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Cafe-au-lait macule treatment

What are Cafe-au-lait Macules?

Cafe-au-lait macules (CALMs) or spots are flat light tan or brown spots that are usually oval in shape with a clear margin. This appearance resembles ‘coffee with milk’ that is exactly what it is in its medical term.

They usually appear at birth but some may develop and become more obvious in the first few years of a child’s life. These spots are usually a normal type of birthmark which can vary in size from a few millimetres to more than 10cm.

Solitary cafe-au-lait spots are not related to any other issues. However, when there are multiple, large cafe-au-lait spots are related to genetic conditions and a complete clinical examination should be undertaken.

Cafe au lait spots are caused by an increase in melanin content in the basal cells. Up to 10% of the population have at least one Cafe-au-lait spot. They are usually found in the trunk.

What are the treatments for Cafe-au-lait Macules?

Cafe-au-lait spots without relation to any genetic syndromes do not usually require any treatment. This pigmentation is asymptomatic, benign and they are not at risk of developing malignancies.

The reason for treatment is mainly to achieve a more aesthetically pleasing outcome, especially when they are found on the face.

The use of topical lightening agents including hydroquinone has not been effective in treating these pigmentation.

Multiple types of laser treatments including Pulsed-dye laser, Er:YAG, Q-switched and Picosecond lasers have been studied in the treatment of these pigmentation.

Q-switched Nd:YAG laser reports about total clearance in as high as 50% of patients, and the other half reporting partial removal and recurrence. Pico lasers are a more advanced form of laser compared to Q-switched Nd:YAG lasers.

Another study involving pulsed dye laser achieved complete clearance in most spots with 4-14 treatments, with no recurrence at 12 months follow-up.

Er:YAG laser is not conventionally used and there has been reports of complete removal.

Laser treatments are generally effective in lightening these spots, even when complete removal is sometimes not possible.

The risk of recurrence in patients with complete removal reports a low recurrence rate of 10%, while in patients with partial removal, the recurrence is noted to be higher at ~50%. It is also studied that the possibility of achieving good response with laser treatment is higher when performed on irregular, jagged, ill-defined bordered spots compared to smooth regular spots.

Post-inflammatory hyperpigmentation is reported to be as high as 50% per session and when this happens, it is essential to wait for about 2-3 months until it clears before resuming further laser treatments.

How do I know if my Cafe-au-Lait spots are related to any syndromes?

The presence of numerous lesions should raise the suspicion of a genetic disorder, including the freckling in the underarms and inguinal regions, red pigmentations in the eye. Other symptoms in early childhood include visual impairment, high blood pressure,epilepsy, mental retardation etc.

Do not be overly worried if you have CALMs. Solitary CALMs with a negative family history are not usually associated with any syndromes or abnormalities. Neurofibromatosis type 1, the most common associated syndrome is only found in less than 10% of patients with multiple CALMs. Consult a doctor if you are in doubt to determine if further investigations or genetic testing is required.

Will my Cafe-au-lait Macules respond to treatment?

Many laser treatments have been used to treat cafe-au-lait macules with variable response.

Whilst no guarantees can be made, in my opinion, the risks of lasers are generally low and it is worth trying them out, especially with many reporting good clearance with low risk of recurrence.

By assessing the spot based on darkness of the lesion, the skin type, the borders of the spot, we can predict that some CALMs respond better to treatment than the others.

It is very important to seek treatment with qualified doctors and good quality machines so that you can get the best possible results with the minimal risks of lasers such as transient hyperpigmentation, hypopigmentation, permanent hyperpigmentation and scarring.

Is laser the only way to treat CALMs?

Apart from lasers, other treatments commonly involve a more invasive approach which involves higher risks of discoloration and scarring. There are usually not considered.

These treatments include cryotherapy, electrofulguration, chemical peeling, mechanical grinding and surgical removal.

The principle of laser treatments is that lasers selectively target pigment cells in a very short period of time, breaking down the pigmentations while protecting the surrounding normal skin by the selective photothermal effect.

Should I treat my child’s CALMs?

Treatment at early stages (in children lesser than 3 year of age), who have relatively thinner skin and lighter spots, have achieved a better response to laser therapy.

However, further recurrences can still occur later in life and repeated treatment is most likely required. Furthermore, laser treatment can cause discomfort and some level of sedation will be required to allow the procedure to be carried out smoothly. Sedation on its own is also not without its risk. I would not rush into seeking treatment for a young child. The possibility of more effective treatment in 10-20 years’ time is something that we can look forward to too!

However, early treatment can also mean less discomfort and pain with more immature spots requiring less treatment sessions involving a smaller area. Depending on where these CALMs are located, treating them early can prevent negative feelings from social isolation or bullying in nursery and primary school. It is not an easy decision.

What is the price/cost of cafe-au-lait spot reatment?

Cafe-au-lait spot treatment using Pico laser costs from $200, depending on size of the spot.

Multiple treatment sessions are required.

For detailed price estimate, please contact us.


Jin Ok Baek, Il-Joong Park, Kyung Real Lee, Ha Ryeong Ryu, Jeongsoo Kim et al. High-fluence 1064-nm Q-Switched Nd:YAG Laser: Safe and Effective Treatment of Café-Au-Lait Macules in Asian Patients. J Cosmet Dermatol. 2018 Jun;17(3):380-384.

Daniel A Belkin, Julia P Neckman, Hana Jeon, Paul Friedman, Roy G Geronemus. Response to Laser Treatment of Café Au Lait Macules Based on Morphologic Features. JAMA Dermatol. 2017 Nov 1;153(11):1158-1161.

Jiehoon Kim, Hoon Hur, Yu Ri Kim, Sung Bin Cho. Treatment of Café-Au-Lait Macules With a High-Fluenced 1064-nm Q-switched Neodymium:yttrium Aluminum Garnet Laser. J Cosmet Laser Ther. 2018 Feb;20(1):17-20.

T S Alster. Complete Elimination of Large Café-Au-Lait Birthmarks by the 510-nm Pulsed Dye Laser. Plast Reconstr Surg. 1995 Dec;96(7):1660-4.

Bin Zhang MD  Yan Chu MD  Zigang Xu MD  Yujuan Sun MD  Li Li MD  Xiaofeng Han MD  Chen Wang MD  Li Wei MD  Yuanxiang Liu MD  Lin Ma MD. Treatment of Café‐Au‐Lait Spots Using Q‐Switched Alexandrite Laser: Analysis of Clinical Characteristics of 471 Children in Mainland China. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc. May 2019.


Medical Director

After graduating from the National University of Singapore, Dr Boey’s journey in aesthetics brought him to esteemed institutions such as Harvard Medical School, American Academy of Aesthetic Medicine and Queen Mary University of London in diverse cities like Seoul, London, Boston and New York.