The blemish fix-it guide

Life leaves us with blotches and blemishes. Dermatologist Dr Ann-Maree Kurzydlo lists the main offenders and how to treat them.

At birth our skin is like a seamless piece of fabric, flawless and woven to perfection. Then life happens. Pigmentation, prominent vessels, pimples and some battle wounds are part of the big adventure. But don’t despair — let’s check out some of these pesky problems and see what we can do to ban the blemishes (or at least reduce their impact).

Pigmentation perils

Freckles may look cute on little kids, but as we march into adulthood these brown spots, marks and patches can make our skin tone look uneven. Pigmentation affects the face, neck, décolletage, backs of the hands and the top of the shoulders. They’re caused by Ultraviolet (UV) rays from the sun stimulating the pigment-producing cells in our skin (melanocytes) to produce melanin. Melanin is what gives us a tan, but also creates freckles, brown spots and patches on our skin. Here are some of the main problem pigments.

Melasma

These dark pigment patches appear on the face where we get the most sun (forehead, cheekbones and upper lip), and are a common and very unpopular condition. Hormones and sunlight play a role in their development. Melasma is more common in pregnancy, but can also occur in women on the contraceptive pill.

Melasma can be tricky to treat. The pigment is deeper in the skin and may respond less predictably to treatment. Ways to tackle this unwanted pigment include:

  • Strict sun protection. Use SPF 50+ broad spectrum sunscreen every day. Any pigmentation treatment is destined to fail if you don’t wear sunscreen.
  • Fading cream applied at night and washed off in the morning. These typically contain ingredients such as hydroquinone, tretinoin, ascorbic acid, azelaic acid or kojic acid. There are some over-the-counter products containing low concentrations of these ingredients, but tretinoin is a retinol and requires a prescription. They may cause irritation, so use them sparingly and gradually build up to nightly application. Wash off in the morning with a gentle soap-free product, pat dry and apply sunscreen.
  • Stopping the contraceptive pill often helps, but some pigment may remain.
  • Pigment lasers and Intense Pulse Light (IPL) are not first line treatments for melasma. They’re not always effective and in some cases can even worsen pigmentation. It’s best (and safest) to treat a small test area first in a less obvious place to see how it responds.

Freckles and spots

Brown spots such as freckles and sun-induced age spots (solar lentigo) have pigment deposited in the top layers of the skin, so IPL and laser often work very well.

Laser often clears pigmentation quickly, but it does have the disadvantages of cost and recovery down time. It’s more difficult to treat darker skin types too. Strict sun protection alone may fade some spots, and fading creams can also be tried in these cases.

Birthmarks

There are several different types of coloured birthmarks, with some becoming more prominent in teenage years. These can appear as a flat brown spot (café-au-lait macule), thicker moles of varying size (congenital melanocytic nevus), a coloured patch that grows thicker hairs (Becker’s nevus) or a red/purple area consisting of blood vessels (capillary malformation).

For some brown birthmarks that contain melanin, lasers that target pigment can be tried. For red marks containing blood vessels, lasers targeting these vessels can be useful. Results may vary, and if laser doesn’t eliminate them, makeup coverage can be useful to blend birthmarks with the surrounding skin.

War wounds and scars

Scars are a natural part of life. Bumps, dings and collisions all leave us with battle wounds. They’re the result of the normal, natural healing process. The way we heal depends on several factors, including genetics, depth of the injury and where on the body the injury occurs. For example, areas with a lot of movement or tension, like the tops of the shoulders, tend to form wider or thicker scars.

There are a few different types of scars:

  • Keloid scars can occur if the healing process is overly aggressive, producing a thickened, raised scar which extends beyond the original wound.
  • Hypertrophic scars are also raised scars, but remain within the confines of the original injury.
  • Atrophic, icepick, rolling or depressed scars are usually due to severe cystic acne on the face or other illness, such as chicken pox.

Scars go through many phases as they develop. They’re made from collagen (fibrous tissue), which remodels as it ages. Early on scars may be thick and red, but they gradually fade and flatten out, improving in appearance over time (usually over a 6-12 month period). For this reason it’s often best to be patient, allowing time to see what the end result is.

A large number of lotions, potions and gels promise to improve scarring, including Bio-oil, onion extracts and vitamin E. Massaging scar tissue can help to soften and flatten it. Silicone-based gels used in scar treatment work by helping the top layer of the skin retain moisture, which is thought to help reduce inflammation and foster new skin cell growth.

For hypertrophic or keloid scars, cortisone injections directly into the scar can be used to flatten and break down the thickened tissue.

Laser treatment can also be used to reduce scar thickness, using a fractional laser to remodel the scar tissue. This works by punching thousands of microscopic holes in the skin or scar, causing the generation of new collagen, breaking down thickened clumps that have formed.

Some scars contain prominent blood vessels and look red. A laser that targets blood vessels can remove this redness and make the scar less obvious. With both vascular and fractional laser, 3-6 treatments at set intervals are normally required.

Subcision (sweeping a needle backwards and forward under the skin to break down scar tissue) and cutting out obvious scars with stitch repair can improve some scarring. Filler can also be injected to plump up divots or depressed areas in scars caused by acne.

Annoying acne

We’re all familiar with pimples — those pesky little beasties that miraculously appear when we need to look our best. What could be worse than waking up to find Mount Vesuvius has erupted on your nose? Ravaging our teenage years, acne can also occur through your 20s, 30s and 40s.

Here’s some methods to treat it:

  • Switch to lighter skin care products during summer, preferably those that are water based.
  • Look for moisturisers, makeups and sunscreens which are labelled “oil-free” or “non-comedogenic”, which are less likely to feed acne.
  • Avoid scrubs, exfoliants and abrasive cleansing agents. Use simple cleansers instead.
  • Don’t pick or squeeze pimples! Although tempting, it might worsen marks and scars.
  • Prescription medications such as topical and oral antibiotics, retinoids and oral contraceptives can help clear spots that just won’t budge. See your doctor.

Repressive redness

Annoying redness and blood vessels can gradually appear on our face, neck and chest with age and sun exposure. These prominent dilated vessels are close to the skin surface — I’m sure you’ve seen these little squiggly red or purple lines around the nose, chin and cheeks. These open blood vessels worsen with sun exposure, and occur due to the breakdown of the collagen scaffold which supports them.

Vascular laser and IPL can help to shut down these blood vessels over several treatment sessions. But — you guessed it — unless you find the fountain of youth, sunscreen is still the best preventative measure! Try to use it every day. Even when it’s cloudy the UV index can still be high, so daily application is essential.

Vexing veins

Prominent blood vessels can appear on our legs, mapping networks of roads and rivers on the once blank canvas. The two types of vessels most typically seen include the ever unpopular spider veins, which are small red or blue veins on the surface of the skin, and varicose veins, the large, tortuous veins that bulge though the skin and often cause secondary symptoms like ankle swelling and throbbing or aching legs, especially at the end of a long day.

Veins are all designed to return blood back to the heart. We’re all born with one-way valves inside our veins, which prevents the backflow of blood. The calf muscles push this blood upwards, and the valves prevent the pooling of blood in our feet. When valves wear out and no longer do their job properly, pressure increases and we end up with visibly bulging veins. Reasons for this can include:

  • Hereditary factors — once again our genetics are to blame. If mum or dad has bad veins, there’s an increased likelihood you will too!
  • Excessive weight puts pressure on our veins. Yet another great reason to exercise and hit the gym regularly.
  • Having a job where you stand for long periods of time.
  • Hormones. Pregnancy, hormone replacement therapy or oral contraceptives can play a role.
  • Having a history of clots in your legs (deep vein thrombosis).
  • Anything which increases the pressure in your abdominal area such a tumour, or even severe prolonged constipation! Eat plenty of fibre!
  • Being female. Varicose and spider veins are more common in women and develop as we get older.

From the list here, you’ll see that regular exercise, keeping trim and avoiding standing for long periods will help.

If you’re at risk, compression stockings squeeze the skin, muscles and veins in your legs to help move blood upwards and stop it pooling at your feet. They should be applied in the morning and removed in the evening. They’re very useful during pregnancy. Compression stockings can be purchased at pharmacies, but check with your doctor first. If you have poor circulation, compression that is too tight may impair blood supply to the lower legs.

Other treatment options for more serious veins include:

  • Sclerotherapy. This technique for treating veins involves injecting them with a solution (usually a highly concentrated salt solution or a special type of detergent) that affects the lining of the vein, causing it to close and seal up. Over 3-6 weeks the veins gradually disappear. This is quite a simple outpatient procedure and you don’t need to have it done in hospital. There are doctors that specialise in this treatment.
  • Laser and IPL for smaller surface spider veins. Heat from the laser damages the vein, causing it to close. Surrounding skin is spared. Endovenous laser can treat larger vessels. A small laser fibre is passed up and inside the vein. Pulses of laser light are emitted into the vein, heating the lining and causing it to collapse and eventually disappear. This procedure can be done in a doctor’s office under local anaesthetic.
  • Surgical techniques including tying off the veins and stripping, where large dilated veins are removed though a cut in the skin.

So there you have it! I hope this glimpse into the book of blemishes has given you a better idea about some common problems that blight our skin, and how they can
be treated.


Dr Ann-Maree Kurzydlo is a Consultant Dermatologist and a Fellow of the Australasian College of Dermatologists. She has a degree in nuclear medicine and studied medicine at Newcastle University, graduating with Honours. Dr Kurzydlo specialises in general, paediatric, surgical and cosmetic dermatology. She is an expert in all things health and beauty. Follow her on Instagram @drkurzydlo.