lentigos	Many are sized from about 0.5mm to 3mm. There are black ones and brown ones.
pigmented nevus	Black spots which exists from birth.
melasma	On the cheek and forehead, symmetrical, flat,  light brown macules.
freckles	Many small brown spots scattered on both cheeks and nose.
cafe au lait macules	From birth or adolescence, light brown, rather dense, there are also some which accompany black hairs.
solar (senile) lentigines	Appear after 30 years old and increase with age.  Dark or light brown, flat blotches whose outline can be clearly seen.
verruca senilis	Wart which appears with age. Raised, dark brown. Also called seborrheic keratosis.
postinflammatory hyperpigmentation	Pigmentation after inflammation of scratches, burns, acne, etc.

*	can be treated in a relatively short time	solar lentigines, postinflammatory hyperpigmentation, freckles
*	Things that becomes thin, but in order remove completely, time is required	melasma, cafe au lait macules
*	laser treatment should be combined	acquired dermal melanosis, verruca senilis, nevus of Ota, etc.

■ How long will it take?

Usually facial blotch treatment period is approximately 2 months. In the cases of melasma and cafe au lait macules, the treatment period is longer.

■ Treatment course

The treatment period is divided into two parts:  the first half is bleaching phase (2-6 weeks), the latter half healing phase (2-6 weeks). After starting, the treated skin becomes red and the skin peels. After that, redness increases gradually, but the blotch becomes thin. Most of the first 1-2 weeks is balance time, but after that the skin gets accustomed to the medicine, it keeps improving without either redness or stinging. During the first 2 weeks of bleaching, be sure to get examined by a doctor 1 time. The medicine is modified with every medical examination. If the skin gets too dry, please use moisturizer, oil, etc., in accordance with your doctor’s advice. Standard treatment period for blotches is 8 -12 weeks. After you improve, maintenance care is done 1 time after 2 months, or a 2^nd round of therapy, if needed.

Be sure to read the following instructions before you start.

■ Basic protocol

The basic protocol for facial blotches therapy is below:

1. First, wash face with soap, the sebum is taken off. Try not to rub the skin too hard.
2. Moisturize with non-alcoholic hypoallergenic moisturizer.
3. Vitamin C lotion is applied evenly. High concentrations are recommended (for example: ascorbic sodium phosphate 10% lotion).
4. Tretinoin aqueous gel (yellow gel) is applied thinly with a small cotton-tip applicator, let dry (1-2 minutes). Because it is strong medicine, pay attention to the points of caution below:
5. If your doctor indicates, apply moisturizer as needed with your fingers.
6. Apply hydroquinone lactic acid ointment (the ointment of translucent color) using your fingers, covering as widely as possible. Applying all over the face is OK. Be sure to use hydroquinone twice daily.
7. In the morning, apply UV protection cream. Without rubbing strongly, please apply repeatedly. You can also use cream foundation or concealer for make-up. At night, you can cover with oil. Do not use milky and liquid type lotions.
8. Lastly, in the morning, use UV protection powder. (not always necessary)
9. The method of application above is used when starting the therapy. As therapy advances, contents of the medicine and method of application etc. may change a little. Please follow your doctor's instructions.

It is very important to receive this therapy under the guidance of a doctor. Please be sure to receive medical examination as needed because therapy and usage are sometimes modified by the doctor. When periodic observation is not done, unexpected or negative results can occur.

■ General care

■ To whom are pregnant or want to be pregnant

In animal experiments, tretinoin induced inborn deformities when used with large quantity doses. In people, the causal relation with topical use of tretinoin and deformities is not clear. Please use contraception during tretinoin treatment.

■ Advice

Several types of blotches appear on the face. When senile lentigines are present, they should be treated first, because after getting used to this treatment, other blotches are relatively easy to treat.

In addition, if you have senile pigment spots on both the hands and face, we recommend treatment begins with the face. The reason, as mentioned later, is that hand treatment can be very difficult, so those who are already used to this remedy are more desirable.

■ If scaling and redness are seen (two or three days after treatment start )

Usually not much happens in this treatment during the first 1 or 2 days.

However, when about 3 days pass, the skin becomes red and dirt or scales easily come off when washing the face.

This reaction is always present in treatment with tretinoin.  If treatment is discontinued, the skin gradually recovers.

Please pay attention to the following when the skin starts changing:

 

■ Signs indicating you should suspend therapy

When the conditions below appear, please consult doctor before discontinuing tretinoin only.

There is a possibility the concentration is not appropriate for your skin quality. Please consult your doctor.

　

Blotches of the hand

Hand blotch treatment is principally same as the face, but hand treatment is much more difficult. If there are face blotches as well we recommend that you treat them first, then the hands after getting used to tretinoin therapy.

Actually, Q-ruby laser treatment is recommended for hand blotches, and 4 weeks later, tretinoin therapy can be started for treatment of postinflammatory hyperpigmentation induced by the laser.

■ Reasons hand blotch remedy is difficult:

■ Notes when undergoing hand blotch treatment

• As in case of the face above, please moisturize sufficiently.
• When possible, we recommend that gloves, etc, made of cotton are worn.
• Please do not forget to protect your hands as well from UV rays.

■Mechanisms of tretinoin therapy for acne

Acne is formed by accelerated function of the sebaceous gland and abnormal keratinization of hair follicles. Comedo is built up by abnormal keratinization and obstructs the normal discharge of the sebum. Tretinoin suppresses the function and induces atorophy of the sebaceous gland, and prevents acne by peeling off the comedo. Retinoids, such as tretinoin, are the first choice drug for acne in Europe and North America. 　

■ Basic protocol

Use 2 times a day (morning and night), or once a day at night. Follow your doctor's instructions.

1. Wash your face.
2. Apply vitamin C lotion.
3. Apply tretinoin thinly and widely to the affected parts with the fingers.
4. When your doctor indicates, apply AHA gel to the affected part(s).
5. Apply moisturizer as necessary.
6. In the morning be sure to use UV protection cream. Use make-up as normal.

The method of application above is used when starting the therapy. As therapy advances, medicine contents and method etc of application may change.

■ General notes

■ To whom are pregnant or want to be pregnant

In animal experiments, tretinoin induced inborn deformities when used with large quantity doses. In people, the causal relation with topical use of tretinoin and deformities is not clear. Please use contraception during tretinoin treatment.

■ If scaling and redness are seen (two or three days after treatment start )

Usually not much happens in this treatment during the first 1 or 2 days.

However, when about 3 days pass, the skin becomes red and dirt or scales easily come off when washing the face.

This reaction is always present in treatment with tretinoin.  If treatment is discontinued, the skin gradually recovers.

■ Combination with hormone therapy

Most acne improves within 3 weeks after starting tretinoin therapy. There are times, however, even with tretinoin, when patients will develop new acne. In those cases, a combination therapy is recommended. You can use oral spironolactone (6 tabs) for 2 months. It will improve significantly new acne formation in the second month. Any other hormonal therapy such as oral contraceptives can also be combined with tretinoin therapy. Periodical blood tests for hepatic and renal function, as well as hormonal levels, are strongly recommended.