Melasma is not sun damage

It is chronic and relapsing. It is managed, not cured. A clinic offering to remove melasma is either using the word loosely or has not been treating it for very long.

The instinct is to reach for the same tools: intense pulsed light, aggressive pigment-selective lasers, strong peels, energetic settings. They frequently produce a good result at four weeks. Then the pigment returns, and returns darker than it started, because the treatment delivered heat to skin whose defining feature is that heat provokes it.

This is the single most common way we see melasma made worse, and it is usually done with good intentions in a clinic that treats sun damage perfectly well.

The assessment that prevents it takes two minutes: history, distribution, the character of the edges, and a Wood's lamp to judge how much of the pigment is epidermal and how much has dropped deeper. Dermal pigment responds slowly and rewards patience. Epidermal pigment responds faster. Both punish aggression.

• Photoprotection that includes visible light. A tinted sunscreen containing iron oxides, applied at the proper quantity, reapplied, and worn indoors near windows. Without this, nothing else works, and there is no point starting anything else until it is habitual.
• Tyrosinase inhibitors, used in cycles. Hydroquinone remains the most effective and is used in courses with breaks, under supervision. Azelaic acid, cysteamine and topical tranexamic acid are useful and better suited to long-term maintenance.
• Oral tranexamic acid in selected patients, with screening for clotting risk and the prescriber involved. It has good trial support in melasma and it is not appropriate for everyone.
• Low, slow energy. Gentle non-ablative approaches at conservative settings, widely spaced, introduced only once the pigment is calm — and never as the opening move.
• Removing the trigger where that is possible. Sometimes a conversation with the prescriber about hormonal contraception. Always keeping the face out of direct heat: saunas, hot yoga, standing over a stove, a long drive with the sun on one cheek.

Two things make the assessment easier for everyone. Bring the history: when it first appeared, what you were taking at the time, whether it fades in winter, whether a previous treatment made it darker. And expect to be photographed under fixed lighting at every visit, because melasma changes slowly and in patches, and memory is a poor instrument for judging it. Nobody can tell from the bathroom mirror in August whether they are eight per cent better than they were in June.

A seventy to eighty per cent reduction, held with maintenance, with a setback most summers. That is a good result in melasma and it is worth having. Skin that is entirely and permanently even is not on the table, and being told otherwise is usually the beginning of a course of treatment that ends worse than it started.

Plenty of faces have melasma and sun damage together, and this is where the sequence matters. Calm the melasma first — months of photoprotection and topicals — and only then treat the discrete lentigines, carefully, on a face that is no longer inflamed. Doing it the other way round treats the easy problem and provokes the difficult one.

That order is unsatisfying, because the lentigines are the part that can be dealt with quickly and visibly and the melasma is the part that requires months of unglamorous consistency. It is still the order, and a practitioner who reverses it to give you an early result is trading your twelve-month outcome for your four-week one.

There is more on managing the seasonal pattern in Melasma through a Toronto summer.