Dark spots and uneven skin tone: which treatment works for which type

"Dark spots" is not one condition — it's a category that includes several distinct types of pigmentation with different causes and, critically, different treatments. The same procedure that clears sun spots can worsen melasma. Understanding your pigmentation type is the most important first step.

Types of pigmentation and how to identify them

Solar lentigines (Sun spots, age spots)

What they look like: Flat, well-defined brown spots; sharp borders; uniform color. Common on sun-exposed areas (face, hands, forearms, chest).

Cause: Cumulative UV exposure causes localized overproduction of melanin.

Key characteristic: Present since childhood or adolescence; more numerous with age; stable (not hormonally driven).

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Melasma

What it looks like: Larger, diffuse, blotchy brown or grey-brown patches, often symmetric. Most common on forehead, cheeks, upper lip, and chin. Can look similar to sun damage but covers larger areas in a more diffuse pattern.

Cause: Hormonal influence (estrogen, progesterone) combined with UV exposure triggers melanocyte overactivity. Common during pregnancy ("mask of pregnancy"), with hormonal contraceptives, and during hormonal changes.

Key characteristic: Hormonally driven and UV-sensitive — it can return or worsen with sun exposure, hormonal changes, or aggressive treatments. This is why it's the most difficult type to treat.

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Post-inflammatory hyperpigmentation (PIH)

What it looks like: Dark spots where acne, rashes, injuries, or other inflammation previously occurred. Often flat, not raised.

Cause: After skin inflammation, excess melanin is deposited as part of the healing process.

Key characteristic: Location corresponds to prior inflammatory lesions. More common and more persistent in darker skin tones. Often fades on its own over months.

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Freckles (Ephelides)

What they look like: Small, flat, light-tan spots that appear in childhood, often concentrated on the nose and cheeks. Darken with sun exposure; fade in winter.

Cause: Genetic tendency to localized melanin overproduction in response to UV.

Key characteristic: Appear early in life, lighten with age, fluctuate seasonally.

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Seborrheic keratoses

What they look like: Waxy, stuck-on appearing raised brown, tan, or black growths. Not flat — slightly elevated.

Cause: Non-cancerous skin growth; not related to sun or hormones specifically; hereditary.

Important: These are benign growths, not pigmentation in the melanin sense. They're removed differently (cryotherapy, laser ablation) and don't respond to pigment-targeted treatments.

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Before any treatment: rule out melanoma

Any pigmented lesion that has irregular borders, multiple colors, asymmetry, or is changing should be evaluated by a dermatologist before any cosmetic treatment. This is not a cosmetic consideration — it's medical. Never have a provider treat an unexamined spot with laser or another modality before a proper skin check.

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Treatments by pigmentation type

For solar lentigines (sun spots)

Best options:
IPL (Intense Pulsed Light): Highly effective for sun spots. Spots typically darken and "pepper-fleck" for 1–2 weeks before lifting off. 2–3 sessions typically.
Q-switched or picosecond laser: Highly targeted; effective for discrete spots. 1–3 sessions.
Chemical peels: Medium-depth glycolic or TCA peels improve overall photodamage and help fade spots.
Topicals: Hydroquinone, kojic acid, tranexamic acid, vitamin C — slower but useful for maintenance and prevention.

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For melasma

The melasma challenge: Melasma responds to treatment but tends to return, especially with sun exposure or hormonal triggers. The goal is management, not cure.

First line (topical):
Hydroquinone (2–4%): Still the most evidence-backed topical for melasma; works by inhibiting tyrosinase
Tranexamic acid: Emerging evidence; works through a different mechanism; good for patients who can't tolerate hydroquinone
Azelaic acid (15–20% prescription): Effective and safe across all skin tones, safe during pregnancy
Tretinoin: Increases cell turnover, helps topicals penetrate; use carefully in combination

In-office:
Low-fluence Q-switched Nd:YAG (1064 nm): The safest in-office option for melasma; low energy reduces the risk of PIH or rebound
Chemical peels (mild): Mandelic acid, low-concentration glycolic; must be managed carefully to avoid triggering rebound
Tranexamic acid injections: Microinjections of tranexamic acid into melasma patches — used in some practices with early supporting evidence

What to avoid for melasma:
Standard IPL — can worsen melasma dramatically
Aggressive laser resurfacing — triggers inflammation that reactivates melanocytes
Heat-generating procedures — thermal energy can trigger melasma

Daily non-negotiable: Broad-spectrum SPF 50 (mineral preferred) — without daily sun protection, no melasma treatment is sustainable.

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For post-inflammatory hyperpigmentation (PIH)

The good news: Most PIH fades on its own over 6–24 months in lighter skin tones; patience + sun protection often is sufficient.

For persistent PIH:
Topicals: Vitamin C, tranexamic acid, kojic acid, azelaic acid (all safer than hydroquinone for long-term use)
Mild chemical peels: Mandelic, lactic, or low-glycolic; stimulate turnover without triggering rebound
Low-fluence fractional laser or RF microneedling: For PIH that has persisted 12+ months and overlaps with textural concerns (acne scarring)

Avoid: IPL and high-fluence laser on active or recent PIH in darker skin — high risk of worsening

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For freckles

Freckles can be lightened with IPL or Q-switched laser if desired, but they will return with sun exposure. This is a maintenance-dependent treatment. Daily SPF significantly slows the re-darkening.

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How skin tone affects treatment selection

| Skin type (Fitzpatrick) | Safe options | Use with caution | Avoid |
|---|---|---|---|
| I–III (light) | All options | — | — |
| IV (olive/medium) | Nd:YAG, mild peels, topicals, RF microneedling | IPL (low fluence) | Aggressive IPL, ablative laser |
| V–VI (dark/deep) | Nd:YAG, RF microneedling, topicals | Nothing else without expert guidance | IPL, aggressive peels, ablative laser |

This is the most important consideration for darker skin tones — PIH from inappropriate treatment can be worse and more persistent than the original concern.

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The baseline maintenance every patient needs

Regardless of treatment type:
SPF 50 daily: Non-negotiable. UV activates melanocytes. No pigmentation treatment is durable without daily photoprotection.
Broad spectrum (UVA + UVB): Many cheaper sunscreens only protect against UVB (burning); UVA drives pigmentation
Physical sunscreen (zinc oxide, titanium dioxide): More protective for melasma and photosensitive patients; less irritating for rosacea

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Questions to ask your provider

Based on the distribution and appearance of my pigmentation, what type do I have?
Is any spot you're planning to treat something I should have evaluated by a dermatologist first?
Given my skin tone, which device or peel concentration is safe for me?
Is my pigmentation likely to return after treatment, and what maintenance do I need?
Do you have experience treating melasma specifically, and what's your protocol?

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