Aesthetic Treatments for Hyperpigmentation and Melasma

Understanding hyperpigmentation and melasma

Hyperpigmentation is one of the most common skin concerns presented at aesthetic clinics in the UK, affecting individuals across all skin types and ethnicities. It refers to patches of skin that become darker than the surrounding area due to excess melanin production. Melasma, a specific form of hyperpigmentation, presents as symmetrical brown or grey-brown patches typically on the face, and is notoriously challenging to treat.

We take an evidence-based, multimodal approach to treating pigmentation disorders. Practitioners understand that effective management requires accurate diagnosis, appropriate treatment selection, and long-term maintenance strategies tailored to each patients skin type and lifestyle.

Types of Hyperpigmentation

Before embarking on treatment, it is essential to correctly identify the type of pigmentation present, as this directly influences the treatment approach:

• Melasmahormone-related, often triggered by pregnancy, oral contraceptives, or HRT. Presents as symmetrical patches on the cheeks, forehead, upper lip, and chin. Classified as epidermal, dermal, or mixed
• Post-inflammatory hyperpigmentation (PIH)darkening that follows skin injury or inflammation such as acne, burns, or aggressive treatments. More common and severe in darker skin tones (Fitzpatrick IV-VI)
• Solar lentigines (sun spots)flat, brown spots caused by cumulative UV exposure, typically on the face, hands, and decolletage
• Freckles (ephelides)small, light brown spots that darken with sun exposure, genetically determined
• Drug-induced pigmentationcertain medications including minocycline, amiodarone, and some chemotherapy agents can cause pigmentary changes

The role of melanin

Melanin is produced by melanocytes in the basal layer of the epidermis. When these cells are stimulated, by UV radiation, hormones, inflammation, or injury, they increase melanin production. In hyperpigmentation, this process becomes dysregulated, leading to excess melanin deposition in the epidermis, dermis, or both. Treatment strategies target various points in the melanin production pathway.

Aesthetic treatment options

Chemical Peels

Chemical peels are a first-line treatment for many types of hyperpigmentation. They work by removing the superficial layers of pigmented skin and stimulating cell turnover:

• Glycolic acid peels (20-70%)effective for epidermal pigmentation, suitable for most skin types at appropriate concentrations
• Mandelic acid peelsgentler option, particularly suitable for darker skin tones due to larger molecular size and slower penetration
• Lactic acid peelshydrating with brightening properties, well-tolerated by sensitive skin
• Modified Jessners peelcombination of salicylic acid, lactic acid, and resorcinol for stubborn pigmentation
• TCA peels (15-35%)medium-depth option for more resistant pigmentation, requires experienced application

Laser and light-based treatments

Laser treatments can be highly effective but require careful selection based on the type and depth of pigmentation, as well as the patients skin type:

• Q-switched Nd:YAG (1064nm)safest laser option for darker skin types, targets deeper pigment
• Picosecond lasersultra-short pulse duration minimises thermal damage and reduces PIH risk
• IPL (Intense Pulsed Light)effective for solar lentigines in lighter skin types (Fitzpatrick I-III)
• Fractional laserscreate micro-columns of treatment for general skin rejuvenation with pigmentation improvement

Important caution: Laser treatment of melasma remains controversial. While it can produce initial improvement, rebound hyperpigmentation is common. Many experts reserve laser therapy for melasma only after topical treatments have been optimised.

Microneedling

Microneedling creates controlled micro-injuries that stimulate skin remodelling and improve the penetration of topical depigmenting agents. It is generally safe for all skin types when performed correctly, making it a valuable option for patients with darker skin who may not be candidates for certain laser treatments.

Mesotherapy and skin boosters

Intradermal injection of brightening cocktails containing ingredients such as tranexamic acid, glutathione, vitamin C, and alpha-arbutin can target pigmentation from within the skin. Tranexamic acid mesotherapy has shown particular promise for melasma in recent clinical studies.

Topical treatment protocols

Topical agents form the foundation of any hyperpigmentation treatment plan and are essential for maintaining results achieved with in-clinic procedures:

• Prescription retinoids (tretinoin 0.025-0.1%)accelerate cell turnover and disperse melanin granules
• Hydroquinone (2-4%)the gold-standard depigmenting agent, available on prescription in the UK. Used in cycles of 3-4 months
• Azelaic acid (15-20%)inhibits tyrosinase and has anti-inflammatory properties, safe in pregnancy
• Vitamin C (L-ascorbic acid 10-20%)antioxidant that inhibits melanin production and protects against UV-induced pigmentation
• Tranexamic acid (topical)reduces melanin synthesis by inhibiting plasminogen activator in keratinocytes
• Niacinamide (5%)reduces melanosome transfer to keratinocytes
• Alpha-arbutinnatural tyrosinase inhibitor derived from bearberry

Special considerations for melasma

Melasma deserves particular attention due to its chronic, relapsing nature. Key principles for managing melasma include:

1. Rigorous sun protectionbroad-spectrum SPF 50+, reapplied every 2 hours. Visible light and infrared radiation also trigger melasma, so tinted sunscreens containing iron oxide are recommended
2. Gentle approachaggressive treatments often worsen melasma through inflammatory rebound
3. Combination therapyno single treatment is sufficient; the best outcomes combine topical agents with in-clinic treatments and sun protection
4. Hormonal assessmentconsidering contraceptive changes or HRT modification in consultation with the patients GP
5. Long-term maintenancemelasma is a chronic condition requiring ongoing management, not a one-off treatment

“Melasma should be treated like a chronic disease rather than a condition that can be cured with a single procedure. Setting realistic expectations with patients is as important as the treatment itself.”, British Association of Dermatologists

Skin type considerations

The Fitzpatrick skin type classification is essential for safe treatment planning. Patients with darker skin tones (types IV-VI) carry a higher risk of post-inflammatory hyperpigmentation from treatments and require more conservative approaches. Practitioners are experienced in treating all skin types and will adapt treatment protocols accordingly.

Frequently asked questions

Summary

Effective treatment of hyperpigmentation requires accurate diagnosis, a tailored multimodal approach, and realistic expectations. Practitioners combine in-clinic treatments with evidence-based topical protocols and rigorous sun protection advice to deliver the best possible outcomes for all skin types. We believe in treating the whole patient, not just the pigment.