Melasma and dark spots: options in dermatology and how to prepare for visits

I didn’t realize how many kinds of “dark spots” there are until I started sorting my own sun freckles from melasma patches and the little marks that acne sometimes leaves behind. The differences matter—emotionally and practically—because what calms one type of hyperpigmentation can irritate another, and what fades quickly for a friend may barely budge for me. Today I wanted to write down everything I’ve learned about the options dermatology actually uses for melasma and common dark spots, plus how I prepare for clinic visits so I get real answers instead of vague “try a brightening cream” advice.

Why these patches act the way they do

The first shift for me was understanding melanin is a protector first, not a flaw. Skin cells dial pigment up to defend against UV and even visible light and heat. That means repetitive triggers—sun, heat from workouts or the kitchen, a hot yoga session, certain hormones, and even irritation from products—can keep pigment switches turned on. Melasma, especially, behaves like a relapsing condition. It improves with consistent care and then flares if the triggers return. That frame helped me replace all-or-nothing “cure” thinking with a steadier plan.

• Melasma tends to be symmetric and prefers the cheeks, forehead, upper lip, and jawline.
• “Dark spots” can also mean post-inflammatory hyperpigmentation (after acne or eczema) or solar lentigines (age spots).
• Depth matters: epidermal pigment usually fades more predictably than deeper mixed or dermal pigment.

The quiet workhorse is still daily protection

Every time I skimped on sun protection, I paid for it later. The most boring step is the most powerful:

• Broad-spectrum SPF 30 or higher every morning, reapplied; hats and shade when possible.
• Tinted or iron-oxide–containing sunscreens help block visible light, which can worsen melasma for some people.
• Think beyond noon sun: window light during a long drive, a run on a cool but bright day, or a stroll at golden hour still counts.

When I made sunscreen and sun-smart habits automatic, my treatments stopped feeling like a treadmill and started to actually stick.

At-home topicals I found reasonable to discuss with a dermatologist

I used to collect random “brightening” products. Now I keep a short list and focus on consistency, tolerability, and combinations that make sense:

• Azelaic acid (often 15–20% by prescription, lower OTC): helpful for acne-prone and sensitive skin; gradual brightening without the sting of stronger acids.
• Niacinamide: barrier-friendly support that pairs well with almost everything.
• Retinoids (adapalene OTC or tretinoin by prescription): speed up cell turnover and improve the look of uneven tone over months; start low and slow.
• Kojic acid, arbutin, vitamin C: often used in blends; I learned to introduce one change at a time so I can tell what’s actually helping.

One important legal/regulatory point in the U.S.: over-the-counter hydroquinone products were removed from shelves and hydroquinone is prescription-only now. If you see an OTC “skin lightener” claiming hydroquinone, that’s a red flag. Dermatologists may still prescribe 4% hydroquinone (and sometimes in combinations) for carefully monitored courses with breaks.

What dermatologists commonly use and how they sequence it

This is the part I wish I had known earlier: dermatologists don’t jump straight to lasers for most melasma. They build from gentle, steady measures first, and they’re cautious because overtreatment can backfire with rebound pigment.

• Prescription “triple” creams (often hydroquinone + retinoid + mild steroid) used in limited cycles, interspersed with maintenance phases using non-hydroquinone agents.
• Peels (like low-strength glycolic, lactic, or salicylic): useful in selected cases and skin tones when applied by experienced clinicians; spacing and aftercare are crucial.
• Tranexamic acid (TXA): emerging option that can be used topically, orally (by prescription only and with screening for clotting risk), or via procedural delivery (e.g., microneedling-assisted). It’s not for everyone, but evidence is growing, especially for stubborn cases under medical supervision.
• Lasers and devices: low-energy approaches and careful protocols can help certain patterns, but they’re not first-line for most melasma and can worsen pigment if mismatched. Sun protection before and after is non-negotiable.

In real life, the plan looks like cycles: protect every day, use prescription tools for defined periods, then pivot to maintenance blends that your skin tolerates long term.

My clinic-visit checklist that changed everything

When I treated the appointment like a collaborative project, the visits felt more satisfying and less rushed. Here’s what I prepare:

• Photos in consistent lighting from the past 3–6 months. I bring front, left, and right angles—no filters, same room and time of day.
• Trigger diary for two to four weeks: sun exposure patterns, workouts/saunas/hot kitchens, new products, breakouts, and any hormonal changes.
• Product list with strengths and frequency, including “sometimes” items like exfoliating toners or at-home peels.
• Medical history highlights: pregnancy plans or current pregnancy, birth control changes, clotting risks (for TXA conversations), history of keloids or post-inflammatory hyperpigmentation after procedures.
• Goal statement: “Lighten upper-lip patches by one shade and smooth edges within 3 months; avoid irritation.” Being specific invites specific plans.

Questions I actually ask the dermatologist

• “Which type of hyperpigmentation do you think I have and at what depth?” (This affects whether topicals alone are likely to help.)
• “What’s your preferred first-line plan for my skin tone?” (Different Fitzpatrick types carry different risks.)
• “If we consider TXA or a peel, what’s the monitoring and stop rule?” (Agree on what improvement would look like and when to pause.)
• “What maintenance looks like when we stop prescription hydroquinone?” (So I’m not left without a bridge.)
• “Which sunscreens or filters fit my routine so I’ll actually use them?” (Texture and tint matter for adherence.)

Routines that helped me without wrecking my barrier

I used to chase brightness so hard I ended up red and flaky. The routine that finally stuck is boring—in a good way:

• AM: gentle cleanse (or rinse), antioxidant or niacinamide, moisturizer if needed, tinted broad-spectrum sunscreen. Makeup over that if I want.
• PM: cleanse, then either a retinoid night or a non-retinoid active night (azelaic/kojic/niacinamide). I avoid layering three “actives” at once.
• Two barrier nights per week with just moisturizer if I feel any creeping irritation.
• Temperature management: I skip hot yoga during active flares and give my face a chance to cool after workouts before applying actives.

When I slow down and get help sooner

Not everything should be DIY. I reach out or schedule ahead when I notice:

• Sudden, asymmetric, or fast-growing dark or changing spots (especially with irregular borders or colors) that don’t match my usual pattern.
• Persistent irritation—stinging, peeling, or redness that doesn’t settle with a step back.
• New medications or hormonal shifts that line up with pigment changes.
• Procedures on the calendar (peels, lasers, microneedling): I discuss pre- and post-care plans and sun strategy in advance.

What I’m keeping and what I’m letting go

What I’m keeping: respect for sun and visible light, a simple routine I actually follow, and the idea that maintenance is success with melasma. What I’m letting go: miracle timelines and guilt when pigment ebbs and flows. My best visits have been the ones where I walk in with photos, a short list of questions, and an openness to a stepwise plan rather than a single “fix.”

FAQ

1) How do I know if it’s melasma or just acne marks?
Melasma is usually symmetrical and patchy on the central face, while post-acne marks match where pimples were. A clinician can examine depth and pattern to guide treatment.

2) Are lasers the fastest way to clear melasma?
Not usually. Many dermatologists start with sun protection and topicals. Certain low-energy device approaches can help selected cases, but they’re not first-line and can worsen pigment if misused.

3) Is hydroquinone safe?
It’s a prescription medication in the U.S. and can be effective when supervised and cycled. It’s not for indefinite use, and some people can’t tolerate it. Discuss risks and alternatives with your clinician.

4) What about tranexamic acid?
Topical TXA is an option; oral TXA requires a prescription and screening for clotting risk. It can help in stubborn melasma for the right patient under medical care.

5) Does tinted sunscreen really matter?
For pigment-prone skin, yes. Tints with iron oxides can help reduce visible-light–induced darkening, complementing UV filters. Many people notice fewer relapses when they switch.

Sources & References

• AAD — Melasma diagnosis and treatment
• MedlinePlus — Skin pigmentation disorders
• FDA — OTC skin lightening products and hydroquinone status
• PubMed — Tranexamic acid in melasma (2023 review)
• JAAD — Tinted sunscreens for skin of color (2023)

This blog is a personal journal and for general information only. It is not a substitute for professional medical advice, diagnosis, or treatment, and it does not create a doctor–patient relationship. Always seek the advice of a licensed clinician for questions about your health. If you may be experiencing an emergency, call your local emergency number immediately (e.g., 911 [US], 119).