So we have talked about how to tell what kind of brown spots you have in the precious post, Out, damn’d spot! Out, I say! Get Rid of Brown Spots on the Face so you know what needs to be done to get rid of them. Since we solved the sun damage spot problem in the last post How to Get Rid Of Your Past: Removing Brown Spots From The Sun, let’s move up the difficulty ladder to how to remove those horrible growths that come over time. They are the dreaded “age spots” or “liver spots.”

To recap, here is what you see:

• In the mirror: Tan to dark brown flat or raised growths.
• Diagnosis: Seborrehic Keratosis, which dermatologists call SK’s and you call age spots or liver spots. They often run in families, and are more common as you age.
• Treatment: First—physician evaluation to be sure they are benign, then destruction with liquid nitrogen, electric needle and curette or Fraxel Laser Treatment.
• Ease of treatment: Moderate.

People really hate these kinds of spots. The reason is that young skin is smooth, without ugly raised growths. In fact, studies have shown that people’s impression of the age of another person is primarily determined by the absence of spots and growths even more than the absence of wrinkles. In other words, a person with spots and growths but minimal wrinkles looks older than a person with few spots and more wrinkles. Sometimes the SK’s are itchy or get irritated and rubbed with clothing or things that rub up against them.

Now before we talk about how to remove them, I have to give you a disclaimer. There is another, and serious, skin growth that can be a raised brown or black growth. And that is melanoma. Melanoma is a serious skin cancer that is fatal if untreated or if treatment is delayed. It can be very hard to tell a benign non-cancerous SK from a cancerous melanoma. So hard in fact, that it is not uncommon for it to be difficult at times for a non-dermatologist physician to be sure that a particular lesion is benign. Even dermatologists, who see many tens of thousands of these lesions over a career, will need to biopsy some of them to ensure that we are not missing a melanoma. So it is very important that your brown growth is accurately diagnosed as an SK before treatment. And no, Dr. Google can’t do it and you can’t either.

So you should see a dermatologist for diagnosis and treatment. The other reason dermatologists are the best doctors to treat these are that these age spots or liver spots have to be removed by physical methods. Treatment has to be aggressive enough to remove them, but aggressive treatments can leave permanent lighter spots, permanent darker spots, or scarring. There is a fine line between the best cosmetic result and either incomplete removal or over aggressive removal with resultant scarring or pigment change. And you don’t want to cross that line. So see your dermatologist who will be sure they are benign SK’s, not cancerous melanoma and then treat them. Lecture over.

Some families tend to grow a lot of SK’s and interestingly in each family people tend to get them either on the face, or on the trunk. They range in size from pin head size to the size of a half dollar, and can be tan, brown, and dark brown or almost black. Some are dry and scaly, or hard and rough. Some are more smooth and greasy looking, which back in the day lead to them being thought to come from oil glands. Numbers can vary from one or two up to many hundreds, or as we in the medical field call TNTC—too numerous to count. There is nothing you can do to prevent SK’s from coming. If they are, they are.

There is a variant of SK’s called dermatosis papulosis nigra or DPN. Dermatologists love long names, and makes us sound so smart don’t you think? Anyway, it is most often seen in skin types IV-VI, especially in people from or of origin in the African or Asian continents. It consists of hundreds of tiny pinhead sized black growths, especially in women and predominantly on the cheeks. We treat it as discussed below but it is a challenge due to the tendency of darkly pigmented skin to develop pigment change in response to trauma.

Home Treatment:

• Basically, none. These are growths that have to be physically removed. The dark color doesn’t come from increased melanin pigment; it comes from a lot of cells with normal or increased pigment stacked up on top of each other. Over the counter or prescription bleaches don’t help, although we do use them for a month or so before treatment to help stabilize pigment in patients who have a fair amount of natural pigment in order to help prevent or reduce the post-inflammatory pigmentation that often follows procedures. There are all sorts of home remedies to remove age spots that you hear about; castor oil, salt water and friction and others. They can peel off the top layer temporarily, but I have never seen them work long term.

Office Treatment:

• Destruction with Liquid Nitrogen: The most common way to treat age spots is by freezing then with liquid nitrogen. It is effective, relatively inexpensive and quick. The SK’s scab up, and fall off in about 7-10 days on the face, and 3-4 weeks on the body. But they have to be frozen hard enough to go through the growth, separate it from the underlying tissue. Sometimes the whole growth falls off, sometimes only part of it. Unfortunately it may leave an area that is lighter than the surrounding tissue as the pigment producing cells are killed.

• Electric Needle and Curette:A more time consuming way to treat these brown growths is to inject a local anesthetic, cauterize the growth, and then scrape away the tissue. The nice thing about this treatment is that the growth is gone immediately. But just like freezing with liquid nitrogen, it can leave a change in pigment after healing. But if done carefully, I like this method best for dermatosis papulosis nigra, and for patients who have a lot of natural pigmentation, because it can heal with no or less pigment change.

• Fraxel Laser Treatment: Although we don’t use often Fraxel Laser Treatment as first choice of treatments, patient with age spots will often get improvement if they are undergoing Fraxel for other problems, such as wrinkles, or after one of the other treatments.

Both of the primary methods of treatment have been around for a long time. Not nearly as exciting or as lucrative for the physician as laser, but it just goes to show you that sometimes new is not better. Treatment sounds simple but it does take experience to be able to treat these with a minimum of pigment change.

Next we will be getting into much more difficult pigment problems, the bane of dermatologist’s existence—post inflammatory pigmentation and melasma.