Hyperpigmentation
Brown patches come from several different mechanisms — sun damage, post-inflammatory response, and melasma — and they look similar enough that they get treated identically and then do not respond. Melasma in particular is hormonally driven, sits deeper, and gets worse with aggressive heat-based treatment, which means the wrong laser makes it worse rather than doing nothing. Identifying which one you have is the entire treatment plan, and it is why we will not book a device appointment for pigment without seeing you first.
Why this happens
Melanocytes sit at the base of the epidermis and produce pigment on demand. The demand signal is what differs between the three common patterns, and the signal determines what will switch it off.
Sun-induced pigment — the discrete, well-defined spots on the cheekbones, the tops of the hands and the chest — is cumulative ultraviolet damage. Individual melanocytes have been chronically stimulated and now produce pigment continuously. The pigment sits relatively superficially, which is why it responds well to light-based and exfoliating treatment.
Post-inflammatory pigment is the aftermath of something else: a spot, a scratch, a reaction, a treatment that went too hard. The inflammation drives pigment production, and in richly pigmented skin it drives it enthusiastically. It is temporary by nature — the signal has already stopped — and it clears on its own if nothing re-inflames the area.
Melasma is the difficult one. It is symmetrical, patchy rather than spotted, sits across the cheeks, forehead and upper lip, and is driven by hormones plus light — including visible light and infrared heat, not only ultraviolet. The pigment often extends deeper into the dermis. Heat is a trigger in its own right, which is why an aggressive device treatment can leave a melasma patch darker than it started, and why it recurs even after a good response.
What actually helps
Each of these does something specific about the mechanism above. The sentence under each one is what it does for this, which is not the same as what its own page says it does in general.
- Chemical peels
Lifts pigment that is sitting in the epidermis, with the depth chosen conservatively, and it is the option we reach for first when melasma is on the table because it adds no heat.
- IPL photofacial
Excellent on discrete sun spots, where broad-spectrum light is absorbed by concentrated pigment and clears it — and specifically not appropriate for melasma or for every skin tone.
- Laser resurfacing
For pigment bound up with texture and sun damage together, where treating the surface and the discoloration in one course is the more efficient path.
What won’t work
- Intense pulsed light on melasma. It is the single most common mistake made with this concern, the light and heat both feed the mechanism, and the patch frequently comes back darker than it was.
- Any single treatment, for melasma of any kind. It is a chronic, relapsing condition managed over years with sun protection, topicals and conservative in-office work. A course that promises to resolve it is describing something that does not happen.
- Treating pigment while the thing causing it is still happening. Post-inflammatory marks from ongoing breakouts, from picking, or from an irritating routine will keep being replaced faster than any treatment clears them.
- Skipping daily broad-spectrum sun protection and expecting a result to hold. Every mechanism behind this concern is driven or maintained by light exposure, and the treatment is the smaller half of the plan.
- Hydroquinone bought from an unregulated source, used continuously for months. Misused, it causes a paradoxical darkening that is considerably harder to treat than what it was applied to.
Where we’d start, and why
- 1We look at the pattern before we look at the color. Discrete spots with defined edges on sun-exposed surfaces read as sun damage. Symmetrical patches across the cheeks and forehead read as melasma. Marks that map onto where you had spots or scratches read as post-inflammatory.
- 2We ask about hormonal context — not as a medical history, but because melasma commonly appears or worsens in specific circumstances and the answer changes what we recommend rather than what we prescribe.
- 3If there is any suggestion of melasma, we start conservatively: sun protection you will genuinely use daily, a topical routine, and light peels rather than a device. Heat is the thing to avoid, and no device appointment gets booked before that has been established.
- 4For clear sun damage in an appropriate skin type, intense pulsed light is efficient and satisfying, and we will say how many sessions it usually takes rather than booking one and letting you assume.
- 5Nothing here starts without a conversation about what you use at home, because pigment is the concern where the home routine does the largest share of the work.
What would make us decline
These are the answers we actually give in the room, and they are the reason the practice is called what it is called.
- You have melasma and you want a device treatment because it worked for a friend with sun spots. We will explain the mechanism, offer what genuinely helps, and decline the device — this is one of the treatments we say no to most often, and the reason is that the likely outcome is worse skin.
- Your skin tone and the device in question are a poor match. Light-based treatment carries a real risk of burning and of causing the exact pigment problem you came in to treat, and a practice that treats everyone with the same settings is a practice that has decided not to look.
- You have a pigmented lesion that is irregular, changing, or has an unusual border. We will not treat it and we will not photograph it and move on — we will tell you to have it looked at by a dermatologist first.
- You are unwilling to use daily sun protection. That is a legitimate choice and it makes the treatment a waste of your money, so we would rather say so than take it.
What this is not
Any pigmented spot that is new, changing, asymmetric, irregularly bordered, multi-colored, or larger than about six millimeters needs a dermatologist before anyone treats it cosmetically. Removing a lesion's appearance without knowing what it is destroys the thing a physician would have needed to look at. That is a boundary we do not go near.
Questions about hyperpigmentation
How do I tell melasma from sun spots at home?
Melasma is usually symmetrical, appears as patches with soft edges rather than discrete dots, sits across the cheeks, forehead and upper lip, and fluctuates with the season and with heat. Sun spots are individual, defined, and sit where the sun lands. If it is symmetrical and patchy, treat it as melasma until someone tells you otherwise.
Why does my pigment get darker in summer even with sunscreen?
Because ultraviolet is not the only trigger. Visible light and infrared heat both stimulate pigment, and most sunscreens filter ultraviolet only. A tinted mineral formulation adds visible-light protection, which is why we recommend one specifically for melasma rather than any sunscreen.
How long before I see a change?
Superficial sun damage often changes visibly within one to three sessions. Melasma is managed rather than cleared, improvement is measured across months, and it fluctuates. Anyone giving you a number of weeks for melasma has not distinguished it from sun damage.
When is this something I should see a dermatologist about instead?
Any single spot that is changing, itching, bleeding, or that looks different from your others. Any pigment with an irregular border or more than one color in it. And any widespread darkening that came on quickly, because that can have a medical driver that no aesthetic treatment addresses.