Irregular pigmentation is one of the most common skin concerns, yet it remains one of the most frequently misunderstood. People often assume that all brown spots are the same and can be treated the same way. This assumption can lead to frustration, wasted time and money, and in some cases, a worsening of the very condition they were trying to improve.
Research has consistently shown that, regardless of natural skin colour, an even complexion is perceived as more attractive and healthier than patchy skin. This holds true across all ethnicities and skin types. The goal is never to lighten one’s natural skin tone, but rather to address areas of uneven pigmentation that can make us look tired, older, or simply less vibrant.
Before any treatment can begin, however, a correct diagnosis is absolutely essential. The reason is simple: what works brilliantly for one type of pigmentation may be completely wrong for another.
1. Melasma
Melasma presents as larger patches of pigmentation that are sharply demarcated and often symmetrically arranged on the face. These patches have a distinctive, almost bizarrely configured appearance and frequently display what dermatologists call a ‘confetti sign’. Common locations include above the upper lip, along the cheekbones, on the temples and across the forehead.
This condition has a strong hormonal link. It is more common in women, particularly during pregnancy, which is why it is sometimes referred to as the ‘mask of pregnancy’. Taking the contraceptive pill or other hormonal treatments can also increase the risk of developing melasma. It tends to occur more frequently in those who tan easily or have Mediterranean type olive complexions.
Here is an important word of caution. Laser treatment for melasma specifically is generally not advisable. While it may appear to produce good initial results, there is often a rebound effect several weeks or months later. The pigmentation can return darker and more stubborn than before. For melasma, other treatment approaches tend to yield more reliable, lasting results.
2. Chronic Sun Damage
Chronic sun damage manifests as a mottled appearance across the face, with numerous smaller, less sharply defined pigment spots called solar lentigines, commonly known as sunspots. These may also appear on the hands, where they are sometimes called ‘liver spots’, though they have nothing to do with the liver. The entire face can become covered with this generalised freckling, including sun exposed areas such as the tops of the ears, shoulders and forearms.
This type of pigmentation is more common in those with fairer skin and, unsurprisingly, in people with a significant history of UV exposure. Growing up in a hot climate, working outdoors, or having outdoor hobbies all increase the risk.
The important point about solar lentigines is that, unlike melasma, they tend to respond quite well to pigment targeting lasers. This makes them one of the more straightforward types of pigmentation to treat from a technical standpoint.
3. True Freckles
True freckles, known medically as ephelides, are often confused with sun damage. They are smaller than solar lentigines, typically around one to two millimetres in diameter, compared to five millimetres or more for sunspots. They appear as light brown, quite symmetrically round spots.
The classic freckle patient has fair skin with red or blonde hair and blue or green eyes. There is a strong genetic component to freckling. True freckles characteristically darken with sun exposure in summer and fade noticeably during the winter months.
Here is how to tell the difference. In adults, if the entire face appears covered in what looks like freckles, this is usually chronic sun damage rather than true freckles. True freckles typically appear in childhood, often by the age of two. Solar lentigines from chronic sun damage appear later in life as the cumulative effects of sun exposure become visible.
Another key distinction is behaviour. True freckles fluctuate with the seasons. Solar lentigines remain relatively constant throughout the year.
It is worth noting that having true freckles does not protect against developing chronic sun damage later. Both conditions are more common in fair skinned individuals, and one can certainly develop the mottled appearance of sun damage on top of a pre existing freckle pattern.
4. Seborrhoeic Keratoses
These pigmented lesions can sometimes be confused with sunspots or freckles when they appear on the face. On the body, seborrhoeic keratoses tend to be more obviously raised and warty, making them easy to distinguish. On the face, however, they can be quite flat.
The way to differentiate them is to look very closely, ideally with magnification, and to touch the lesions. Seborrhoeic keratoses are usually slightly raised compared to solar lentigines and freckles, which are completely flat. There also tend to be fewer of them, often just a single lesion or a handful of isolated spots.
A subtype called dermatosis papulosa nigra, or DPN, is particularly common in darker skin types. In this condition, there are numerous smaller brown bumps rather than the isolated lesions typical of standard seborrhoeic keratoses. DPN has a very strong association with family history. Around a third of black Americans show some degree of DPN.
From a treatment perspective, seborrhoeic keratoses do not respond as well to laser treatment as solar lentigines do. They can, however, be effectively removed through freezing, electrocautery, or surgical curettage.
5. Post Inflammatory Hyperpigmentation
Post inflammatory hyperpigmentation, often abbreviated to PIH, presents as brown patches in areas where there has been previous inflammation. A common example is the dark marks left behind after acne spots have healed.
PIH is significantly more common in darker skin types and requires a two pronged treatment approach. Addressing the pigmentation alone is not enough. The underlying inflammation that drives the pigmentation must also be tackled. Without addressing both, the cycle simply continues.
Why Correct Diagnosis Matters
It is entirely possible, and indeed quite common, to present with more than one type of pigmentation simultaneously. A patient might have both melasma and chronic sun damage, for example. Each requires its own treatment approach.
The crucial point is this: treatment for one type of pigmentation may be completely contraindicated for another. A laser that works beautifully for sun damage could make melasma significantly worse. An approach that addresses PIH effectively will do little for seborrhoeic keratoses.
This is why starting with a thorough assessment and correct diagnosis is so important. Everything else follows from getting this first step right.
Whether you have a medical skin condition which needs treatment or simply want to look your very best, our specialised dermatology team will help you achieve the very best result.
