Bye-Bye Brown Spots, Hello Glow
My office distributes a questionnaire that asks patients to check off any cosmetic concerns that they may have. A pretty consistent concern is brown spots.
Also known as sun spots, liver spots and age spots, the name doesn't really matter ... not a day goes by that I don't treat these pesky patches.
A combination of hormones and photo damage are to blame for these patches, which age our appearance and drive patients in for treatment.
Allow me to preface by saying that most over-the-counter products do not work on melasma. I cringe every time I see a catchy commercial or Photoshop-treated before-and-after photo in popular magazines, marketing a product that I know is not going to get patients the results they want. Usually before they seek professional help, they've spent quite a bit of money on several OTCs that just don't work.
That makes our job all the more fun, because there are such great, effective treatments to share with patients. I like to make sure patients are aware that the treatment of melasma, or hyperpigmention, is not a one-time treatment. Skin lightening, and most importantly, maintenance, is a process. A combination of prevention, treatment and exfoliation is the key to a successful outcome.
Patients can prevent these skin changes by applying a good sunscreen every day. I probably sound like a broken record, but I need to get my point across that this is the most important step. Patients really need to adhere to this step to see results and maintain them. I am very honest with them that any discoloration they are treating will likely return if they don't also apply sunscreen with the proper SPF. For the face, I recommend at least SPF 30 with UVA/UVB protection. A nice tinted mineral sunscreen is my pick, and a patient favorite.
I will classify treatment as all topicals and procedures that can treat hyperpigmention. They can be divided into those containing hydroquinone (HQ) and those that do not contain HQ. Hydroquinone is a gold standard in the treatment of melasma. We see incredible results with this in percentages ranging from 2% (OTC) to upwards of 12% to 14% (less commonly used). Most patients with mild to moderate discoloration do well with a 4% HQ prescription. One of my favorites is Blanche skin lightening cream by Neocutis. HQ can also be formulated by a compounding pharmacy to contain a retinoid, which allows the hydroquinone to have even better penetration, and/or cortisone to reduce associated inflammation from the other components.
Non-HQ products include antioxidants and botanicals. These are safe for more long-term use. These include azelaic acid, glycolic acid, kojic acid (also used on fruit to prevent oxidation or browning), phytic acid, lactic acid and ascorbic acid, just to name a few. I like Perle (Neocutis) and Mela-D (La Roche-Posay).
There are also very effective in-office procedures to improve age spots, such as Fraxel laser, Melange peel, Cosmelan depigmentation treatment, trichloroacetic acid (TCA) peels and photofacial treatments. To produce the best results, we typically bleach patients' skin prior to these procedures.
Last but not least, exfoliation. Gentle, consistent exfoliation is key. This can be obtained using retinoids, in-office peels, and alpha or beta hydroxy acids. Retinoids (both acid and alcohol forms) are a go-to product to increase cell turnover. This can make HQ and non-HQ products much more effective. I like Retin-A Micro, Renova and retinol. A newer tretinoin, Atralin, contains emollients and is a good substitute for patients with sensitive skin who may not be able to tolerate stronger retinoids.
It is extremely important to stress follow-up care. I typically see patients back in 6 to 8 weeks for re-evaluation and, depending on their progress, may continue a hydroquinone product for only an additional 4 to 6 weeks if necessary. Every case is different. There are instances we use HQ longer; the literature pretty consistently agrees that it should not be used more than 4 to 6 months consecutively. Remember, HQ is off the market in some countries so it is essential that you work to ensure that patients use this product responsibly. Discuss proper duration of use and proper application and document this. If you weren't already prepared to tackle brown spots, now you have the basics. Go for it! Your patients will love their new bright, even-toned skin.