Melasma: A Condition to Manage, Not a Result to Deliver
Melasma is the condition most likely to damage an aesthetic practitioner's reputation, because it responds to treatment, recurs anyway, and worsens in response to several of the interventions most clinics own. The practitioners who do well with it are the ones who stopped promising to clear it.
Recognising what you are looking at
Melasma typically presents as symmetrical, blotchy brown to grey-brown patches on the cheeks, forehead, upper lip and jawline, with irregular but reasonably defined borders. It is far more common in women, strongly associated with hormonal factors including pregnancy and combined oral contraception, and more common in richly pigmented skin. In darker skin it is also a recognised indication for chemical peeling, and both skin type and ethnicity should guide the choice of agent [1].
It is not the same as post-inflammatory hyperpigmentation, which follows an identifiable insult and generally resolves, nor the same as sun-induced lentigines, which are discrete and respond well to targeted treatment. Confusing them leads directly to the wrong plan: an approach that clears lentigines can inflame melasma and leave the patient worse than before.
Where the picture is uncertain, or where the patches are asymmetrical or unusual in distribution, a dermatological opinion is the correct next step rather than a treatment.
Why it is difficult
Melasma is a chronic disorder of pigment regulation, not a stain to be removed. The melanocytes involved are hyper-responsive, and they respond not only to ultraviolet light but to visible light and to heat. That last point is the one most often missed in aesthetic practice, and it explains why a patient can be diligent about sun protection and still relapse after a treatment that warmed the skin.
It also explains why heat-generating devices call for caution here. Deep and high-concentration peels carry their own risk of post-inflammatory hyperpigmentation, particularly in darker skin types, and can leave the patient worse than the starting point [2].
The plan that works
Successful melasma management is unglamorous and mostly happens outside the clinic.
Photoprotection is the treatment, not the aftercare. Broad-spectrum protection applied properly and reapplied, plus protection against visible light — tinted formulations containing iron oxides are worth naming specifically, because ordinary sunscreens give little protection against visible light, which also drives this condition. Hats and shade matter. So does the observation, uncomfortable but true, that a patient who will not commit to this will not hold a result.
Address the drivers. Hormonal contraception, pregnancy and certain medications are relevant, and a conversation with the patient's own doctor is sometimes more useful than anything done to the skin.
Topical treatment is the workhorse, prescribed and supervised, with the specific agents and regimens a matter for the prescriber. What matters at the level of principle is that it is long-term and that it is maintained after visible improvement, because relapse after stopping is common.
Procedures are adjuncts to that daily routine, not a substitute for it. Where a peel is used, glycolic acid is often the first choice, with the agent and depth selected for the patient's skin type [3].
The conversation that decides satisfaction
Tell the patient at the first appointment that melasma is managed rather than cured, that recurrence is expected rather than a sign of failure, that summer and pregnancy will undo progress, and that the plan is measured in years. Patients accept this readily. What they do not accept is discovering it after paying for a course of treatments sold as a solution.
Document with consistent photography. Improvement in melasma is gradual, and memory is unreliable in exactly the direction that produces complaints.