Why Are Dark Spots Appearing on My Face?

Dark spots and uneven pigmentation are among the most common skin concerns I see. Sometimes they develop slowly over the years, while in other people they seem to appear quite suddenly.

The important thing to understand is that not all pigmentation is the same, and therefore the treatment should not be the same either.

What causes facial pigmentation?

Pigmentation happens when the skin produces or deposits more melanin than usual. There are several possible causes.

Sun exposure is one of the biggest factors. Years of UV exposure can lead to freckles, sun spots and uneven pigmentation, particularly on the face, chest and hands.

Hormones can also have a major influence. Pregnancy, hormonal contraception and other hormonal changes can stimulate pigment-producing cells. This is particularly important in melasma, a common condition causing symmetrical brown or grey-brown patches, usually over the cheeks, forehead, nose or upper lip. (AAD⁠)

Genetics matter as well. Some people are simply more prone to developing pigmentation, and melasma often runs in families. (DermNet®⁠)

Other causes include inflammation from acne or eczema, previous injury to the skin, certain medications and irritation from skin products. This is why simply buying a “pigmentation cream” may not necessarily solve the problem.

What is melasma?

Melasma is one of the most common and sometimes frustrating forms of facial pigmentation. It is particularly common in women and can be influenced by a combination of genetics, hormones and exposure to sunlight and visible light. (AAD⁠)

Melasma can also sit at different depths within the skin. Some pigmentation is predominantly superficial, while some is deeper or mixed. This can affect how well it responds to treatment.

Why is the correct diagnosis important?

Before treating pigmentation, we first need to understand what type of pigmentation it is and why it is occurring.

Melasma, sun spots, freckles and post-inflammatory pigmentation can look similar to an untrained eye but may require very different approaches. Occasionally, a changing pigmented lesion can represent something more significant and should be medically assessed rather than simply treated cosmetically.

A proper skin examination, sometimes combined with dermoscopy and imaging, can help determine the most appropriate treatment. (DermNet®⁠)

What treatments are available?

Once the diagnosis is established, treatment can be personalised.

Topical treatments may include prescription or medical-grade products that reduce excessive pigment production and gradually improve skin tone. Depending on the condition, ingredients such as hydroquinone, retinoids, azelaic acid, cysteamine or tranexamic acid may be considered. (DermNet®⁠)

Sun protection is essential. Without controlling ongoing UV and visible-light exposure, pigmentation can return even after successful treatment. For melasma in particular, tinted broad-spectrum sunscreen containing iron oxides can be useful because visible light can contribute to pigmentation. (AAD⁠)

Laser and light treatments can also be useful for selected types of pigmentation. However, the correct laser and settings need to be chosen carefully. Some pigmentation—particularly melasma—can actually become darker or recur if treated too aggressively. (DermNet®⁠)

For many patients, the best results come from a combination of good skincare, sun protection, appropriate topical treatment and carefully selected laser or other procedural treatments.

The key message

If you have persistent dark spots or uneven pigmentation, the first step is not choosing a laser or buying another cream. The first step is getting the diagnosis right.

Once we understand the cause and depth of the pigmentation, we can develop a treatment plan suited to your skin and reduce the risk of making the pigmentation worse.

Dr Colin McTari

Skin Doctor, Brisbane