Patients with pigmentary changes on their skin seek advice primarily for cosmetic reasons; they complain of having either too much or too little pigmentation, or they are unhappy with its distribution. Although pigment changes are usually asymptomatic and of no medical consequence, they may signify systemic disease.

The following are types of hyperpigmentation:

1. Melasma is found most often on the facial areas of women who either are taking birth control pills or are pregnant and has been called the “mask of pregnancy.” However, it also may be found in men or women with no apparent endocrinologic abnormalities. Its cause remains unknown, but exposure to the sun is necessary for its development. It is present more frequently in dark caucasians (e.g., Puerto Ricans and those of Mediterranean background).

2. Freckles, like melasma, are present only on light-exposed skin; neither is found on mucous membranes. Freckling is genetically determined, usually appears by age 5-7, and is seen most commonly in redheads, blondes, and other fair-skinned individuals. Freckles, like melasma, darken considerably in the summertime and may fade almost completely in the winter.

3. Large freckles are different. These large spots, which may appear at any age, are usually darker than freckles and neither increase in darkness in the summer nor fade in the winter. These freckles are inaccurately known as “liver spots” and appear on the exposed surfaces of fair-skinned people long exposed to the sun, usually in association with other changes from sun damage, including wrinkling and dryness. Multiple dark spots are rare. If present on the palms, sales, mucous membranes, or non-sun-exposed skin, they are often indicative of significant internal abnormalities.

4. Post injury hyperpigmentation is common in more darkly pigmented persons and is more related to the nature of the insult than to the degree of previous inflammation.

5. Acne is an important cause of dark spots especially in African-Americans. The acne should be treated first. The dark spots will eventually fade but can be helped by the same treatments as other dark spots.

There are a few ways you can treat dark spots. Dark spots may be removed or their intensity of pigmentation diminished by light cryosurgical freezing with liquid nitrogen. They can also be removed by lasers. The intensity of pigmentation in melasma, freckles, and senile dark spots and the epidermal component of post inflammatory hyperpigmentation may be decreased by the conscientious application of 2-5% hydroquinone cream or lotion. Since the ability of the sun to darken these lesions is much greater than that of hydroquinone to “bleach” the pigment, strict avoidance of sunlight is imperative. Sunscreens help and a broad-spectrum sun protection factor (5PF) 30 or greater sunscreen should be applied year round.