Melasma treatment, private in London.

Melasma is an acquired disorder of skin pigmentation that appears as symmetric brown or grey-brown patches on sun-exposed areas of the face, most often the cheeks, forehead, upper lip, nose and chin. It is far more common in women than men, and disproportionately affects patients with darker skin phototypes (Fitzpatrick III to V).

The cause is multifactorial: ultraviolet and visible light exposure, hormonal drivers (pregnancy, combined oral contraceptives, hormone replacement therapy), heat, a genetic predisposition, and, in some patients, thyroid dysfunction. Melasma is chronic and relapsing. Treatment aims to fade the pigment and prevent recurrence, not to cure the underlying tendency.

A dermatologist takes a full history (onset, hormonal factors, medications, sun exposure, prior treatments) and examines the face under natural light and a Wood’s lamp. Wood’s lamp examination helps differentiate epidermal melasma (accentuated under UV, generally more responsive to topical treatment) from dermal or mixed melasma (less accentuated, more stubborn).

The Melasma Area and Severity Index (MASI) may be scored at baseline and follow-up to track objective change. Differential diagnoses that must be excluded include post-inflammatory hyperpigmentation, drug-induced pigmentation, exogenous ochronosis (a paradoxical darkening from long-term hydroquinone misuse), and lichen planus pigmentosus.

Nothing else works without it. A broad-spectrum mineral sunscreen of SPF 50 or higher, containing iron oxide for visible-light protection, applied every morning and reapplied every two hours during daylight exposure, is non-negotiable. Add a wide-brimmed hat, seek shade, and avoid midday sun. Patients who skip this step rarely see meaningful improvement, regardless of the prescription or procedure.

Kligman’s triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone 0.01%) is the gold standard, prescribed at night for 8 to 12 weeks and then cycled down to avoid rebound pigmentation, telangiectasia and exogenous ochronosis. It is used under close dermatology supervision, not indefinitely.

Alternatives and adjuncts include azelaic acid 20% (pregnancy-compatible), kojic acid, ascorbic acid (vitamin C) serums, niacinamide and alpha arbutin. Response is measured at 8 to 12 weeks. A conservative maintenance routine, combined with rigorous sun protection, holds the result.

Low-dose oral tranexamic acid (250 to 500 mg twice daily for 3 to 6 months) has modest evidence for moderate to severe melasma. A venous thromboembolism screen and history (personal or family clotting history, oral contraceptive use, smoking, recent surgery) is essential before starting. Oral glutathione is popular but has limited evidence and is not recommended by dermatology guidelines.

Superficial chemical peels (glycolic acid 30 to 50%, salicylic acid 20%, Jessner’s solution) delivered as a course of 4 to 6 sessions can accelerate fading when combined with topical treatment. Mild trichloroacetic acid (TCA) peels at 15 to 20% are used selectively. Medium-depth peels are largely avoided because the risk of post-inflammatory hyperpigmentation often outweighs the benefit, particularly in darker skin.

Low-fluence Q-switched Nd:YAG laser toning (using PicoSure or PicoWay platforms) may be offered cautiously for dermal or refractory cases. Fractional non-ablative erbium or thulium at very low settings is sometimes used, though evidence is mixed and paradoxical worsening is a known risk. Every procedural option requires an experienced operator, honest counselling and a plan for recurrence.

Melasma is chronic and relapsing. Complete clearance is uncommon. A realistic goal is substantial fading (typically 50 to 80% pigment reduction after a full course of treatment) with long-term maintenance. Recurrence should be expected with UV exposure, hormonal change (pregnancy, contraceptive change, HRT) or heat exposure. Patients who understand this at the start are the patients who stay ahead of it.

Melasma is often triggered or worsened by pregnancy, commonly called the “mask of pregnancy”. It usually fades in the months after delivery, but frequently persists and can recur with subsequent pregnancies or hormonal contraception. Treatment during pregnancy and breastfeeding is limited to rigorous sun protection and, where advised by a dermatologist, azelaic acid. Hydroquinone, tretinoin and oral tranexamic acid are avoided. Definitive treatment resumes once breastfeeding ends.