“I thought it was melasma, so I received toning treatments, but the darker spots are still there.”

 

In actual practice, this happens quite often.

 

On the surface, they may all look like brown spots, but inside the skin, they are often different problems.

Some lesions may be solar lentigines related to sun exposure, some may be closer to freckles, and others may be mixed with melasma or post-inflammatory hyperpigmentation.

 

That is why it is important to first distinguish what type of lesion it is, rather than simply thinking, “If the laser is strong enough, it will disappear.”

If you look at the before-and-after photos above, both cases show multiple small brown spots widely distributed around the cheekbones and outer cheeks.

 

Before treatment, individual dark spots are visible, but the overall facial tone also appears somewhat uneven and blotchy.

 

After treatment, the areas that looked darker appear generally lighter, and the skin tone looks more even.

 

One of the questions many people ask here is how many sessions are needed.

 

Pigmentation on the face may look like the same brown color, but the depth and cause can be different, so the lesions need to be separated and reduced selectively where needed.

 

Some cases may improve with one session, but others may require three or more sessions.

 

So what should we look at first to create this kind of change?

The first step is to distinguish whether the lesion is melasma, solar lentigo, freckles, or post-inflammatory hyperpigmentation.

 

Solar lentigines often appear as brown spots with relatively clear borders, while freckles are usually small and scattered in multiple areas.

 

Melasma, on the other hand, tends to spread broadly and hazily over the cheekbones or cheeks rather than appearing as individual dot-like spots.

 

Simply put, prominent pigmentation may need to be reduced separately with “spot treatment,” while broadly spread background pigmentation may need to be gently adjusted with treatment such as “toning.”

 

One treatment is not automatically better than the other; they simply have different purposes.

 

This distinction is important because if strong spot treatment is repeatedly performed on skin that also has melasma, the skin may become more sensitive or the pigmentation may appear darker.

On the other hand, if there are many dot-like lesions such as solar lentigines or freckles, but only toning is repeated for a long time, the overall tone may become slightly brighter, while the visible brown spots still remain.

 

In other words, facial pigmentation treatment is difficult to explain simply as “how many laser sessions.”

 

We need to evaluate the type of lesion, depth, border, skin sensitivity, and sun exposure habits together.

 

Rather than pushing the treatment aggressively, it is more stable to combine the necessary methods within the range that the skin can tolerate.

 

There is a study that helps explain this point.

 

In a 2020 study published in Annals of Dermatology, Kim and colleagues treated 20 Korean patients with facial solar lentigines using a split-face design: one side of the face was treated with a 532 nm picosecond Nd laser, and the other side was treated with a 532 nm Q-switched Nd laser.

Because both sides of the same person’s face were compared, this study had the advantage of reducing differences caused by individual skin type.

 

After one treatment session, the researchers followed the patients at 2, 4, 8, and 12 weeks, and three dermatologists evaluated the degree of improvement based on photographs.

 

The results showed that both methods helped improve solar lentigines, but at 12 weeks, the clinical improvement was higher on the picosecond laser side.

 

In addition, post-inflammatory hyperpigmentation, or PIH, was reported in 5% of the picosecond laser-treated areas and 30% of the Q-switched laser-treated areas.

 

This point is quite important.

 

In facial pigmentation treatment, reducing brown spots is important, but preventing darker marks from remaining after treatment is also important.

 

Especially in Asian skin, pigmentation can remain for a long time if an inflammatory response occurs after laser treatment, so an unconditionally aggressive approach is not always the best choice.

 

In Fig. 3 of the study, the side treated with the 532 nm picosecond laser was described as showing clearer removal of solar lentigines with less post-inflammatory hyperpigmentation.

 

Fig. 4 also showed less PIH on the side treated with the picosecond laser compared with the opposite side.

Ultimately, this study shows that treatment results are affected not only by “how well the pigmentation is removed,” but also by “how few traces are left afterward.”

 

Post-treatment care also affects the result.

 

After spot treatment, the treated area may temporarily look darker or form a thin crust.

 

If the crust is forcibly removed at this stage, skin that has not fully healed may become exposed, and redness or pigmentation may last longer.

 

UV protection and moisturizing are also important.

 

This is because the risk of PIH may increase if the skin is exposed to a lot of sunlight while it is still sensitive after laser treatment.

 

To summarize, the dark spots we see on the face are not all the same problem.

 

As shown in the before-and-after photos above, if we want the skin tone to look more even, we need to first separate the lesions and then decide the right device, intensity, and treatment sequence.

 

Good facial pigmentation treatment does not begin with one strong energy setting; it begins with diagnosis and design.

Prominent pigmentation should be reduced selectively, broadly spread background tone should be adjusted gently, and sensitive skin should first be allowed to recover.

 

Finding this balance is one of the most important parts of pigmentation treatment :)

 

This was Director Won Dae-han.

 

Thank you for reading.

 

Source:
Kim JY, Yang J, Huh G, Choi YJ, Kim WS.
A Split-Face, Single-Blinded, Randomized Controlled Comparison of 532 nm Picosecond Neodymium-Doped Yttrium Aluminum Garnet Laser versus 532 nm Q-Switched Neodymium-Doped Yttrium Aluminum Garnet Laser in the Treatment of Solar Lentigines.
Annals of Dermatology. 2020;32(1):8-13. DOI: 10.5021/ad.2020.32.1.8.