What Causes Dark Spots?
Not all dark spots are created equal. As a dermatologist, I've treated thousands of patients for dark spots, most commonly compared with hyperpigmentation. Here I'll break down the questions I get asked most:
- What causes dark spots?
- When should I visit a doctor for your dark spots?
- What skincare products and ingredients should I look for today that will help fade my dark spots?
What causes dark spots to form and how common are they?
Dark spots are not a one-size-fits-all condition. A number of factors can lead to them appearing. Before you begin looking for treatments, it's critical that sure you know what you are treating, because while some dark spots can be treated with over-the-counter creams, not all can be.
What we commonly call a “sun freckles,” are the small, round, light brown spots scattered across the skin from sun exposure. These spots are most common in people who have light or pale skin. Aside from freckles, another class of dark spots is called lentigines.
Different forms of dark spots and what causes them to form:
- One form of lentigo is lentigo simplex. These spots are usually darker and appear during childhood. Unlike freckles, these can appear anywhere on the body and aren’t caused by sun exposure, and do not fade in the wintertime.
- Another type of lentigo is solar lentigo. As the name suggests, these are caused by sun exposure, and typically appear on the hands, foreheads, or cheeks of older people.
- There are also seborrheic keratoses. These dark spots can be very flat and are the result of too much of a good thing. We as doctors still do not know why people get these spots, but most people will see them on their skin eventually. They are not seen usually before 35-40 years of age and will not lead to skin cancer. These can be very flat, light tan, brown or dark brown. There is no cream over the counter that will budge these spots.
- Mottled pigmentation that occurs often on both cheeks is known as melasma. The most common causes of melasma are an interaction between the sun, hormones, irritation and genetic predisposition.
- Dark spots that come from inflammation such as a pimple, scratch or irritation are typically described as post-inflammatory hyperpigmentation.
Are the dark spots on my face normal?
Before looking at how to reduce dark spots, you need to ensure that those dark spots on your face are not turning into cancer, that they are safe or benign.
Here are a few of the most common types of dark spots you might notice on your face and how to know whether your dark spots are safe.
- Lentigo - Typically a round to oval shape and begin to appear as you get older. This type of spot is typically light to medium brown, located on the back of your hands, cheeks or in sun-exposed areas with sharp edges surrounded by normal-looking skin. Importantly, they will not fade in the winter.
- Ephelis – A common freckle from sun exposure. This will usually fade in the winter.
- Lentigo simplex – No predilection (preference) towards or against areas that have experienced more or less sun, they are mostly evenly pigmented, brown or black.
- Lentigo maligna - This is one to keep a special eye out for. It is an early-stage melanoma that appears on sun-damaged skin. The difference between a solar lentigo (harmless dark spot) and early melanoma is that in melanoma, these spots will change with some of the following features: show irregular edges, an enlarging diameter, and sometimes uneven pigmentation. Usually, these will present over time and do not “bother” you until they are advanced, e.g. they do not cause irritation.
- Lentigo maligna melanoma - These usually evolve from lentigo maligna lesions mentioned above, but may appear more rapidly with an invasive component that increases the risk of melanoma spreading to other areas such as the lymph nodes and beyond.
- Moles (nevi) and birthmarks- These flat (or raised) lesions should be stable, no changes in size, texture or color. If there are any changes, they could be evolving into a more serious problem like cancer.
- Seborrheic keratois- These can be flat or raised brown spots that appear almost "stuck on". They come with age and genetic disposition. They can become irritated and inflamed.
What are the best ingredients for fading dark spots?
The most commonly used ingredient is called hydroquinone. It is the gold standard for reducing melanin synthesis, which essentially will help to fade splotchy spots on your face. This ingredient is widely available at 2% over the counter, prescription at 4-8%. The higher concentrations tend to be irritating and are often mixed with a topical corticosteroid steroid cream and sometimes a retinoid. It is important to avoid irritation as that can lead to more hyperpigmentation.
Before starting with hydroquinone you should be aware that sometimes, rarely in the U.S., with prolonged use, people can see a response called ochronosis, or black spots to appear on the skin.
Hydroquinone isn't the only option we can use in fighting against dark spots. Other key ingredients include:
- Sunscreen - Using a broad-spectrum sunscreen is one of the easiest ingredients to help treat dark spots that you can get started with today. Using a broad-spectrum sunscreen of SPF 30 that is mineral-based is the best option for people with post-inflammatory hyperpigmentation. Not only do you need to avoid ultraviolet rays from the sun but it's also best to avoid additional heat from the use of chemical sunscreens. In addition, blue light, pollution and infrared exposure can worsen hyperpigmentation. Therefore the core at your treatment of your hyperpigmentation should include a daily product. If you will be outside, reapply every two hours, wear sunglasses with a hat are essential to getting ahead of your hyperpigmentation and keeping it from recurring. Some causes of hyperpigmentation include chronic conditions, so if you are improving, you will need to understand your underlying reasons for hyperpigmentation. It may be a marathon that requires a maintenance program, not just a quick fix. This holds true for all skin types but especially in darker skin types.
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- Azelaid Acid - Derived from yeast that is a common resident of our skin, it works to diminish hyperpigmentation by not only enzyme inhibition, but also reducing DNA synthesis to reduce abnormal melanocytes. This is often a terrific non-hydroquinone option for those with both melasma and/or post-inflammatory hyperpigmentation from acne or acne rosacea. It addresses both issues without risks of irritation often seen with other products.
- Vitamin C, E - These two vitamins work best together to inhibit melanogenesis. These vitamins improve not only melasma but also hyperpigmentation from inflammation. Rarely Vitamin E can cause allergic reactions.
- Niacinamide - Vitamin B3 interrupts the pigment transfer from melanocytes (pigment-producing cells) to keratinocytes (skin cells) as well as dampen down inflammation that can also promote darkening of spots from acne, etc.
- Kojic Acid - Derived from fungus it inhibits production of tyrosinase and has strong antioxidant properties typically used at 2-4% concentrations. This has been best studied in combination (2% kojic acid 10% glycolic acid and 2% hydroquinone). This ingredient has been associated with irritation.
- Arbutin - Derived from a number of plants including blueberries and pear trees. This inhibits tyrosinase activity as well. It may make hyperpigmentation worse if used in too high concentrations.
- Green Tea extracts - This ingredient has anti-inflammatory, anti-oxidant and anti-carcinogenic benefits. The exact mechanism of how these ingredients work may be inhibition of tyrosinase but no human studies are available.
- Aloesin - Derived from the aloe plant this also inhibits the key enzyme in melanin synthesis.
- Coffeeberry - This extract has anti-oxidant properties. How this ingredient improves hyperpigmentation is not well known, however, there has been limited clinical evaluation showing improvement after four weeks of application.
- Soy - The contents of soy work to inhibit not only the enzyme that creates melanin, but also works to inhibit the transfer of existing pigment granules to skin cells.
- Pycnogenol - Derived from a specific pine, it contains ingredients that are both antioxidant and anti-inflammatory. It has been found to improve melasma.
- Licorice extract - Derived from the root of Glycyrrhia, it diminishes hyperpigmentation by multiple actions. It has anti-inflammatory effects and prevents sun-induced pigmentation.
- Retinoids - Derivatives of Vitamin A, it has been used in synthetic forms and shown to reduce melasma and post-inflammatory hyperpigmentation. Historically these compounds are used to treat acne. This vitamin diminishes the ability of pigment transfer to keratinocytes and increases the normal exfoliation rate of the epidermis. It can when used chronically it can increase the health of the outermost layer of the skin and decrease the amount of melanin. These products tend to work best in combination with topical steroids to reduce the inflammation that can be seen.
- Algae metabolites- Different extracts of various algae have been shown to suppress the melanin transfer causing skin darkening.
How do we use dark spot serums for best results?
All products are not created equally. Try to lean towards products that have published studies to demonstrate their effectiveness. Serums containing the above ingredients are typically used wherever the hyperpigmentation is present with gently blending into the surrounding skin. However, suppose you have an underlying condition such as acne or rosacea and are also using the azelaic acid or retinoid products. In that case, you should use them wherever you tend to have issues.
How long does it take to notice results?
The skin turns over every 4-6 weeks, so any product should be given a minimum of this time to determine the effectiveness.
Are there any products you should avoid when using a dark spot serum?
You'll want to make sure in general you are not using any products that could be irritating, thereby worsening your skincare problems. Avoid scrubs and abrasive cleansers and be cautious when combining products. Start with one product every 5-7 days and stop any product that is causing itching immediately as well as irritation.
Are dark spot treatments/serums safe for all skin types?
Most treatments are okay for all skin types. However, serums that have ingredients that can be irritating are especially frustrating, as they can worsen, rather than help the problem. What is not included in this question is what is the role of tranexamic acid in the treatment of melasma. Oral tranexamic acid is helpful in the treatment of recalcitrant melasma. Recent reports examining the use of topical tranexamic acid with micro needling was shown to improve melasma. If you had trouble following along with this last paragraph, we get it. It's a lot. In that case - send us a follow-up question here and we'll cover it on our weekly update newsletter.