Melasma: Procedures
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Direct answer
Why add a procedure to a melasma prescription? Because creams plateau. Procedures — chemical peels, low-fluence Q-switched Nd:YAG laser toning, and microneedling with tranexamic acid — push pigment clearance beyond what triple-combination ointment achieves, but only in epidermal-type melasma and only with ruthless sun protection. Indian skin sits overwhelmingly in Fitzpatrick types IV-V, where the margin between improvement and post-inflammatory hyperpigmentation is thin, so peels begin superficial (glycolic 30-50 per cent, mandelic, lactic, salicylic), priming with hydroquinone or retinoid for two to four weeks beforehand, and series of three to six sessions at monthly intervals replace single aggressive attempts. Dermal melasma responds poorly to everything; maintenance, not cure, is the realistic endpoint.
What you must remember
- Type first: Wood's lamp examination separates epidermal melasma (accentuation, procedure-responsive) from dermal (no accentuation, refractory) — the single decision that saves wasted procedures.
- Peel menu for Indian skin: glycolic acid 30-70 per cent timed and neutralised; mandelic acid 20-35 per cent (large molecule, gentler, a favourite in dark skin); salicylic acid 20-30 per cent (lipophilic, self-neutralising); trichloroacetic acid kept to 10-20 per cent.
- Priming ritual: hydroquinone 2-4 per cent with or without tretinoin for 2-4 weeks before peeling, stopping retinoid 3-5 days pre-peel to damp reactivity.
- Laser toning: low-fluence Q-switched Nd:YAG 1064 nm at multiple weekly-to-fortnightly sessions photothermolyses melanosomes; prolonged courses risk mottled hypopigmentation, reported repeatedly in darker skins.
- Microneedling plus drug: needling drives topical tranexamic acid into the dermis; oral tranexamic acid 250 mg twice daily (with standard thrombotic contraindications excluded) is the systemic adjunct many Indian clinics pair with procedures.
- Interval and number: re-peel every 3-4 weeks, typically 3-6 sittings; judge response photographically under identical lighting.
- Non-negotiable: broad-spectrum sunscreen SPF 30+ with iron-oxide tint against visible light, reapplied — visible light darkens Fitzpatrick IV-V skin, a fact uniquely relevant to Indian patients.
- Score it: MASI quantifies severity when comparing before and after; papers and vivas both respect the number.
A peel programme walked through, step by step
A 32-year-old woman presents with malar pigmentation of three years' duration, worse after her second pregnancy and relentlessly sun-exposed. Wood's lamp shows sharp accentuation — epidermal melasma — and her baseline MASI is 18. Weeks minus four to zero: she applies hydroquinone 3 per cent at night and sunscreen daily; the priming both lightens pigment and tests her tolerance. Week zero: glycolic acid 35 per cent is painted on with timed contact, neutralised with sodium bicarbonate when erythema appears, and she leaves with post-peel care — sunscreen, emollient, no picking. Weeks four and eight: concentrations step to 50 per cent as tolerance grows, with photographs at each visit. At MASI 10 the plateau arrives, and the options are laid out: continue the series, add monthly microneedling with tranexamic acid infusion, or add oral tranexamic acid 250 mg twice daily after excluding thrombotic risk and pregnancy. What she must never be offered is a deep peel or an enthusiastic IPL pass — in type V skin both convert melasma into leopard-spotted dyschromia faster than they clear it.
How the exam frames it
The vignette usually hands you two clues: dark skin plus a procedure gone wrong. The girl whose "laser facial" left reticulated hypopigmentation points to over-aggressive QS Nd:YAG toning; the woman whose deep peel triggered darker rebound patches points to post-inflammatory hyperpigmentation in Fitzpatrick IV-VI; both questions resolve to the same principle — depth and fluence are paid for in pigment. A second favourite asks which adjunct addresses dermal pigment, expecting tranexamic acid (anti-plasmin, blunting UV-induced prostaglandin release from keratinocytes and melanocyte stimulation) rather than another peel. And when asked why melasma relapses, the expected chain is: melanosomes are protected, melanocytes remain hyperactive under oestrogen and visible light, so maintenance therapy — not repeat procedures — is the long-term plan.
Frequently asked questions
Which melasma subtype responds best to chemical peels?
Epidermal melasma, identified by Wood's lamp accentuation; dermal melasma responds poorly to peels and lasers alike.
How long should skin be primed before the first peel?
Two to four weeks of hydroquinone with or without tretinoin, stopping the retinoid a few days before the procedure to reduce reactivity.
What is the role of oral tranexamic acid in melasma?
Adjunctive systemic lightening at 250 mg twice daily in regimens used widely in Indian practice, contraindicated with thromboembolic disease and pregnancy.
Why is QS Nd:YAG laser toning used cautiously in Indian skin?
Repeated low-fluence sessions can produce mottled or reticulated hypopigmentation, a complication repeatedly reported in darker phototypes.
Which sunscreen ingredient matters specifically for melasma in Fitzpatrick IV-V?
Iron oxides in tinted formulations, because they block visible light that provokes pigmentation in deeply pigmented skin.