Pigmentation and melasma treatment in London

The rule that comes before everything

Pigmented lesions are not all cosmetic. A new mark, a mark that is changing in size, shape or colour, a mark with an irregular border or more than one colour, a mark that itches, bleeds or does not heal, and any mark that looks different from your others all need assessment by a doctor before anybody treats them.

Lasering an undiagnosed pigmented lesion removes the visible sign of something that may need diagnosis, without removing the thing itself. It is the single most serious avoidable error in this area. A responsible clinic will examine your skin properly and will refuse to treat anything it is not certain about, referring you instead.

Any clinic willing to laser a mole without a diagnosis has told you everything you need to know about it.

Four conditions, one word

Solar lentigines

Flat brown patches with a defined border, on skin that has had long-term sun exposure: face, hands, chest, shoulders. Caused by localised increases in pigment production. These respond well to light-based treatment and to topical management.

Post-inflammatory hyperpigmentation

Flat brown or grey marks appearing where inflammation occurred: a spot, an injury, an aggressive treatment. Common in skin of colour. Fades over months to years and responds to topicals, patience and rigorous sun protection. It is not scarring.

Melasma

Symmetrical, blotchy brown or grey-brown patches, typically across the cheeks, forehead, upper lip and jaw. Strongly associated with hormonal factors and with sun and heat. Chronic, relapsing and easily made worse. This is the difficult one.

Freckles

Small, sun-responsive spots that darken in summer and fade in winter, usually appearing in childhood. Generally left alone unless someone particularly wants them treated.

The treatments for these overlap only partially, and one of them can be made permanently worse by a treatment that works well for another. That is why the diagnosis is the whole job.

Why melasma is different

Melasma behaves less like a stain and more like a condition. The pigment-producing cells in affected areas appear to be persistently overactive rather than simply having produced too much pigment once. That has three consequences.

• It relapses. Treatment improves it and it comes back, particularly with sun exposure, heat, and hormonal change including pregnancy and some contraceptives.
• It responds to heat as well as to light. Cooking over a hot stove, a hot yoga class and an aggressive radiofrequency treatment can all provoke it.
• Aggressive laser can make it substantially and sometimes permanently worse. This is well recognised and it is the reason careful practitioners are conservative here.

A sensible melasma plan is topical-led, patient, and built around avoidance: broad-spectrum protection including protection against visible light, avoiding heat where practical, and long-term topical management. Procedural treatment, where it is used at all, is cautious and sits on top of that foundation rather than replacing it.

What actually works

Topical treatment

This is the foundation for every type. Agents that inhibit pigment production, agents that accelerate cell turnover, and antioxidants that reduce the stimulus all have a role, and some of the most effective are available only on prescription. A practitioner who can prescribe has more options than one who cannot, and this is one of the areas where that matters most.

Chemical peels

Useful across several types, with agent and depth chosen against skin type. Mandelic acid is often preferred in darker skin. See chemical peels.

Light and laser

Intense pulsed light and pigment-specific lasers work well for solar lentigines in lighter skin. In darker skin the calculation changes, in melasma it changes again, and a test patch is essential in every case. See laser resurfacing.

Microneedling

Used as a delivery route and as a remodelling treatment, with more caution in melasma than the marketing usually implies.

Time

Post-inflammatory marks fade. Treating them aggressively out of impatience is a common way to create more of them.

Building a realistic plan

1. Get any suspicious lesion assessed medically. Nothing else happens until this is done.
2. Establish daily broad-spectrum protection, correctly applied, for several weeks before any procedure.
3. Identify the type or types you have, and treat any active inflammation such as acne first.
4. Begin topical treatment and give it time to work, generally three months before judging.
5. Add procedural treatment only where the type is appropriate for it, with a test patch.
6. Plan maintenance from the outset, because pigmentation is a long-term management problem rather than a one-off.

Expect improvement rather than erasure, and expect it slowly. A plan that promises clear skin in six weeks is describing something that does not exist.

Risks worth knowing

• Making it worse. Heat, aggressive light and inflammation can all deepen pigmentation, and in melasma the setback can last a long time.
• Post-inflammatory hyperpigmentation from the treatment itself, which is the recurring theme of this entire field in skin of colour.
• Loss of pigment, producing pale patches, which is harder to correct than excess pigment.
• Treating an undiagnosed lesion.
• Spending significantly on procedures while skipping the sun protection that determines whether any of it holds.