Melasma: causes, treatment and why laser is not the first answer

01What causes melasma

Melasma is overactivity of pigment cells in chronically light-exposed skin, appearing as brown to grey-brown patches — usually symmetric, on the cheeks, forehead, nose bridge or upper lip.

Recent research shows it is not only a pigment problem: melasma skin carries increased vascularity, more mast cells and basement-membrane damage. That multi-layer pathology is the mechanistic reason colour-only treatment tends to relapse — the rest of the disease is untouched.

Ultraviolet and visible light exposure is the dominant trigger; hormones are next, with pregnancy and hormonal contraception clearly associated. Genetics sets individual susceptibility, and Asian skin sits in the higher-susceptibility group.

02Melasma vs freckles

These are the two most-confused pigment problems, and telling them apart decides the care path — they respond very differently.

03Evidence-based treatment order

The 2025 Delphi consensus (38 dermatologists, 11 countries, Pigmentary Disorders Society) is explicit about order: broad-spectrum photoprotection is essential; physician-prescribed depigmenting topicals are the mainstay; adjunct procedures such as chemical peels or microneedling can enhance topicals case-by-case; and lasers are reserved for refractory cases.

Notice that this order is nearly the inverse of aesthetic-market messaging, which leads with laser. The difference is not opinion but disease behaviour: melasma is a chronic condition sensitive to provocation, and overly aggressive treatment is itself a provocation.

Some oral medicines have supporting evidence in suitable cases, strictly under physician assessment and follow-up. This article deliberately names no drugs — medicine selection is an individual clinical decision.

04Is laser good for melasma? The complete answer

Laser has a real place — for melasma that has not responded to properly used topicals and photoprotection. Specialist reviews describe low-fluence pigment-targeted lasers and light devices, always alongside strict sun protection and topical therapy, never alone.

The side that must be said out loud: light-based treatment carries its own risk of post-inflammatory hyperpigmentation and melasma stimulation, particularly in Asian skin, and the risk rises with energy and frequency. That is why melasma laser work belongs with a physician, on an individual plan with maintenance follow-up — not an identical package for everyone.

Before agreeing to laser, ask: has my melasma had adequate first-line care; how are the device and settings chosen for Asian skin; and what is the plan if my melasma darkens after treatment?

05Living with melasma, controlled

The realistic goal is control — fading it and preventing rebound — not permanent erasure. Studies agree that abandoning photoprotection is the leading cause of relapse, so sun protection is a permanent routine, not a treatment phase: daily broad-spectrum sunscreen, hats, midday shade.

For melasma linked to hormonal contraception, discussing alternatives with your physician is an overlooked part of care. Pregnancy-related melasma sometimes fades after delivery, so assessment often precedes active treatment.

This article is general information, not a diagnosis or individual treatment advice. Some pigment conditions must first be distinguished from other skin diseases by a physician.