Chronic · Relapsing · CityLink Mall
Melasma is not a stain to be removed. It is a chronic, relapsing disorder of an overactive melanocyte sitting above a damaged dermis — and the aggressive lasering that promises to clear it is among the commonest reasons it gets worse.
Melasma is not caused by having too many pigment cells. The melanocytes in a melasma patch are present in roughly normal numbers; they are larger, more dendritic and metabolically hyperactive, producing and distributing far more melanin to the keratinocytes around them than their neighbours do. That distinction matters enormously, because a cell you cannot remove without destroying the skin is a cell that has to be persuaded to behave, repeatedly, for years.
The stimulus is light and heat, and not only ultraviolet. Visible light — particularly the high-energy blue end of the spectrum, from the sun and to a lesser degree from screens — independently stimulates melanogenesis in Fitzpatrick III to V skin, which is why a sunscreen offering excellent UV protection and no visible-light coverage frequently fails to hold melasma stable. Infrared heat contributes as well, which is the physiological reason a treatment that heats the skin can worsen the condition it was meant to treat.
The dermis beneath a melasma patch is abnormal, and this is the part most often left out. There is solar elastosis, an increase in small vessels, mast cell infiltration, and disruption of the basement membrane separating epidermis from dermis. The breached membrane allows pigment to fall through into the dermis, where it is far less accessible to any treatment and far slower to clear. Melasma is therefore a condition of the whole skin unit, not a superficial deposit.
Hormonal influence is real but secondary. Pregnancy, oestrogen-containing contraception and hormonal therapy commonly initiate or intensify it, which is why it appears in the second and third trimesters and why some cases settle after delivery. Removing the hormonal driver, where possible, improves control; it does not by itself resolve established melasma, because the melanocyte has already been sensitised and the light exposure continues.
Classification
Melasma is sorted by the depth at which pigment is deposited, because depth determines both how it looks and how much it can realistically improve. Wood's lamp examination assists this but is less discriminating in darker skin types, so the assessment also rests on clinical appearance and on how the pigment has behaved over time.
Any plan that promises to clear melasma is describing a different condition. The honest objective is control, held for years.
Realistic Expectations
Photoprotection is the treatment, not the precaution that accompanies it. A broad-spectrum sunscreen with iron oxide or another tint providing visible-light coverage, applied every morning and reapplied through the day, plus shade, a hat and awareness that Singapore's ambient light is high year-round, does more to hold melasma stable than any device. A patient who will not do this reliably will not maintain a result, and it is fairer to say so at the outset than to sell a treatment course around it.
Topical therapy is the second pillar — tyrosinase inhibition, agents interrupting pigment transfer to keratinocytes, and in selected patients oral tranexamic acid, which addresses the vascular and plasmin-mediated component and is prescribed with appropriate screening for thrombotic risk. These are used in planned cycles rather than continuously. Devices come third, not first, and the principle is minimal thermal injury: low-fluence laser toning or a conservatively dosed picosecond laser, spaced generously, with the plan abandoned rather than escalated if the pigment rebounds.
The most important warning is about aggression. Melasma responds to injury by producing more pigment, so high-fluence resurfacing, intense pulsed light at ordinary settings, heat-intensive tightening devices and over-frequent toning all carry a real risk of rebound worse than the starting point — and in Fitzpatrick III to V skin, of post-inflammatory hyperpigmentation layered on top of the melasma. A great deal of the difficult melasma seen at Atelier Aesthetics arrives that way. The condition can be held in good control for years; it cannot be removed, and it will relapse with sun, heat and hormonal change.
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Atelier Aesthetics · Owned by AYA
1 Raffles Link, #B1-28, CityLink Mall, Singapore 039393 · +65 8023 7170
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