principle of Q-switched laser treatment involves breaking down pigment or dark spots without affecting the surrounding skin. The laser energy is absorbed by the pigment, causing it to fragment into smaller particles within the skin cells, which are then naturally eliminated by the body’s lymphatic system. 

The advantage of Q-switched lasers lies in their ability to penetrate deeper layers of the skin compared to creams or superficial treatments, targeting the root cause of pigmentation problems. Additionally, the procedure is minimally invasive and has fewer side effects compared to ablative laser resurfacing. 

However, it’s essential to note that while Q-switched Nd:YAG laser treatment is generally safe, it may still have some side effects. These can include temporary discomfort during the procedure, redness, swelling, itching, or temporary darkening (hyperpigmentation) or lightening (hypopigmentation) of the treated area. These side effects usually resolve on their own within a few days to weeks. 

Overall, Q-switched Nd:YAG laser is considered an effective and safe option for treating various pigmentation concerns, but it’s essential to consult with a qualified dermatologist or laser specialist to determine if it’s the right treatment for your specific needs.