Three Pigment Lesions Mistaken for Age Spots in Clinic

When I hear "I'm here to get my age spots removed" in the clinic, I do not immediately get the laser ready. That is because brown lesions that look like age spots include pigmentary conditions of different natures, and the direction they need to be treated in differs completely depending on which one it is. Even when the same laser is used on the same spot, misreading the identity of the lesion can lead to recurrence or hyperpigmentation.

So today I would like to separate, from a clinical perspective, three pigmentary conditions that are often confused with age spots.

"Age spots" is closer to an everyday term that patients use. In actual practice, I first look at whether the lesion is raised or not. If the surface is thickly raised, it leans toward seborrheic keratosis; if it lies flat, it leans toward solar lentigo. When redness and the lesion's history of change are added to this, a third candidate appears.

Comparing the three conditions at a glance looks like this.

Seborrheic keratosis arises mainly from aging and genetic factors. Hormonal changes and UV exposure can also influence its development. As keratinocytes proliferate abnormally, it rises on the face, chest, back, arms and elsewhere on the body as a thick, rough surface ranging from brown to black.

Whether it is raised is the easiest criterion for telling age spots and lentigo apart. It mainly appears after middle age and is often removed for cosmetic reasons using an Er:YAG laser or CO2 laser. Removal itself is relatively simple.

Solar lentigo arises mainly from ultraviolet (UV) exposure. UV light stimulates the skin's melanocytes, causing excessive production and accumulation of melanin. As a result, it appears as flat brown macules with clear borders on areas heavily exposed to UV, such as the face, hands and arms.

Compared with age spots, the change on the surface is minimal. When photographed with special equipment, a pale white band can sometimes be observed around the border. It mainly occurs in people in their 50s and older, but it is a lesion that is also seen fairly often in people in their 20s and 30s.

The problem is treatment. Solar lentigo is also removed for cosmetic reasons, and a very wide variety of lasers can be brought in.

If it is approached carelessly as if shaving it off with a CO2 or Er:YAG laser, it is a pigmentary condition with a relatively high likelihood of incomplete removal leading to recurrence, post-inflammatory hyperpigmentation, or worsening of underlying melasma. I covered in more depth why lentigo does not clear well with simple toning alone, and why I consider the wavelength first, in my post looking at lentigo through histology.

For these reasons, when clearing lentigo, I tend to choose an approach matched to the depth of the lesion, such as the Reepot Laser. However, since there are individual differences, it is safest to decide the direction after examining the lesion in person. Consult via chat now

The exact cause of benign lichenoid keratosis (Benign Lichenoid Keratosis) is not known, but it arises from an inflammatory reaction and can appear while an existing solar lentigo (Solar Lentigo) or seborrheic keratosis (Seborrheic Keratosis) is regressing.

• Minor trauma such as friction
• Medications, dermatitis
• UV exposure

Factors like these can act as triggers. It mainly appears in adults in their 30s and older as flat or slightly raised brown or red plaques on the face, upper body and limbs. It can disappear on its own and is known to have almost no likelihood of becoming malignant.

It is distinguished from lentigo and age spots by the lesion's history and appearance, and it can also be told apart by its response to laser treatment. As an initial treatment, using a topical steroid ointment to suppress the inflammatory reaction at the epidermal-dermal junction can be effective. When keratinocytes have proliferated and the lesion has thickened, cases are reported in which laser treatment suited to this lesion clears it without recurrence. Responses vary between individuals.

To sum up, the three lesions above are easily confused on the surface. That is why it is important to get an accurate diagnosis through consultation with a board-certified dermatologist and to approach each lesion in the direction that suits it. The point I always emphasize with pigmentary conditions is the same: diagnosis comes first.

When age spots and lentigo appear together, and for pigmentation where both the epidermis and the dermal background need to be read, the posts below will help your understanding.

• What I check when looking at age spots and lentigo on the face together
• Why melasma comes back even after removing only the epidermal melanin
• Managing post-inflammatory hyperpigmentation, which I often see in the clinic

If you have lesions similar to those above, I recommend having them examined in person rather than forcing yourself to judge on your own. Feel free to ask about anything you are curious about.

Author: Dr. Cho Mingyeol, Medical Director (board-certified dermatologist; Master Certification in Pigmentation, Acne, Rosacea and Hair from the Korean Dermatologists Association). You can find the full profile on the Medical Team page. First published 2024-06-26 / Last reviewed 2026-07-09

This article is intended for general information only; the appropriate treatment and outcomes may vary depending on each individual's condition.