Derms have range of tools to fade freckles

National Report - Freckle-faced patients - whether they have one bothersome lentigo or a face full of mottling - have many options when it comes to achieving clearer, more even-toned skin. Depending on a patient's perceived concern, dermatologists have at their disposal therapies ranging from topical treatments to more aggressive lasers and light sources to combinations of both.

Tina West, M.D., a dermatologist in Chevy Chase, Md., says that patients come in daily complaining of freckles. In most cases, treatment to remove freckles revolves around her use of the pigment specific 532-nm Q-switched Nd:YAG laser.

"People complaining of aged skin generally have a combination of wrinkles around the nasolabial fold and mouth, dynamic wrinkles of the upper face and mottled pigment," Dr. West says. "We often even out the pigment using a topical regimen with retinoids and, sometimes, other topicals. We might also use chemical peels or microdermabrasion to even the background. Then, we target the discrete brown spots with laser treatments because it is the only solution that I know of that will eliminate the freckles in one treatment."

Patients who have faces covered with freckles, however, usually fare better when Dr. West treats surrounding skin mottling with peels or microdermabrasion. Occasionally, she will use a six-week course of Tri-Luma Cream (Galderma); then, switch to a retinoid. Tri-Luma, a combination of 4 percent hydroquinone, 0.01 percent acetonide and 0.05 percent tretinoin, helps to jump-start the skin-lightening process. But Dr. West does not use it for the long term because it has not been proven to be safe with chronic use, she says.

Once the skin tone is more even, Dr. West uses the laser to target remaining lentigines, if patients want them removed.

According to Dr. West, the 532-nm Q-switched Nd:YAG results in an immediate tissue-whitening phenomenon, or an ash-white look, showing good tissue absorbance and predicting good treatment outcome. The treated area turns to purpura after five to 10 minutes.

She prescribes an antibiotic ointment for patients to apply to their faces for two days. After that, they can wear makeup, and most have clear skin in a week.

Dr. West does not use intense pulsed light therapy to treat freckles but says the therapy is an option. The benefit of IPL versus treatment with the YAG laser is that, in some states, a non-physician can perform the treatment, and there is minimal purpura afterward. The downside is that it usually takes between three and five treatments to clear lentigines.

Photodynamic therapy Photodynamic therapy is yet another option for removal of lentigines. Little pain is associated with the therapy, but it can cause slight crusting and purpura, and patients are photosensitive for 24 hours after treatment.

Dr. West uses photodynamic therapy to treat lentigines when patients have a lot of precancerous changes on the skin, including actinic keratoses.

Yet another option is to combine use of the pulsed dye laser with YAG laser treatments. Dr. West uses the YAG laser, but this time in a diffuse mode, to treat the whole face; then, she usually alternates treatments with the YAG and the pulsed dye laser.