Blemishes:

This report covers three types of blemishes: Liver spots, purpura, and seborrheic keratoses.

Liver Spots

"Liver spots" (known as lentigos, or sun-induced or pigmented lesions) are flat brown spots on the skin. Despite the common name, these blemishes have nothing to do with the liver. Instead, they are almost universal signs of aging. Occurring most noticeably on the hands and face, these blemishes tend to enlarge and darken over time. The extent and severity of the spots are determined by a combination of skin type, sun exposure, and age. These spots are harmless, but they should be distinguished from lentigo maligna, which is an early sign of melanoma.

Liver spots or age spots are a type of skin change associated with aging. The increased pigmentation may be brought on by exposure to sun or other forms of ultraviolet light, or other unknown causes.

Treating Liver Spots. Liver spots do not require treatment, although some people are distressed by their appearance. Treatments may include the following:

• Trichloroacetic acid (a chemical peel).
• Tretinoin (Retin A) alone, or in combination with Mequinol (Solag). Tretinoin is related to vitamin A, and is also effective in treating wrinkles.
• Gentle freezing with liquid nitrogen (cryotherapy).
• Laser treatment. Specific lasers, such as the Nd:YAG, are effective in eliminating 80% of liver spots in one treatment. Laser treatment may be more effective than cryotherapy and may have fewer side effects.
• Bleaching creams are commonly available but are not as satisfactory as peels, and high concentrations can sometimes cause permanent loss of skin color.

Purpura

Purpura occurs when tiny capillaries (blood vessels) break and leak blood into the skin. In older people, the condition (called senile or actinic purpura) is usually caused by fragile blood vessels. The capillaries appear as flat purplish patches. These patches are called petechiae when they are smaller than 3 mm (about a tenth of an inch). When they are greater than 3 mm, they are referred to as ecchymoses. Patients typically have a rash, which may appear reddish at first but gradually changes color, turning brown or purple.

Treatment. Although there is no specific treatment for purpura, patients are advised to avoid trauma, including vigorous rubbing of the skin, which may damage the capillaries. Emollients that soften the skin may be helpful. Some doctors also recommend vitamin C, but its effectiveness is unproven.

Seborrheic Keratoses

Seborrheic keratoses are among the most common skin disorders in older adults. Their cause or causes are unknown. They usually appear on the head, neck, or trunk and can range in size from 0.2 - 3 cm (a little over an inch). They are well defined and appear to be pasted onto the skin, but their appearance can vary widely:

• They can be smooth with tiny, round, pearl-like formations embedded in them.
• They can be rough and warty.
• They can be brown or black.

Seborrheic keratoses sometimes look like melanoma, because they can have an irregular border, but they are always benign. A dermatologist can tell the difference between them, although experts warn that melanomas may "hide" among these benign lesions and go unnoticed without close inspection. In general, seborrheic keratoses have a uniform appearance, whereas melanomas often have a smooth surface that varies in height, color density, and shading. In some cases, keratoses may cause itching or irritation. They can be easily removed with surgery or freezing. Vitamin D3 ointment is also showing promise in clinical trials.