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Pigmentation Treatment

Skin Spot (Pigmentation) Treatment:

There is no single “best” method for treating skin pigmentation; the right choice depends on the type of spot (melasma, sun spot, post-inflammatory pigmentation) and the patient’s skin type. Scientific evidence shows that prescription triple-combination creams (hydroquinone + tretinoin + corticosteroid) are considered the gold standard, while chemical peeling methods and low-fluence Q-switched lasers may serve as supportive options. Strict sun protection is essential for the success and long-term maintenance of every treatment.

Skin spots are among the most common reasons for visits to dermatology clinics and can significantly affect patients both aesthetically and psychologically. However, a “spot” is not a single disease; melasma, sun spots (solar lentigo), post-inflammatory hyperpigmentation and freckles develop through different mechanisms and require different treatment approaches.

What Are the Types of Skin Spots?

  • Melasma: Brown–gray patches that are more common in women, associated with hormonal changes (pregnancy, birth control pills), and usually located symmetrically on the forehead, cheeks, nose and upper lip area.
  • Sun spots (solar lentigo): Brown spots caused by long-term, unprotected sun exposure; they are commonly seen on the face, backs of the hands and chest area.
  • Post-inflammatory hyperpigmentation (PIH): Temporary or permanent darkening that develops in areas of inflammation after acne, eczema, injury or aggressive skin procedures.
  • Freckles (ephelides): Small, pinpoint spots that darken with sun exposure, especially in fair-skinned individuals with a genetic predisposition.
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Why Do Skin Spots Develop?

The common underlying factor in skin pigmentation is excessive melanin production by melanocyte cells. The main triggers of this process include UV (sun) exposure, visible light, hormonal changes (pregnancy, birth control pills, hormone therapies), genetic predisposition, skin trauma or inflammation (such as acne or after aggressive peeling/laser procedures), and phototoxic reactions caused by certain medications. Melasma is a chronic and recurrent condition in which many of these factors come together.

Methods Used in Pigmentation Treatment

Current dermatology guidelines recommend not a single method, but a treatment plan adapted according to the type of pigmentation. The main methods include:

1. Prescription Topical Treatments (Creams)

Triple-combination creams containing hydroquinone, tretinoin and a low-dose corticosteroid (Kligman formulation) are the gold standard topical treatment for melasma, with the highest level of scientific evidence. In addition, agents that suppress the tyrosinase enzyme, such as azelaic acid, kojic acid, arbutin, vitamin C (ascorbic acid), retinol and phytic acid, may be used alone or in combination.

2. Cosmelan® / Dermamelan® Peeling System

This depigmentation system of Spanish origin starts with an in-clinic mask that contains active ingredients such as azelaic acid, kojic acid, arbutin, phytic acid and ascorbic acid. After the mask is left on the skin for 6–8 hours, it is washed off at home and then maintained with a home-care product protocol. Its mechanism of action is based on suppressing tyrosinase, the key enzyme in melanin production. In a published clinical evaluation, an average 70% reduction in hyperpigmented spots and high patient satisfaction were reported 30 days after treatment initiation. Cosmelan is preferred for milder cases, while Dermamelan is used for more intense pigmentation concerns; both systems have similar active ingredients and application logic.

3. Chemical Peeling

Superficial chemical peels such as glycolic acid peels can be used alone or combined with topical treatments to help reduce pigment accumulation in the upper layer of the skin and accelerate skin renewal.

4. Laser and Light Systems

Systems such as Q-switched Nd:YAG laser, fractional lasers, IPL (intense pulsed light) and pulsed dye laser may be used in pigmentation treatment. Low-fluence Q-switched Nd:YAG laser stands out as a more reasonable option, especially in darker skin types, and is the most studied laser method in the literature. However, the outcomes of fractional laser and aggressive protocols may vary; in chronic and hormone-sensitive pigmentation such as melasma, laser procedures performed with inadequate protection may paradoxically worsen the pigmentation (rebound hyperpigmentation). This risk is more pronounced in darker-skinned patients (Fitzpatrick III–V, which includes a large part of the Turkish population).

5. Oral Tranexamic Acid

In stubborn melasma cases resistant to topical treatment, low-dose oral tranexamic acid may be added under physician supervision. This is not a first-line treatment, but a complementary option considered in resistant cases.

6. Mesotherapy and Microneedling

Mesotherapy and microneedling procedures aimed at improving skin quality are not standalone pigmentation treatments; however, they can support other methods by enhancing the penetration of active ingredients into the skin.

The Importance of Combination Treatments

Clinical studies show that correctly planned combinations may provide better results than a single method alone. For example, in patients who did not respond adequately to triple-combination cream, significant improvement was reported in 67.1% and moderate improvement in 21.1% of patients when treatment was combined with a fractional 1540 nm Erbium-glass laser. Similarly, the combination of hydroquinone and fractional CO2 laser provided superior results compared with hydroquinone alone. Therefore, the best outcome in pigmentation treatment is achieved with a staged and combined protocol designed specifically for the patient.

Which Approach Is Preferred for Which Type of Spot?

Type of Pigmentation

Preferred Approach

Melasma

Strict sun protection + triple-combination cream (first-line); low-fluence laser or oral tranexamic acid may be added in resistant cases

Sun spots (solar lentigo)

Q-switched laser, IPL, chemical peeling, topical tyrosinase inhibitors

Post-inflammatory hyperpigmentation (PIH)

Gentle topical agents (azelaic acid, niacinamide), control of the underlying inflammation (such as acne), avoidance of aggressive laser treatments

Freckles

Sun protection, mild chemical peeling, low-fluence laser/IPL

This table is intended as a general guide; the final treatment plan is determined by the physician after evaluating the depth of the pigmentation (epidermal/dermal), skin type and the patient’s medical history.

The Critical Role of Sun Protection

Regardless of the method chosen, long-term success in pigmentation treatment is not possible without strict and regular sun protection. When the skin is left unprotected from the sun, melanocyte activity is stimulated again and many types of pigmentation, especially melasma, may recur in a short time. Experts recommend using a broad-spectrum (UVA+UVB) sunscreen with at least SPF 30–50; in conditions such as melasma that are also sensitive to visible light, physical (mineral) sunscreens containing zinc oxide or titanium dioxide are often preferred. Sunscreen should be reapplied every day, even in cloudy weather and indoors, due to screen light and UVA entering through windows.

Risks and Points to Consider in Pigmentation Treatment

  • Melasma is a chronic and multifactorial condition; even if significant improvement is achieved with treatment, there is always a risk of recurrence and maintenance care is required.
  • Aggressive laser and peeling procedures may temporarily worsen the treated pigmentation, especially in darker-skinned patients (rebound hyperpigmentation); therefore, protocol selection should be made carefully according to skin type.
  • Creams containing hydroquinone should not be used for long periods or without supervision; they should be applied for defined periods under physician follow-up.
  • During pregnancy and breastfeeding, agents such as hydroquinone, retinoids and oral tranexamic acid are generally not recommended; the treatment plan is reassessed by the physician during this period.
  • Temporary redness, peeling and sensitivity may occur after peeling systems such as Cosmelan/Dermamelan; sun exposure must be strictly avoided during this process.

How Long Does the Treatment Process Take and When Are Results Seen?

With topical treatments, noticeable change usually begins within 4–8 weeks; a full response with triple-combination creams may require 8–12 weeks. In the Cosmelan/Dermamelan protocol, the first visible results are generally evaluated around 30 days after treatment. In laser-based treatments, the number of sessions and intervals vary according to the type of pigmentation; a protocol of 3–6 sessions with 3–4-week intervals between sessions is generally recommended. In all methods, long-term maintenance is directly related to compliance with sun protection.

Frequently Asked Questions About Pigmentation Treatment

Is pigmentation treatment permanent?

It depends on the treatment method and the type of pigmentation. In sun spots and freckles, results are usually long-lasting; however, melasma is chronic and prone to recurrence, so maintaining results is possible with strict sun protection and maintenance treatment when necessary.

Both work through different mechanisms and may provide varying results from patient to patient. Cosmelan/Dermamelan works with active ingredients that suppress tyrosinase, while laser targets and breaks down pigment. In many cases, the best result is achieved by combining these two approaches or combining topical treatment with laser; the choice is determined after examination.

During pregnancy and breastfeeding, agents such as hydroquinone, retinoids and oral tranexamic acid are generally not recommended. During this period, gentler alternatives approved by the physician are preferred; definitive treatment is usually planned after delivery or breastfeeding.

No. Without sun protection, the chance of long-term success with any pigmentation treatment is low; UV and visible light exposure can trigger melanocyte activity again and cause the pigmentation to return in a short time.

Melasma is a multifactorial and chronic condition. Treatment can provide significant and often cosmetically satisfying improvement, but a complete and permanent “cure” cannot be guaranteed; regular maintenance care is recommended.

They may be beneficial for mild, superficial pigmentation and for preventive care, but in more resistant conditions such as melasma, they are usually not sufficient on their own; they often need to be supported with prescription treatments or in-clinic procedures.

In melasma, first-line management includes strict sun protection and triple-combination cream; for sun spots and freckles, laser/IPL and peeling are more prominent; in post-inflammatory pigmentation, control of the underlying inflammation and gentle agents are preferred. The final plan is determined after examination.

Pigmentation Treatment Evaluation at Dr. Seher Arı Clinic

It is not possible to determine the correct treatment method and duration without evaluating the type of pigmentation (melasma, sun spot, post-inflammatory pigmentation or freckle), its depth and your skin type. At Dr. Seher Arı Aesthetic Dermatology Clinic in Göktürk, Istanbul, a personalized treatment plan is created after examination. You may contact the clinic for appointments and further information.

Legal Notice: This content is for informational purposes only, does not replace healthcare services and cannot be used for diagnosis or treatment. Please consult a dermatology specialist for a personalized evaluation.

References

  1. Sarkar R, et al. “Medical Management of Melasma: A Review with Consensus Recommendations by Indian Pigmentary Expert Group.” Indian J Dermatol. (PMC) https://pmc.ncbi.nlm.nih.gov/articles/PMC5724303/
  2. “Combination of Hydroquinone and Fractional CO2 Laser versus Hydroquinone Monotherapy in Melasma Treatment: A Randomized, Single-blinded, Split-face Clinical Trial.” PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC6440181/
  3. “Triple Combination of Hydroquinone, Tretinoin and Mometasone Furoate with Glycolic Acid Peels in Melasma.” PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800888/
  4. “Laser and light-based therapies combined with topical agents for melasma: A systematic review and meta-analysis.” PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC12795099/
  5. “Hyperpigmentation and Melasma: Causes, the Efficacy of Cosmelan Treatment.” ResearchGate. https://www.researchgate.net/publication/371189591_Hyperpigmentation_and_Melasma_Causes_the_Efficacy_of_Cosmelan_Treatment
  6. Dermatology Advisor — “Consensus on Evidence-Based Strategies for Melasma Management Published.” https://www.dermatologyadvisor.com/news/consensus-evidence-based-strategies-melasma-management-published/