Treating pigmentation on the face

Sun-induced pigmentation — solar lentigines, or what most people call age spots — appears as discrete, well-defined brown patches on the areas that catch the most light: cheekbones, forehead, nose, the backs of the hands. It accumulates over decades and it does not fade on its own.

Post-inflammatory hyperpigmentation is the flat brown or grey mark left behind after a spot, an ingrown hair or any other inflammation of the skin. Its distinguishing feature is that it sits exactly where the inflammation was. It usually fades by itself, but that can take months, and in deeper skin tones it takes longer.

Melasma is different from both. It presents as larger, symmetrical, ill-defined patches — usually across the cheeks, upper lip and forehead — and it is driven by hormones as well as light. It is a chronic condition that is managed rather than cured, and it is the one that heat and aggressive treatment will make worse. If your pigmentation is symmetrical and appeared during pregnancy or after starting hormonal contraception, read the separate melasma guide before booking anything.

Every pigmentation problem is driven or sustained by ultraviolet light, and in melasma also by visible light and heat. Treating pigment without controlling exposure is emptying a bath with the tap running — the treatment lightens what is there while new pigment is laid down behind it.

A broad-spectrum SPF 50 used every day, all year, is the single most effective intervention available for this concern, and it is the cheapest. For melasma and for deeper skin tones a tinted mineral sunscreen is better still, because the iron oxides in the tint block visible light in a way clear chemical filters do not.

I say this before naming a single treatment because a clinic that skips it is selling you a course you will need to repeat. If you are not willing to wear sunscreen daily, tell me at consultation — it changes what is worth doing, and I would rather adjust the plan than watch it fail.

Chemical peels work by controlled exfoliation, accelerating the turnover that carries pigmented cells to the surface and away. For sun damage and post-inflammatory marks a course of superficial to medium-depth peels is a reliable option, and it improves texture and tone at the same time.

Microneedling helps by a different route — creating a controlled healing response that remodels the skin over weeks — and it is particularly useful where pigmentation sits alongside texture problems or acne scarring. In melasma it needs a much more cautious hand, because inflammation is part of what drives the condition.

Topical treatment is doing more of the work than most people credit. A well-built routine with a vitamin C in the morning, a retinoid at night and a pigment-targeting agent will visibly improve most pigmentation given three to six months, and it is what holds the result after a course of treatment ends.

Heat. Not only sunlight but hot yoga, saunas, standing over an oven and, in melasma particularly, heat-based devices used on the face. Melasma responds to temperature as well as to light, which is why some laser treatments have made it dramatically worse.

Aggressive treatment of any kind in deeper skin tones. Any inflammation risks leaving post-inflammatory pigment behind, so the treatment intended to fix the marks can create new ones. This is a reason to be treated conservatively and in stages rather than to avoid treatment altogether.

Picking. Squeezing a spot deepens and prolongs the mark it leaves, often by months. It is unglamorous advice, and it is the one that would prevent most of the post-inflammatory pigmentation I see.

Nothing here is fast. A course of peels usually runs to four to six sessions at three to four week intervals, with visible improvement building across it. Topical routines need a full skin cycle to show anything and three months to be judged fairly.

I photograph before we start, in the same position and the same light, because pigmentation fades slowly enough that day-to-day comparison is unreliable and people frequently conclude nothing is happening when it is.

The result is maintained rather than finished. Sun protection, an ongoing topical routine and occasional maintenance treatment is what keeps it; stopping all three returns you to where you began within a year or two.