No. It can be controlled, often very well, and it will relapse with enough sun, heat or hormonal change. Anyone promising a cure has misunderstood the condition.
Overview
Diagnosis before device
Uneven tone is not a diagnosis. Treating melasma as though it were sun damage is how melasma gets worse.
Three quite different processes produce brown patches, and they respond in opposite directions. Sun-induced pigmentation — lentigines, freckling, actinic change — sits mostly in the epidermis and responds well to energy and resurfacing. Post-inflammatory hyperpigmentation follows acne, injury or a treatment that went too deep, and generally fades with time, protection and gentle handling.
Melasma is the difficult one, and it is worth understanding why rather than simply being told it is stubborn. It is no longer regarded as a disorder of melanocytes alone. The basement membrane separating epidermis from dermis is damaged in melasma skin, though how often varies a great deal between series — from a few per cent up to more than nine specimens in ten in the study that looked for it most carefully — and pigmented cells drop through that gap into the dermis, where no cream can reach them. Alongside that sit solar elastosis, increased mast cells, new blood vessels and senescent fibroblasts that keep signalling the melanocytes to produce. In other words, melasma behaves like a photoageing disorder of the whole dermal–epidermal unit. Suppressing the enzyme that makes pigment treats the output, not the cause, which is exactly why it returns.
That also explains the thing patients find hardest to accept: aggressive laser treatment frequently makes melasma worse, sometimes permanently. The first step here is establishing which of the three you actually have.
That is a dermatological question, not a device question, and it is why this page begins with diagnosis rather than a treatment list.
At a glance
- Treatment timeVaries by modality
- AnaestheticUsually none
- DowntimeNone to several days
- SessionsA managed course; melasma requires ongoing maintenance
- ResultsGradual; melasma is controlled rather than cured
- Combines withPrescription topicals, strict photoprotection
How it works
Diagnosis, then the correct instrument
Examination under different lighting, including where appropriate Wood’s light, helps establish whether pigment is epidermal, dermal or mixed. That distinction determines almost everything that follows.
Epidermal, sun-induced pigment responds to resurfacing, targeted energy and topical agents. Melasma is managed rather than cured: strict photoprotection, prescription topical therapy, carefully chosen superficial peels, and in selected patients oral tranexamic acid — which is the one intervention shown in randomised trials to reduce recurrence rather than simply to lighten. Devices, when used at all, are used at conservative settings with a low threshold for stopping.
Photoprotection in melasma is not ordinary sunscreen advice. Visible light drives melasma as well as ultraviolet does, and conventional sun protection factor says nothing about visible light — which is why a tinted, iron-oxide-containing product matters here and a clear SPF 50 is not enough. Heat is a trigger in its own right. On the Costa del Sol, that is the whole treatment plan rather than a footnote to it.
Post-inflammatory pigmentation is usually a matter of protecting the skin and waiting, supported by topical agents. It resolves; the mistake is treating it impatiently and re-inflaming the skin.
Indications
Assessed and treated
- Sun-induced pigmentation, lentigines and freckling
- Melasma — epidermal, dermal and mixed
- Post-inflammatory hyperpigmentation after acne or treatment
- Uneven tone on the face, neck, chest and hands
- Pigmentary change in Fitzpatrick types III–VI
- Prevention of pigmentation around other treatments
- Aggressive pigment-specific or ablative lasering of melasma, which we will decline
- Any device treatment while the melasma is actively inflamed or spreading
- Oral tranexamic acid where there is a personal or family history of clotting, active malignancy, or combined hormonal contraception that cannot be reviewed
- Hydroquinone used continuously and indefinitely, which carries its own pigmentary risk
- A patient who wants it gone permanently — melasma is managed, and we will say so at the first consultation
In the clinic
Step by step
Diagnosis
Clinical examination under several lighting conditions to establish the type and depth of pigment. Any suspicious lesion is assessed dermatologically first.
Photoprotection and topical therapy
For most patients this is the foundation, not an afterthought. Prescription topical therapy is started before any device is considered.
Careful escalation
Superficial peels, targeted energy or resurfacing — chosen for the diagnosis and introduced conservatively, with a test area where appropriate.
Maintenance
Melasma in particular relapses with sun and hormonal exposure. A maintenance plan is part of the treatment, not a failure of it.
Recovery
Downtime, honestly
Topical therapy, weeks one to four
Retinoid dermatitis — dryness, flaking and irritation — is common early and is managed by building up slowly rather than by stopping.
Weeks four to eight
The first visible lightening. Triple-combination therapy is typically used nightly for eight to twelve weeks and then tapered to intermittent maintenance rather than stopped.
Oral tranexamic acid
Where it is used, response is usually apparent within two months. In the largest published series, median treatment was four months.
Superficial peels
A course, two to four weeks apart, with no social downtime. Depth is kept deliberately modest.
Afterwards, indefinitely
Photoprotection, including visible light, continues permanently. This is the part that determines whether the result holds.
Risks
What can go wrong
Expected
Irritation, dryness and flaking from retinoids and acids, particularly in the first weeks.
Uncommon
Rebound darkening after a treatment that was too aggressive. Irritant contact dermatitis, which itself causes post-inflammatory pigmentation and so compounds the problem.
Rare but serious
Mottled hypopigmentation after laser treatment, which rarely recovers and is the complication that governs how cautiously devices are used here. Exogenous ochronosis after prolonged uninterrupted hydroquinone. With oral tranexamic acid, thrombosis — in a series of 561 patients, adverse events occurred in 7 per cent and one patient developed a deep vein thrombosis.
That single thrombosis in 561 patients is rare, and it is also the reason the screening conversation before oral tranexamic acid is not a formality. Clotting history, family history, hormonal contraception, recent surgery, immobility and smoking are all asked about before a prescription is written.
Evidence
What the evidence shows
Good for topicals, cautionary for lasersThe Cochrane review of melasma found triple-combination cream — hydroquinone, tretinoin and a corticosteroid — significantly better than hydroquinone alone or any two-agent combination, with mild and transient side effects. One caveat we will state rather than bury: its literature search was last run in 2010, so it predates the entire tranexamic acid literature and should not be read as current comprehensive guidance.
Oral tranexamic acid added to triple-combination therapy improved the melasma score significantly across four randomised trials and 490 patients — but the finding that matters is recurrence, which fell to roughly a quarter of the rate seen with topical treatment alone. In a 561-patient real-world series, 90 per cent improved, with relapse in 27 per cent after stopping.
For lasers, the literature is a warning rather than an endorsement. Even the gentlest widely used protocol — low-fluence Nd:YAG — showed recurrence in 59 per cent of patients one year after the last treatment, with scores worse than baseline. High-energy pigment-specific, ablative and fractional lasers are described in the review literature as producing an unacceptably high rate of hyper- and hypopigmentation and rebound melasma. The consensus position is that light and laser are second- or third-line options for recalcitrant disease at low energies. That is how we use them, and often we do not.
If you are travelling
This is the one page on this site where the treatment is largely something you do at home rather than something done to you here. The first consultation establishes the diagnosis and the regimen; most of the work happens over the following months, wherever you live.
Review is at eight to twelve weeks and is done on standardised photographs. Please take them in the same light each time — melasma is unusually sensitive to how it is photographed.
If you are coming to Marbella, consider the season. Melasma worsens with sun and with heat, and a course begun in June on the Costa del Sol is starting at a disadvantage. There is no tactful way to say that, so we say it directly.
Questions
Good to know
If your question is not here, ask it in the enquiry form — Dr. Henningsen answers these personally.
Ask a question- Can melasma be cured?
- Will laser fix my pigmentation?
For sun-induced pigment, often yes. For melasma, laser is where a great deal of harm is done — aggressive treatment can rebound worse than the original. Diagnosis first, always.
- Does sunscreen really make that much difference?
For pigmentation it is the single most important intervention, and visible light matters as well as UV — which is why a tinted mineral sunscreen outperforms a clear chemical one in melasma.
- Is my pigmentation dangerous?
Most is entirely benign, but any changing, irregular or new pigmented lesion should be assessed by a dermatologist. That assessment is part of your consultation.
Consultation
Ready to talk about your skin?
Consultations with Dr. Henningsen are arranged individually. Tell us what you would like to change and we will come back to you with the options, the honest downtime and the realistic result.