Treatment of melasma and hyperpigmentation

What it is

Care begins by naming which pigment disorder is actually present, because melasma, ashy dermatosis, drug-related pigmentation and the paradoxical darkening from long unsupervised use of lightening creams look alike and are managed differently. From there the plan is daily photoprotection and prescribed topical agents first, with peels or devices added slowly and only once the skin is calm.

What this page covers

• Pigmentation consultation and diagnosis
• Melasma subtyping by depth (epidermal, dermal, mixed) and severity documentation
• Melasma trigger review: hormonal, drug, heat and light
• Wood's lamp examination and dermoscopy of pigmented lesions
• Photoprotection counseling including visible light and iron-oxide tinted sunscreen
• Topical hydroquinone under medical supervision, and the modified Kligman triple combination
• Non-hydroquinone topicals: azelaic acid, kojic acid, arbutin, cysteamine, thiamidol, niacinamide, vitamin C, topical tranexamic acid
• Topical retinoids for pigmentation and texture
• Oral tranexamic acid for melasma, after thrombotic screening
• Intradermal tranexamic acid microinjection and brightening mesotherapy
• Depigmenting mask protocol (Cosmelan / Dermamelan type)
• Superficial chemical peels, and TCA where justified
• Low-fluence 1064 nm Q-switched laser toning
• Picosecond laser for pigmentation, in selected cases
• Pulsed-wave RF microneedling for melasma and redness
• Melasma maintenance and relapse plan
• Pregnancy and breastfeeding-safe pigmentation plan
• Counseling on unregulated mixed lightening creams, mercury and steroid content
• Consultation about whitening injections and oral glutathione
• Exogenous ochronosis, lichen planus pigmentosus and drug-induced pigmentation as separate diagnoses
• Periorbital hyperpigmentation and pigmented dark circles
• Laboratory workup when an internal cause is suspected

Who it suits

• Someone with brown patches of much the same shade, symmetrical across the cheeks, the forehead or the upper lip, that darken in summer, in heat and in pregnancy — and who wants the pigment named before anything is aimed at it. Melasma, deeper gray dermal pigment, the darkening left behind by inflammation and pigmentation caused by a medicine look alike in the mirror and are managed differently, and treating the wrong diagnosis makes pigmentation worse
• Someone using a mixture right now, or a lightening cream with no clear name on the container, or a cream prescribed once and carried on for months without review. The first work here is stopping it on a plan and repairing the skin, and that is treatment rather than delay — bring the container with you
• Someone pregnant or breastfeeding who wants an honest answer about what can be done now and what waits
• Someone who accepts that this is managed over years rather than closed in one go: summer, pregnancy, travel, Hajj and Umrah are counted inside the plan rather than counted as its failures. And someone who can carry daily photoprotection, because here it is the treatment itself and not an addition to it
• Not you if you want a device at the first visit, or one course that closes the matter. A plan that starts with a laser is the wrong plan, and on deeper skin an aggressive laser or a deep peel is a recognized cause of melasma getting worse; for some people the honest advice is that no device is used at all, and that is a result of the examination rather than a service withheld from you. And if what you have is darkening left by spots, by an injury or by inflammation, or separate spots with defined edges on sun-exposed skin, the plan is a different one — post-inflammatory pigmentation and sun spots

When we advise delaying or not treating

• Pregnancy, planning a pregnancy, and breastfeeding. Hydroquinone is not used, nor the triple combination cream, nor retinoids — neither the cream nor the tablet — nor tranexamic acid tablets. Photoprotection stays the main tool, alongside whatever is agreed with the doctor looking after your pregnancy. Melasma that appears in pregnancy is usually left to settle after delivery before active treatment is considered, and the dark line on the abdomen and the pigmentary demarcation lines are explained rather than treated. Tell us before the prescription, not after it
• Tranexamic acid tablets are not a treatment you request; they are a prescription that is worked through. They are not given in pregnancy, and not to someone who has had a clot in the leg or the lung, or has a family history of one, or a known clotting disorder. They are not simply added on top of a combined hormonal contraceptive pill, patch or ring — a very common pairing in exactly this group — and the two are settled together before any prescription is written. Smoking is asked about, and weighs more heavily past the age at which the combined pill itself stops being suitable. They are deferred around recent surgery, a period of immobility or a cast, and long-distance travel. They are dispensed with fixed review points rather than open-ended. And they are not taken from a friend's box. One more thing to watch: the same name sits on two different products — topical tranexamic acid cream is one thing, and these tablets are another, with different reasons and different risks. Reading about "tranexamic acid" and arriving at the tablets is not arriving at the cream
• Skin thinned by a mixed cream, or by a topical steroid used on the face for a long stretch. Peels, needling and lasers are deferred until the skin barrier recovers. Stopping abruptly sets off redness, papules and sensitivity that rebound worse than they were, so the cream is withdrawn by degrees and on a plan — and you are told in advance that it gets worse before it settles, because someone who is not told that goes back to the cream
• Hydroquinone with no stop date and no review. It is dispensed for a limited course with a review appointment, not for open-ended use and not for restocking from a pharmacy shelf between visits. Prolonged unsupervised use — which is what happens with imported and mixed creams — irritates the skin and can produce exogenous ochronosis: a blue-gray darkening that is difficult to treat, is made worse by further bleaching, and is reported more often in darker skin
• An area threaded, waxed or sugared in the last few days. No acid, no needling and no laser pass over it; the surface layer has been lifted, so whatever is applied goes deeper than the strength predicts — and the upper lip and between the brows are the two places where the resulting mark shows most. A procedure is also postponed with a recent tan or recent sun, and with travel, Hajj or Umrah coming up; the photoprotection is arranged before the trip rather than after the pigmentation appears
• Pigmentation driven by a medicine or by an internal cause. No lightening treatment outpaces a cause that is still running. Some antibiotics, antimalarials, chemotherapy agents and some psychiatric and anti-epileptic medicines pigment the skin, and a fixed drug eruption leaves round dark marks that return at the same site. The whole list is reviewed — and a prescribed medicine is never stopped on cosmetic grounds; any change is arranged with the doctor who prescribed it. Blood tests may be requested where the history points to thyroid disease, iron deficiency or insulin resistance, on clinical indication rather than for everyone with dark patches
• Deeper gray pigment is not melasma. Lichen planus pigmentosus, ashy dermatosis and Hori's macules are frequently diagnosed as melasma. They are stubborn and prone to disappoint, and lasers and peels aimed at them can make them worse. They are separated out here by examination and dermoscopy, a biopsy is sometimes needed, hair dye and other contact allergens are reviewed as possible drivers, and management starts with conservative medical treatment and with plain talk about the limits of what is possible
• Uncontrolled diabetes, poor healing, and a history of keloid or of darkening after any scratch. Each of these changes the plan on its own: diabetes is brought under control before any peel, for healing and infection reasons, and skin that pigments after a minor scratch gets a slower and more staged plan than the person expected
• We decline whitening injections, intravenous glutathione and whitening tablets. Intravenous whitening is not supported by adequate safety or efficacy evidence and has been the subject of regulatory warnings in several countries, and declining it is a legitimate clinical position rather than a service withheld. We will also name the reason out loud when the request is pressure from family or from a husband rather than your own wish, and we say it gently, because it is said to be understood and not to embarrass. A request made on behalf of an adolescent daughter gets the same answer: care of the skin she has
• And we decline a plan built backwards from a date. A wedding coming up, or a trip in a few days: peels and the depigmenting mask protocol deliberately produce flaking, redness and a long home-care phase, and that is the treatment working rather than failing. We would rather move the appointment than hand you skin in the middle of peeling. We also decline to finish a booked course of sessions while the pigment is getting darker; the plan then begins with stopping, and we know stopping feels like giving up, which it is not

Possible effects

Stated in full, because the decision is not sound without them. The paradox on this page is that most of what treats melasma is also able to worsen it: heat, light and irritation are among the things that drive it, and the tools carry all three. That is why the plan is staged, and why a stopping point is written for every device before it starts:

• The creams: stinging, redness, dryness and flaking at the beginning. Irritation on this skin turns into color, so the strength is started low and built up, and irritation is not answered with more cream
• Hydroquinone: irritation, and with prolonged unsupervised use the possibility of exogenous ochronosis — a blue-gray darkening that is difficult to treat, is reported more often in darker skin, and gets worse if it is met with more bleaching. Preventing it is the plan: a defined course and a review
• The triple combination cream: it contains a steroid, and used open-endedly it thins the skin and brings out visible vessels and a steroid-induced dermatitis of the face and around the mouth. It is dispensed with a stop date and a review appointment, and it is not repeated from a pharmacy on nobody's advice
• Cysteamine: a distinctive odor that some people will not put up with, and stinging or redness on application. Nobody is blamed for not tolerating it; it is swapped for something else
• Tranexamic acid tablets: the risk that matters is a clot, which is why the assessment comes before the prescription rather than after it — your own and your family's history of clots, clotting disorders, a combined contraceptive pill, patch or ring, smoking, recent surgery, a cast or a period of immobility, long travel coming up, and the possibility of pregnancy. They can also cause nausea, stomach upset or headache. They are dispensed with review points, and they are stopped for any of the signs listed in the notice at the top of this page
• Intradermal injections and brightening mesotherapy: any needling into skin affected by melasma carries a risk of darkening afterward if the technique or the aftercare is aggressive. It is used cautiously in Fitzpatrick IV to VI and stopped if the skin reacts, the upper lip is not injected in the days after threading or waxing, and skin thinned by a mixed cream is not injected at all until it has recovered
• Peels and the depigmenting mask protocol: visible flaking, redness, a long home-care phase and strict sun avoidance, with rebound pigmentation possible if the maintenance phase is abandoned. A TCA peel specifically carries a real risk of darkening afterward and, at greater depth, of pigment loss and scarring in deeper skin — and in melasma it is often not the right choice in the first place
• Low-fluence laser toning: a double-edged device here. Repetition, or enthusiasm in the settings, is a documented cause of mottled pigment loss — scattered pale areas that recover slowly, may not recover fully, and have no straightforward treatment — and a documented cause of melasma rebounding darker than it was. Conservative settings, spaced intervals and a stopping point written in advance are not caution added to the treatment; they are the treatment
• Picosecond laser: the shorter pulse reduces the chance of darkening afterward in Fitzpatrick IV to VI without removing it, and melasma can still rebound; conservative settings and a test spot remain the rule. Moles and tattoo ink inside the treatment area are examined and covered, rather than passed over because they are in the way
• After any session: blistering, an open crust, a burn, spreading redness, increasing pain or discharge are not a stage of healing, and they are seen the same day. Delay is what turns them into a lasting pale mark or a scar

And if the pigment is getting darker rather than lighter as the plan goes on, or pale areas appear where the skin around them is not, stop and come in before the next appointment. Completing a session because it is booked is not sticking to the plan; it is departing from it.

A note on darker skin

Melasma is seen most in Fitzpatrick III to VI, and these are the same skin types in which the treatment is a common cause of it getting worse, which is why things are said on this page that are not said on another. What suits this skin: a plan that begins with photoprotection, and protection against visible light rather than against ultraviolet alone, because visible light drives melasma across this range in particular. That is where an iron-oxide tinted sunscreen earns its place, chosen in a shade close to your own so it leaves no white cast, because a sunscreen you dislike is abandoned within days and one that is abandoned protects nothing. Non-hydroquinone topicals suit it too — azelaic acid, niacinamide, cysteamine, thiamidol and topical tranexamic acid — because they allow long maintenance without an open-ended lightening course, and maintenance is what holds the result in a condition that returns. What needs caution: aggressive laser and deep peeling are a recognized cause of melasma worsening in these skin types; repeated low-fluence toning is a documented cause of mottled pigment loss; and a TCA peel at depth risks pigment loss and scarring. So procedures are preceded by priming and by a test spot reviewed after an interval before the full session is booked, and a test spot that passes lowers the risk without removing it. A Wood's lamp is less informative on darker skin than on lighter skin, so it supports clinical judgment rather than replacing it. Covering the face usually leaves a lighter zone under the fabric, which is practical evidence that photoprotection works — but heat and occlusion under the covering drive the same melasma, so the answer is shade, breathable unscented fabric and a tinted sunscreen underneath, not less protection. And the most honest thing to say here: dermal and mixed melasma respond less readily than epidermal, and knowing that at the first visit is what prevents escalation to a treatment that makes it worse.

Afterwards

• Sunscreen every morning and reapplied through the day, iron-oxide tinted because that screens visible light as well. With it: shade, a hat, and attention to the car window. This is the part that decides whether the rest of the plan holds
• Use the cream as it was written for you: in the amount you were shown, at the time you were told, and stop on the date you were given. It is not restocked from a pharmacy shelf between appointments
• Stinging, redness and light flaking are possible with some of the agents — report them rather than pushing through. Irritation on this skin turns into color, so pushing through costs more than it saves
• Heat counts as much as sun does: the oven and the kitchen, a car parked in the sun, steam, long hot showers and the sauna. It is not only sunlight
• No scrubbing, no harsh exfoliant, no repeated rubbing of the patch, and no daily wiping of the area with wet wipes. Friction drives pigment, and the darkening seen around joints and under the arms is the evidence for that
• Bring everything you put on your face to the review, in its packaging — including the mixture, if there is one. We are not asking in order to reproach you; we are asking because what is in the container changes the plan
• Report at the time: darkening that is increasing rather than settling as the plan goes on; mottled pale areas; redness or pain that persists after a session; and any pregnancy or plan to conceive, because that changes the prescription the same day rather than at the next appointment
• Tell us before travel, Hajj or Umrah so the plan is adjusted before the trip rather than after the pigmentation appears, and before you start or stop a hormonal contraceptive or any new medicine — that changes both what drives the melasma and what can be prescribed. And ask about vitamin D: strict photoprotection, covering and an indoor life together make a deficiency likely, and testing and dosing are arranged with the appropriate doctor
• Review is measured on photographs in the same light and the same position, not on an impression in front of the mirror. The impression changes with the light in the room; the photograph does not

Honestly

Melasma is controlled rather than cured, it relapses with sun, heat, pregnancy and travel, and on Fitzpatrick III-VI aggressive laser or deep peeling is a recognised cause of it getting worse, so some patients are advised against a device altogether and skin already thinned by an unlabeled mixed cream is repaired before anything is added.

Common questions

See also

Post-inflammatory marks, Sun spots & sun damage