Melasma: what it is and how it is managed

Melasma is driven by pigment-producing cells that have become overactive rather than simply damaged. Three things provoke them: hormones, ultraviolet light, and heat.

The hormonal link is strong — pregnancy, the combined contraceptive pill and HRT are all common triggers, which is why it is far more common in women and why it sometimes appears for the first time in your thirties with no change in sun habits.

The heat component is the one people do not expect and it matters clinically, because it means treatments that generate heat can worsen the very thing they are meant to treat.

Because the cells are overactive rather than merely holding excess pigment, aggressive resurfacing tends to provoke them further. A treatment that works beautifully on sun damage can make melasma rebound worse than the starting point, and that rebound can take many months to settle.

It also recurs. Someone whose melasma cleared entirely can see it return after one hot summer or a change in medication. That is not treatment failure; it is the nature of the condition.

This is why the honest framing is management, not cure — and why I would rather be dull about it at the start than have you feel misled at month four.

Sun damage and age spots tend to be discrete, irregular and asymmetric. Post-inflammatory pigmentation follows the pattern of whatever caused it — old spots, an injury. Melasma is characteristically symmetrical and patchy, with soft irregular borders, and it appears in the same places on both sides.

Getting this distinction right before treating is the whole game. Melasma treated as if it were sun damage generally gets worse, and that is the single most common mistake I see in people who arrive having been treated elsewhere.

Sun protection first and without exception: broad-spectrum SPF 50, reapplied through the day, ideally a tinted mineral formulation because visible light as well as UV contributes to melasma. This is not the boring preamble to the real treatment — it is the treatment that does the most work.

Then careful topical treatment to calm pigment production, introduced gradually. Then gentle, well-prepared peels rather than aggressive ones, with the skin prepared for several weeks beforehand.

Where a hormonal trigger is identifiable, a conversation with your GP about whether it can be changed is part of the plan rather than an afterthought.

Heat-generating treatments. Aggressive resurfacing. Sunbeds, obviously. And any clinic that promises to clear melasma permanently — if someone guarantees a cure for a chronic relapsing condition, that alone tells you enough about how they will handle the rest of your care.

Also worth avoiding: starting an intensive course in early summer. If you are going to do this properly, autumn and winter are the sensible seasons.

A good outcome is patches that are substantially lighter and less noticeable, with the condition kept stable by ongoing sun protection and maintenance. That is genuinely achievable for most people and it makes a real difference to how skin looks.

Complete permanent clearance is not a realistic aim, and someone offering it is either misinformed or being dishonest. I would rather you heard the ceiling from me before you spend money than after.