Melasma, sun spots and age spots are not the same problem

Three different things arrive in this room under the same description. Melasma, sun spots and age spots get called sun damage as though they were one problem, and the treatment that suits one of them is sometimes the wrong instrument for another.

September is when the question comes up most. A Florida sun season has just ended, pigment is at its most visible, and the question that arrives is almost always about IPL.

Are they the same problem?

No. Sun spots and age spots are generally the same thing under two names: flat, discrete marks that accumulate on sun-exposed areas over years. The two words describe how somebody feels about the mark more than they describe the mark.

Melasma is a different thing. It tends to appear as larger patches rather than discrete spots, it is often roughly symmetrical across the face, and it commonly tracks with hormones as well as with sun. Pregnancy, hormonal contraception and hormone therapy all come up in that history. Heat comes up too, not only light.

Why is IPL generally not my first instrument for melasma?

Because melasma tends to be heat-sensitive, and heat is part of any light-based treatment. In most cases it is not the instrument I reach for first, and in some cases I decline it outright. It is one of the few situations in aesthetics where an in-clinic treatment can leave the picture worse than it was, and that possibility is the reason the question exists at all.

What I generally start with instead is unglamorous. Daily broad-spectrum sun protection, sensible heat avoidance, and a topical routine, which is most of what Skinbetter Science and Hydrinity are on the shelf for. Melasma is managed rather than cured, and it tends to return after sun and after hormonal changes. Anybody describing it as a one-appointment problem is describing something else.

That answer costs me IPL bookings. It is still the answer.

What about sun spots and age spots?

This is where light-based treatment is often appropriate. IPL is in most cases a series of appointments rather than one, so it gets planned against the calendar rather than squeezed into a week.

In South Florida that generally means the cooler half of the year rather than August. A recent tan also changes the assessment, and when somebody arrives with fresh color the appointment moves rather than the settings. There is nothing clever about that decision. It is just the one that avoids the outcome nobody wanted.

How does pigment get assessed?

In person, in good light, with a history taken before anything is looked at through a device. The questions are ordinary ones. When did it appear. Does it change with the seasons. Was there a pregnancy, or a change in hormonal medication, around the time it started. What is on the current medication list, since several common medications are photosensitizing. What has already been tried, and what happened.

Then the pattern gets looked at: whether the marks are discrete or patchy, whether the distribution is symmetrical, whether the borders are defined. Those observations, plus the history, are what decide whether light is an appropriate instrument here or the wrong tool held confidently. How that decision gets made is the same on pigment as on everything else, and it happens before a price is discussed.

What gets sent to a dermatologist instead?

Anything that is changing. A mark that has changed shape, size or color, that has irregular borders, that bleeds or does not heal, or that simply looks unlike the marks around it goes to dermatology, and nothing aesthetic gets booked over it.

That referral is not a formality and it is not a delay tactic. A pigmented lesion that needs a diagnosis needs a dermatologist, and possibly a biopsy, not a light-based device passed across it. I am a nurse practitioner working in aesthetics, which is not diagnostic dermatology, and sending something out is the correct answer rather than a hedge. It is also permanent: once a lesion is in that category, it stays with the dermatologist regardless of what the rest of the plan looks like.

What is worth doing regardless of which one it turns out to be?

• Daily broad-spectrum sun protection, reapplied, all year. It is the only part of this that works on all three.
• Heat avoidance where melasma is in the picture. Cars, cooking, steam rooms and hot yoga all count, not only the sun.
• A photograph in the same light once a month. Pigment changes too slowly to be judged from memory, and memory is where most disappointment comes from.
• Treating the assessment as separate from the booking. Whether light is the right instrument should be settled before any price is on the table.

Pigment is one of the few areas where doing less in September and more in January is generally the better plan. The skin page lists what is carried here, but the sequence matters more than the menu: assess first, protect daily, and let the calendar decide when light is worth using at all.

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Written by The Ginger Injector. Every treatment plan is set in person by Jamie S. Lobacz, APRN, MSN at the consultation.