What it is
Melasma is a brown or grey-brown patchiness that usually sits on the cheeks, forehead and upper lip, and it is driven by sunlight, heat and hormonal change as much as by anything on the surface of the skin. 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
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.