Treatment of sun spots and sun-damaged skin

What it is

Assessment comes first, because a spot that is growing, irregular, multicolored or newly dark is examined and sampled rather than lasered. Treatment then combines daily photoprotection and topical agents with targeted laser or light for the spots that justify it, and a separate medical pathway for anything precancerous.

What this page covers

• Solar lentigines and freckles: assessment, photoprotection and topical agents first
• Dermoscopy of pigmented lesions and the urgent pathway for a suspicious lesion
• Glogau photoaging grading, read with the caveat that it was described in lighter skin
• Photoprotection counseling including visible light, tinted sunscreen and planning for ihram
• Topical thiamidol, vitamin C, retinoids and antioxidant regimens for photodamage
• Q-switched 532 nm for superficial lentigines
• Picosecond laser for pigmentation, including fractional delivery
• Intense pulsed light and broadband light photorejuvenation
• Non-ablative fractional laser (1550 nm erbium glass, 1927 nm thulium) for field photodamage
• Cryotherapy for seborrheic keratoses and lentigines
• Electrocautery and curettage of seborrheic keratoses; dermatosis papulosa nigra
• Actinic keratosis and field photodamage treatment with cryotherapy, 5-fluorouracil or imiquimod
• Photodynamic therapy for field treatment
• TCA peel where the depth is justified and the phototype allows
• Long-pulsed Nd:YAG and telangiectasia treatment for the vascular component
• Neck and décolletage assessment, treated on its own settings rather than the face's
• Skin biopsy of a pigmented or unexplained lesion
• Mole mapping and digital total-body photography

Who it suits

Sun spots are not simply the mark of getting older, and they are not dirt sitting under the skin that scrubbing or a peel will lift: they are years of sun collected in the places the sun reaches most — the face, the backs of the hands, the chest and the shoulders. Several things look like them and are not them: seborrheic keratoses, melasma, marks left by inflammation, the precancerous roughness of actinic keratosis, and occasionally a lesion that needs a biopsy. A laser is not a diagnosis. The device cannot tell those apart; it sees pigment and breaks it up, so it clears the appearance and leaves the question unanswered. The spot is examined first and decided on afterwards — and anyone offering to remove a pigmented spot with a laser or a light before examining it has the order backwards: they have started at the treatment and worked back toward the diagnosis, and that is the order in which the thing that cannot wait is the thing that waits.

• Someone with discrete, settled brown marks on the face, the backs of the hands or the chest, collected over years, who wants them examined before anything is aimed at them
• Someone whose real complaint is not one spot but the change across the whole area: roughness, dullness, visible vessels — here photoprotection and topical treatment carry most of the plan, and a device comes afterwards if it has a place
• Someone whose fingertip finds a rough patch or a small scale before the eye sees it, on the forehead, the scalp, an ear, the lower lip or the back of a hand — that is a medical conversation rather than a cosmetic one, and it starts with an examination
• Not you if what you have is melasma: broader patches, symmetrical across the cheeks, the forehead or above the lip, darker in summer and quieter in winter. Melasma is a different condition, and what suits a sun spot can make it worse — melasma and pigmentation
• Not you if you want one session that ends the subject, or a spot removed today without it being examined. Freckles in a child are protected from the sun and kept under review rather than lasered

When we advise delaying or not treating

• Any pigmented spot that has not yet been examined. It is not lasered, not treated with light, not frozen and not burned off. The examination here is not a formality ahead of a decision already made; it is the decision
• Skin that has recently been in the sun, or is about to be: travel, outdoor work, Hajj or Umrah. The session is postponed, and the photoprotection is arranged before the trip rather than after it
• An area threaded or waxed in the last few days
• Skin thinned under a mixed cream or a cream with no clear label. The skin is repaired first — and bring the container with you so we know what is in it
• Moles and tattoo ink inside the treatment area: examined, then covered, rather than pulsed over because they are in the way. Both take a focal burn, and a mole treated without being examined can no longer be assessed
• A request to have a raised growth taken off for appearance before the diagnosis is confirmed. Pigmented basal cell carcinoma and melanoma can imitate a seborrheic keratosis, and destroying the lesion destroys the evidence with it; anything atypical is sampled rather than curetted away
• Freckles in a child. They are protected and kept under review, not lasered
• The prescription creams used for actinic keratosis — 5-fluorouracil and imiquimod — in pregnancy: they are not used, and the whole decision sits with whoever prescribes and monitors them
• Cryotherapy on a visible area before what it can leave on darker skin has been described: a pale mark, or a dark ring around the site. It is used with more care over the fingers, the ears and the lower leg where healing is slower, and with particular care in poorly controlled diabetes — a blister on the foot there is not a small problem
• A timetable built around an event. Field treatment deliberately produces a period of redness, crusting and soreness before it settles; that is the treatment working, not going wrong. When someone asks for all of it to be finished before next week's wedding or before travel, we would rather move the appointment than hand her skin halfway through peeling
• A laser in place of daily sun protection. Spots return with sun, and freckles come back without it. To someone who wants the device and declines the sunscreen we say plainly that the same sun that made the spots will bring them back, and that we would rather begin with the protection and look again afterwards

Possible effects

Stated in full, because the decision is not sound without them:

• Darkening after the session. The spot goes darker instead of lighter, sometimes a week or two later, and takes months to settle. This is the commonest disappointment on deeper skin, and it is the reason for test spots and conservative settings — post-inflammatory marks
• Blistering or a burn. Q-switched 532 nm and intense pulsed light are strongly absorbed by melanin, so the risk rises as the skin gets deeper, and rises further if the skin has recently seen the sun
• A pale mark where the treatment went. This follows cryotherapy in particular: a spot lighter than the skin around it, or a dark ring around that, which can take a long time to even out with the neighboring skin, and in some people does not fully even out
• The spots come back. They return with sun, and freckles return without daily protection. That is not a shortcoming of the session; it is the nature of the cause
• Waking melasma up. Intense pulsed light and pigment lasers can make melasma worse, and melasma can rebound even after picosecond treatment. That is why the diagnosis is settled before the device is chosen
• Field treatment for actinic keratosis is followed by days of redness, crusting, swelling and soreness. Photodynamic therapy is genuinely uncomfortable during the illumination and is followed by strict light avoidance. This is said before starting rather than afterwards, and it is planned around work and home
• A biopsy leaves a small mark, and on darker skin the site itself can pigment or form a keloid — which is weighed against the value of a firm diagnosis. Poorly controlled diabetes slows healing at the site, which is why it is asked about before anything is cut
• Cautery and curettage leave temporary marks while darker skin heals, and any implanted medical device such as a pacemaker is asked about beforehand
• A partial answer. A pigment laser lifts the brown and leaves the roughness and the vessels where they were, which is why the plan usually has more than one part. And any lesion that has not cleared after treatment, or that comes back ulcerated, firm, tender or growing, is sampled rather than frozen again — squamous cell carcinoma is excluded rather than assumed against

Most of the above is reduced by the same few things every time: a test spot before the whole area, conservative settings, and not treating skin that has recently seen the sun. The one thing no setting reduces is the cost of a delayed diagnosis, which is why the examination stays first.

A note on darker skin

Most of the people we see are Fitzpatrick III-VI, and this page is written on that basis rather than around it. The uncomfortable part first: the devices that clear a superficial brown spot most readily — Q-switched 532 nm and intense pulsed light — are also the least forgiving on deeper skin, where burns, blistering and post-inflammatory hyperpigmentation are all well described, and many patients with Fitzpatrick IV-VI are served better by a different modality than by either of them. Even non-ablative fractional treatment at 1927 nm is a recognized trigger for pigmentation in this skin, so density and energy are reduced, intervals are lengthened, and the skin is primed with a topical agent beforehand. Cryotherapy readily leaves a pale mark or a dark ring in these phototypes, so contact time is kept short and the possibility is described before anything visible is frozen. What actually suits deeper skin is not a particular device but an order of operations: daily protection with a tinted sunscreen that screens visible light and not ultraviolet alone, topical treatment given the time it needs, then a test spot and conservative settings if a device has a place at all — and none of it on skin that has recently seen the sun. Two things usually go unsaid. The Glogau photoaging scale was described in lighter skin and weighs wrinkling more heavily than pigment, so the grade on its own can understate what is actually there. And melanoma is less common in darker skin but is found later and does worse, and the places it most often appears are the sole, the palm and the nail — the same places the box near the top of this page asks you to look at tonight.

Afterwards

• Sun protection is not what comes after the treatment; it is the treatment continuing. Broad-spectrum sunscreen reapplied through the day, a tinted one for preference because it also screens visible light, plus shade, a hat, and an eye on the car window. If Hajj or Umrah is ahead of you, arrange it before you travel: for a man in ihram, an unscented mineral sunscreen whose ingredients he can check on the label, with shade, an umbrella where that is allowed, and the timing of movement. What is and is not permitted is a question for people of religious learning; our part here is the dermatology alone
• Leave the crust alone. Do not rub it or lift it before it falls off by itself; that is where marks are made
• The spot usually darkens before it fades, and that is expected in the first days. Do not judge the result early
• No lightening mixture and no unlabeled cream on healing skin. Whatever you are already using, bring the container to the appointment
• Tell us about a blister or a burn, pain beyond what you were told to expect, or a site that has not healed within the time you were given
• Tell us about the lesion that did not clear, or that cleared and came back. That one is sampled rather than frozen again
• Tell us about anything new between appointments: a spot that bleeds, itches or crusts and returns, a new dark band under a nail, or a dark patch on a sole or a palm. Those do not wait for the next appointment
• If you are asked to cover up and avoid sun strictly every day, raise vitamin D with your own doctor: strict photoprotection alongside an indoor life makes deficiency likely, and testing and dosing are arranged through the appropriate physician rather than guessed at
• Make the follow-up visit a look at the whole skin rather than at the one spot: scalp, nails, palms and soles. You are offered a staged examination that protects your privacy and a same-gender chaperone, and you may limit it to the high-yield sites, which is documented

Honestly

Spots return with further sun exposure and freckles in particular come back without daily protection; the pigment lasers that clear a lentigo most readily are also the ones most likely to blister or darken Fitzpatrick IV-VI skin, so test spots, conservative settings and no treatment at all on recently tanned skin are the rule, and freckles in children are protected rather than treated.

Common questions

See also

Post-inflammatory marks, Melasma & pigmentation