Café au lait spots (CALS) are common, flat patches of skin pigmentation present at birth or appearing shortly afterward. These birthmarks are typically harmless, but their noticeable appearance often leads individuals to seek cosmetic removal. The process involves careful medical assessment combined with specialized dermatological procedures. Understanding the nature of CALS and the available treatments is necessary for anyone considering removal.
Understanding Cafe au Lait Spots
The name “café au lait” is French for “coffee with milk,” describing the light-to-dark-brown, uniform color of these macules. They are flat, well-defined patches varying significantly in size, from a few millimeters to over 20 centimeters in diameter. While they can appear anywhere on the body, they are most frequently observed on the trunk and extremities.
The characteristic hyperpigmentation occurs due to an increased concentration of melanin pigment within the epidermis. This increase results from an unusually high number of melanocytes (pigment-producing cells) or excess pigment production within the cells themselves. Although CALS are a type of birthmark, they may become more noticeable or increase in size and number as a person ages, particularly during early childhood.
Medical Evaluation and Significance
A medical evaluation is a necessary first step before pursuing cosmetic removal, primarily to rule out underlying health conditions. While a solitary café au lait spot is a common, isolated finding, the presence of multiple spots can be a sign of a genetic disorder. The most well-known association is with Neurofibromatosis Type 1 (NF1), a condition affecting cell growth in the nervous system.
Diagnostic criteria for NF1 include the presence of six or more café au lait macules. The size of the spots is a factor, requiring them to be larger than five millimeters in diameter in prepubescent children. For postpubertal individuals, the spots must exceed 15 millimeters in their greatest diameter to meet this diagnostic criterion.
A dermatologist or pediatrician assesses the number, size, and shape of the spots, along with other clinical signs, to determine the risk of an underlying syndrome. The borders of the spots can offer a clue, as CALS associated with NF1 often have smooth edges, sometimes described as “coast of California” morphology. A comprehensive assessment ensures that monitoring or treatment for a systemic condition takes precedence over cosmetic concerns.
Professional Treatment Options
Laser therapy is the primary method for significantly lightening or removing café au lait spots, as it specifically targets excess melanin. Specialized lasers deliver energy in rapid pulses, which the pigment absorbs, causing the melanin particles to fragment. The body’s immune system then naturally clears away these fragmented particles in the weeks following the procedure.
Q-switched lasers are the standard for this treatment. The Q-switched 1064-nm Nd:YAG laser often shows superior results because its wavelength safely penetrates deeper into the skin while being well-absorbed by melanin, making it suitable for various skin types. Other effective options include the Q-switched Ruby (694-nm) and Alexandrite (755-nm) lasers, which also target epidermal pigment.
Multiple treatment sessions are necessary because the spots are resistant to single-session removal. Patients often require an average of six to ten treatments, spaced several weeks apart, to achieve substantial clearance. Clinical studies indicate that laser treatment can achieve at least 50% clearance in approximately 75% of patients. Clearance is variable, with about 43% of patients achieving 75% or greater clearance.
While Q-switched technology is the mainstay, picosecond lasers are also utilized, offering ultra-short pulses that shatter the pigment into finer particles. Less common methods, such as surgical excision, are reserved for very small, localized spots, as this approach carries a greater risk of visible scarring compared to laser treatment. Intense Pulsed Light (IPL) treatments may also be used but are less specific in targeting the deeper pigment of CALS compared to dedicated pigment lasers.
Setting Realistic Expectations
Managing expectations is an important part of the treatment process because achieving complete and permanent removal of CALS can be challenging. A significant limitation is the potential for the spot to return, known as recurrence. Although the pooled recurrence rate is around 13%, recurrence is a known issue. This is thought to happen because the underlying genetic abnormality in the melanocytes remains even after the pigment is cleared.
Patients should also anticipate potential temporary side effects following a laser session. These may include transient lightening or darkening of the treated skin (hypopigmentation or hyperpigmentation). These effects are minimal, with pooled rates for both side effects reported to be around one percent. Topical anesthetic creams are routinely used to minimize discomfort during the procedure.
Topical lightening creams, bleaching agents containing hydroquinone, and home remedies are ineffective for treating true café au lait spots. The pigment in these macules resides in the deeper layers of the epidermis, making it inaccessible to surface-level treatments. Therefore, professional laser therapy remains the most reliable method for achieving noticeable pigment reduction.