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Understanding Pigmented Skin Spots

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What causes them, when they are harmless, and when they need to be checked and treated.

Certain types of dark spots heal and fade naturally over time. Others, however, have a more deep-rooted presence, with effects that can, over a prolonged period, cause even more complications for the skin.

Understanding what causes these darkened areas on your skin and knowing when they need attention will help minimise skin damage and may even save your life.

Harmless Spots

SUN SPOTS are black or brown spots that develop on the most sun-exposed parts of the skin. This happens when there is an over-production of melanin, which is a skin pigment that develops in response to exposure to the sun. Depending on their genes, some people are more prone to developing sun spots than others.

If you spend a lot of time in the sun or under other forms of ultraviolent light, you may find small sun spots on your face, shoulders, backs of the hands, forearms or upper back. Older people — along with fair-skinned people — may be more prone to developing these spots when they spend a lot of time in the sun. Though intrinsically harmless, sun spots do indicate sun damage to the skin that could increase the risk of skin cancer.

AGE SPOTS are dark spots on the skin that result from a combination of sun exposure and age-related changes in the skin. As such, they not only appear in the most sun-exposed areas of the body but in other areas as well. Continuous exposure to ambient ultraviolet rays can affect existing age spots badly by darkening them. Some age spots are flat on the surface of the skin while papular age spots tend to stick out in darkened bumps.

FRECKLES show up as small brown spots on the sun-exposed areas of the face, neck and arms commonly in people with fairer skin and lightcoloured hair, such as Caucasians. Often the result of genetics and excessive sun exposure, their presence is a reflection of sun damage in the skin.

POST-INFLAMMATORY HYPERPIGMENTATION is the darkening of skin affected by an inflammatory skin condition such as acne or insect bites, occurring when there is a build-up of excess melanin after the inflammation heals. Particularly common in East or Southeast Asians, this type of hyperpigmentation is usually more severe in cases where the inflamed area is scratched and irritated before fully healing, resulting in darker scars thereafter.

Various factors can exacerbate the inflammation and prolong its course: direct exposure to sunlight for too long, long-standing unmitigated skin inflammation, friction and picking at the skin. Early intervention to treat the inflammation goes a long way to minimise the severity of post-inflammatory hyperpigmentation.

Treatment Prescription creams can help lighten the appearance of sun spots, age spots, freckles and post-inflammatory hyperpigmentation. Chemical peels, Intense Pulsed Light (IPL) therapy and laser therapy are all effective options as well, depending on the nature and severity of the condition.

Judicious protection of the skin from excessive exposure to sunlight is vital to ensure optimal results from therapy and to maintain good results. Such measures include the use of protective clothing and hats during activity outdoors, the liberal and repeated application of a broad-spectrum sunscreen of SPF of at least 30 and reduction in outdoor activity during the hours of 10am to 4pm.

MOLES are flat, darkened areas on the skin. Some are raised, pale to light brown, and hairy. They may be present from birth or appear any time thereafter. Moles evolve very slowly over time. In young people, they may enlarge gradually and turn from flat to bumpy over several years. Some moles become lighter or disappear over time and some may not change at all. They often appear darker after sun exposure and during pregnancy. Moles that change in colour, texture and size, and bleed from minor trauma should be checked by a skin doctor immediately.

Treatment: Moles that are harmless are removed when their size or location causes symptoms. For example, a bumpy mole on the beard area is susceptible to cuts in the process of shaving. In the absence of symptoms, moles are often removed for aesthetic reasons. Laser treatment, usually recommended for small flat moles located on the face and neck, yield the best cosmetic results when applied appropriately. Surgery to shave off the top of a bumpy mole is a quick and simple way to level it without leaving a big scar. Surgical excision is often required for mature and deep moles especially if complete mole removal is desired.

Harmful Spots

BASAL CELL CANCER (BCC) is the most common type of skin cancer in the world, typically afflicting the skin of the head, neck and upper body. In Asians, this type of skin cancer very often manifests as dark brown spots on the skin, and is commonly mistaken for harmless moles. In Caucasians, the cancer usually causes pink, pearly bumps to surface on the skin. Not surprisingly, the risk of BCC increases with constant and prolonged exposure to the sun. This cancer can go unnoticed for years, only calling for attention when it begins to bleed and ulcerate, resulting in a non-healing sore.

Treatment: Early diagnosis of BCC leads to better treatment outcomes. Talk to your dermatologist about getting a skin biopsy to detect the early signs of BCC. Once the cancer is identified, complete surgical removal of the cancerous tissue must follow, with tests to ensure that no trace of it is left behind.

Surgical removal has a high success rate, as cancerous basal cells are slow-growing and seldom spread to the rest of the body. However, a post-surgery routine should be practised to ensure an optimal outcome. This includes judiciously protecting the skin from excessive sun exposure, undergoing a complete skin examination for any other suspicious spots, and scheduling regular skin examinations over the next few years to detect any recurrence of the cancer at the original site or the development of a second BCC.

MELANOMA is a skin cancer affecting melanocytes, the cells that produce the skin’s melanin. The risk of melanoma is higher for women under 40, and the major risk factors include prolonged exposure to sunlight or tanning lights, the presence of unusual moles on the body, a family history of melanoma, and a weakened immune system. While melanomas can develop on normal-looking patches of skin, they commonly manifest in existing moles that rapidly change in appearance.

Use the ABCDE guideline to check if a mole alerts one to the presence of melanoma:

  • Asymmetrical moles whose halves look unequal;
  • Borders that are notched, jagged or indistinct;
  • Colour that is uneven and present in various shades;
  • Diameter changes to the mole, especially if it grows to more than 6mm;
  • Evolving moles that change in size and shape rapidly, and start to bleed.

If any of these changes apply to you, seek medical attention immediately.

Treatment: A doctor will usually recommend a skin biopsy based on the physical features of the abnormal mole. This will determine the thickness of the cancer and provide an indication of the treatment needed and prognosis of the disease.

Early stage melanomas can be removed surgically, preventing the cancer from spreading further. During surgery, the melanoma is removed along with a margin of healthy-looking skin tissue and sent for microscopic examination. This is to ensure that no trace of the cancer is left behind after surgery. Thicker melanomas will require more extensive surgery, and some of the regional lymph nodes may have to be removed.

Melanomas that have spread beyond the skin into the lungs, liver or lymph nodes, however, require more long-term and aggressive treatment. This ranges from surgery and chemotherapy to radiation, targeted therapy and immunotherapy.

Time is of the essence when it comes to the diagnosis and treatment of melanomas. With early detection, a simple outpatient surgical excision can be curative. The prognosis for survival dips for melanomas detected in advanced stages.

Conclusion

The importance of judicious protection of the skin from excessive sun exposure during outdoor activity cannot be overstated. Having said that, it helps to know that some pigmented spots are harmless, some indicate damage to the skin from too much sun exposure, and others are signs of skin cancer and must be diagnosed and treated as soon as you notice them.

Meet yourDermatologist

Our skin physician, Dr Cheong Lai Leng, is a Ministry of Health certified dermatologist who emphasizes an individualized approach to address your specific concerns whether they are medical, surgical, or cosmetic while maintaining the highest standards for quality and attention to your comfort.

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