Telling these apart matters because they are treated differently, and because treating melasma like a sun spot makes it worse.
The first rule
Stop making more. Every pigment treatment fails in someone who does not protect their skin from light.
That means a broad-spectrum sunscreen every day, reapplied when outdoors, with a mineral filter if you have melasma because visible light drives it too and iron oxides block visible light.
It means a hat for the morning walk. It means understanding that the light through a car window and the light on a shaded café table both count.
Larchmont's bright, mild weather is exactly the pattern that maintains pigment, because there is never a season when people stop going outside.
Readers who resent this advice should know that it is also the cheapest and most effective treatment in this whole piece. Six months of disciplined sun protection alone lightens melasma in most people.
Topical treatments
The workhorses are creams that slow pigment production.
Hydroquinone is the most studied and the most effective, used in courses under a physician because prolonged use has risks.
Azelaic acid, tranexamic acid, kojic acid, niacinamide, vitamin C and cysteamine are gentler alternatives that can be used longer. Retinoids speed the turnover of pigmented cells and are combined with the others.
A physician-directed combination cream is the standard first treatment for melasma and for post-inflammatory marks, and no procedure should be offered for either before a topical course has been tried.
Sunscreen goes over all of them every morning. A brightening cream under no sunscreen is a bucket with a hole in it, and the neighbourhood's light finds the hole by lunchtime.
Expect months, not weeks. Photograph your skin monthly under the same light. The improvement is real and slow.
Peels
Superficial peels lift pigmented surface cells and speed the work of the creams.
Glycolic, lactic and salicylic acid peels help sun spots and post-inflammatory marks in lighter skin; mandelic acid is gentler and often preferred for deeper skin tones because it penetrates slowly and evenly.
A series of four to six is the usual course.
Medium peels can clear sun damage in lighter skin but carry a real risk of triggering pigment in darker skin, and melasma in particular can rebound worse after an aggressive peel.
The peel guide covers depth and preparation in detail.
Lasers and light
This is where the choice of clinic matters most.
For discrete sun spots in lighter skin, a pigment-specific laser or intense pulsed light can lift them in one or two sessions. The spot darkens, crusts and flakes off over a week.
Lasers that target pigment are dangerous for melasma in most hands, because the heat inflames the skin and the melasma rebounds.
And any pigment laser in deeper skin tones needs careful settings, test patches and an operator who treats such skin every week.
Low-energy picosecond and long-pulsed lasers, used gently over several sessions, have a place in melasma and in darker skin when used by experienced clinicians as part of a plan with topicals and strict sun protection.
Fractional non-ablative lasers can help post-inflammatory marks and texture together. Ablative lasers have almost no role in pigment work for deeper skin tones.
Ask any clinic offering a laser for pigment three things.
What is my diagnosis, and why is a laser the right tool now rather than after topicals? What are the settings you would use for my skin type, and how did you choose them?
How many patients with my skin tone have you treated with this device? The third answer should be a number, and it should be large.
Deeper skin tones
Skin that tans easily has more active pigment cells, and those cells respond to any insult, including treatment, by making more pigment.
This means the safest treatments are the gentle ones done repeatedly: sun protection, topicals, mild peels, low-energy laser passes.
It means pre-treatment with pigment-suppressing creams for weeks before any procedure. It means test patches.
And it means that the phrase "safe for all skin types" on a device brochure describes the device, not the operator.
The best signal a clinic understands this is that it says so unprompted.
A consultation that raises the risk of post-inflammatory pigment before you do, and describes what it does to lower it, is a consultation with someone who has seen the problem and learned from it.
Living with the light
Neighbourhood habits shape pigment more than any clinic visit.
The morning walk to the village, the Sunday market, the school run, the drive west into the afternoon sun: each is a small dose that adds up.
Readers who coach or watch youth sport are often outdoors at the brightest hour of the weekend and should treat the sideline as beach exposure.
That includes the sidelines of programmes supported by the LA84 Foundation, where the parents get more sun than the players.
Swimmers and gym-goers ask about chlorine. It dries the skin but does not cause pigment, and the outdoor pool deck does.
The pools and courts of the YMCA of Metropolitan Los Angeles are a case in point: the water is not the problem, the deck at noon is.
The city's civic calendar shapes recovery timing too.
Readers who prefer to avoid an in-person visit to a polling place during a peel or laser recovery can check vote-by-mail options with the county registrar.
For those who like company while indoors, the neighbourhood has a traditional soundtrack for a shaded afternoon.
Local radio at KCRW fills it, and a radio does not ask what happened to your face.
The consultation
Ask for a diagnosis before a treatment. Ask whether a topical course should come first and, if so, for how long.
Ask what the clinic does to prepare skin of your tone before any procedure and what it does if pigment appears afterward.
Ask how many people with your skin tone the clinician treats each month. Ask to see before-and-after photographs of skin like yours, taken under the same light.
Ask who will perform the treatment and look up their licence. If the answer to the first question is a device, leave.
The decision
Protect first, always. Then topicals under a physician, for months.
Then gentle procedures in a series, matched to your diagnosis and your skin tone, from someone who treats your skin tone often.
Lasers last, and gently, and never for melasma without a clinician who can explain exactly why in your case.
Pigment work is slow work, and the neighbourhoods that do it well are the ones that have stopped expecting a single afternoon to fix what the sun spent decades doing.
Photograph your progress, keep your hat on, and be suspicious of anyone who promises clear.
