What can go wrong treating melasma
Complications from Melasma Treatment
Every treatment that works on melasma has a way of going wrong, and several of them go wrong by making the pigment worse. This is the complication profile of each one, set out so the risk can be weighed before treatment rather than after.
Four numbers worth knowing
What we found
Hydroquinone's problems are dose and duration, not the drug itself.
Irritation is the commonest effect. Prolonged use brings guttate hypomelanosis — spotty depigmented marks appearing on the melasma itself — and exogenous ochronosis, a blue-black hyperpigmentation of the treated area. Rotational therapy or lower concentrations in combination reduce both.
Triple combination cream works better and irritates more.
More effective than hydroquinone alone, at the cost of a higher rate of adverse reactions. The retinoid drives erythema, desquamation, burning, dryness and pruritus; the steroid component brings atrophy and telangiectasia after prolonged use. Across studies most effects were mild and transient, and few patients discontinued.
Non-hydroquinone agents trade efficacy for tolerability.
Azelaic acid at 20% had similar efficacy to 4% hydroquinone with more irritation. Cysteamine has not shown tachyphylaxis or ochronosis with long-term use and improved melasma refractory to triple combination cream over three years. Kojic acid irritates more as monotherapy; ascorbic acid is well tolerated but inferior alone.
Oral tranexamic acid works, and its risk is thrombotic.
A meta-analysis found a 1.60-point decrease in melasma severity. Greatest improvement is oral, then microinjection, then topical. Melasma doses of 500–700 mg daily are far below haemostatic doses, and thromboembolic events are rare — but one deep vein thrombosis was reported in a patient later found to have familial protein S deficiency. Patient selection is the safeguard.
Every laser carries a pigment risk, and each carries a different one.
IPL improvement is modest and best suited to lighter skin types. Repeated low-fluence Nd:YAG toning causes mottled hypopigmentation. Q-switched lasers as monotherapy showed no long-term benefit and a high incidence of post-inflammatory pigmentation and rebound. CO₂ and ablative lasers are generally not recommended for melasma at all. Picosecond lasers show promise but post-inflammatory pigmentation has been observed.
Recurrence is the rule rather than the exception.
Roughly half of patients relapse within three to six months of laser or light treatment regardless of device. The longest delay to recurrence is with non-ablative fractional laser, then IPL, then Q-switched. Tranexamic acid showed a 72% relapse rate two months after stopping.
Peels are adjuncts with their own irritation profile.
No peel has been shown superior to topical therapy alone for melasma. Higher-concentration TCA causes rebound hyperpigmentation, which is why lower concentrations are now used. Every regimen including glycolic acid was associated with post-inflammatory pigmentation. Salicylic-mandelic peels are better tolerated in darker skin.
What this means for you
Ask what the recurrence plan is, not just the treatment plan
Around half of patients relapse within three to six months of laser or light treatment. A plan that ends when the sessions end is only half a plan.
Topicals before devices
The review's own conclusion: laser and energy-based devices should be used after topicals have been tried, and in combination with them — not instead.
Hydroquinone is not a forever cream
Guttate hypomelanosis and exogenous ochronosis both come from prolonged use. Rotational therapy, or lower concentrations in combination, are what prevent them.
Tell your doctor about clotting history before oral tranexamic acid
The doses used for melasma are low and events are rare, but a reported DVT occurred in a patient with an undiagnosed inherited clotting disorder. Pregnancy, oestrogen use, coagulopathy, epilepsy and severe renal impairment all need to be on the table first.
Darker skin changes which device is appropriate
IPL is not suited to darker skin types. 1927 nm non-ablative fractional and 1064 nm Q-switched are the ones recommended for them; IPL and pulse dye are for lighter types.
Why this matters
Melasma is chronic, relapsing and genuinely difficult, and no single treatment produces a lasting result. That combination pushes both patients and clinicians toward escalating treatment — which in a pigmentary disorder is precisely where the harm sits.
This review works through each modality in turn — topical, oral, laser and light, chemical peels — and sets out what goes wrong with each. Many of those complications are pigmentary, which means the failure mode of melasma treatment is often a worse version of the problem you started with.
The conclusion
No single treatment produces long-lasting results and all have adverse reactions depending on modality, intensity and frequency. Devices carry a risk of pigmentation and burns and should be used after topicals are trialled, in combination with them. Large controlled trials are still needed before several of these can be recommended in routine practice.
Who was studied
A narrative review of the complications associated with each category of melasma treatment — topical, oral, laser and light-based, and chemical peels — drawing on the published literature, with a summary table of common effects, rare effects and precautions for each.
- Modalities reviewed
- 4 categories
- References
- 68
- Published
- December 2020
- Journal
- ASCD, Vol 1 Issue 1
What this study cannot tell you
Every study has a boundary, and it is fairer to state it than to leave you to guess.
- A narrative review rather than a systematic one, so studies were not appraised against predefined criteria and no pooled estimates were calculated.
- The studies drawn on are frequently small and short. Several of the agents discussed are supported only by trials too brief to show long-term effects.
- Written in December 2020. The picosecond laser and tranexamic acid evidence has both developed since.
- Complication rates in this literature are reported inconsistently, so the figures quoted describe individual studies rather than pooled risk.
- The review concludes that large controlled trials are needed before several of these treatments can be recommended in clinical practice — which is a limitation of the field, not only of this paper.
Questions people actually ask
Does melasma come back after laser?
Usually. Approximately half of patients have recurrence within three to six months of laser or light treatment, regardless of which device was used.
The longest delay before recurrence is with non-ablative fractional laser, then IPL, then Q-switched. This is why ongoing topical therapy and strict sun protection continue after the device treatment finishes rather than replacing it.
What is ochronosis?
A blue-black discolouration of treated skin that can follow prolonged hydroquinone use. It is a paradoxical outcome — a darkening caused by a lightening agent — and it is considerably harder to treat than the melasma it was meant to fix.
It is avoided by rotational therapy, by using lower concentrations in combination rather than high concentrations alone, and by not using hydroquinone continuously for long periods.
Is oral tranexamic acid safe for melasma?
The doses used for melasma — usually 500 to 700 mg daily — are much lower than those used to stop bleeding, and thromboembolic events at these doses are rare.
That said, a deep vein thrombosis was reported in one melasma patient subsequently found to have familial protein S deficiency. Clotting risk, pregnancy, oestrogen use, epilepsy and severe renal impairment all need to be assessed before starting it. The commoner side effects are digestive and menstrual rather than dangerous.
Can laser make melasma worse?
Yes, and in several distinct ways. Q-switched lasers used alone showed no long-term benefit and a high incidence of both post-inflammatory hyperpigmentation and rebound pigmentation.
Repeated low-fluence toning causes mottled hypopigmentation — pale patches within the treated area. CO₂ and ablative lasers are generally not recommended for melasma at all because of the pigmentation and dyspigmentation risk.
Cite this paper
Lim A, Lim D. Complications from Melasma Treatment. Opinions and Progress in Cosmetic Dermatology. 2020;1(1):38–46.
Related reading
Want this assessed properly?
A virtual consultation gives you a written report and a plan before we speak.
Published 2020 · Summary written and reviewed by Dr Davin Lim, FACD · General information, not personal medical advice.
Have some questions?
Send a message and it will be answered personally. Form endpoint — to be wired in production