Melasma: why it comes back, what really works and when intense pulsed light is not the answer

Melasma is the mark that responds worst to the usual logic of “I’ll have it taken off with a machine”. It is a chronic, recurring condition, very sensitive to sun, heat and hormones, and the available evidence is uncomfortable for anyone selling sessions: the broadest published review concludes that laser and light treatments give mixed results, are equal or inferior to topical treatments and carry a greater risk of adverse effects.

That does not mean there is nothing to be done. It means the order matters, that intense pulsed light is not the first step and that in some skins it is best simply not to use it. This page explains why.

This page sets out the most delicate case for intense pulsed light. If your mark is a solar lentigo and not melasma, the page that applies to you is IPL for sun spots and lentigines.

What melasma is, and why it is not a sun spot

They are confused constantly, and the confusion leads to the wrong treatments.

• A solar lentigo is an isolated mark, with a well-defined edge, in areas that have accumulated sun over the years: the backs of the hands, the décolletage, the cheekbones. It responds well to intense pulsed light.
• Melasma is symmetrical patches with blurred edges, typically on the forehead, the cheekbones and the upper lip. It does not appear from a particular burn, but from a combination of predisposition, hormones —pregnancy, contraceptives— and exposure to sun and heat. It appears above all in women.

The key difference for our purposes: in melasma the melanocyte is reactive. It responds to stimuli with more pigment, and a badly judged thermal or light insult can be exactly that stimulus.

What the best available evidence says

Here it is worth quoting precisely, because it is the section that holds up the whole page.

An evidence review published in 2020 analysed 113 studies with 6,897 participants, covering topical treatments, chemical peels, laser and light devices, and oral treatments. Its conclusions:

• Combined topical treatment remains the most effective for melasma, along with hydroquinone.
• Laser and light devices give mixed results and are equal or inferior to topical treatments, with a greater risk of adverse effects.
• Oral tranexamic acid is identified as a promising option in moderate and severe recurrent melasma, pending more data on long-term safety and efficacy.

It is a conclusion that runs counter to the usual sales pitch, and that is why it is worth saying as it stands: if someone offers you the machine as a first step for melasma, they are skipping what works best.

The topical and oral treatments that appear in that evidence are medicines prescribed and monitored by a doctor, with contraindications of their own. This page explains where the support lies, it does not propose a regimen: that is decided in consultation and on a particular skin.

At ICPM melasma is assessed in consultation: it is first confirmed that that is what it is —because not every symmetrical mark is melasma—, the skin type is determined and the order of treatment is set out starting where the evidence says it should start, not with the machine.

So where does intense pulsed light fit?

In its place, which is within a plan and not instead of one.

A meta-analysis brought together 8 studies with 215 patients and concluded that combined therapy with intense pulsed light significantly reduces the melasma area and severity index (MASI) and increases patients’ satisfaction. The word doing all the work in that sentence is combined: the support exists for IPL as part of a treatment that includes the topical approach and sun protection, not for IPL on its own.

And there is a qualification worth knowing before deciding. In melasma, energy devices used on their own can make things worse or cause a rebound when they are stopped, because the same heat that breaks up the pigment can inflame a skin that already over-responds. That is why, when it is used, it is used with cautious settings, within a plan and accepting from the outset that it may not be the right tool for that case.

Why it comes back: the sun, and not only ultraviolet

This is the part that decides the result at twelve months, and the one almost nobody explains properly.

Melasma recurs, and sun exposure is one of the main reasons for that recurrence. A 2024 review on the management of melasma sums it up without evasion: treating the hyperpigmentation on its own can prove ineffective if it is not accompanied by strict sun protection.

And there is a technical detail with practical consequences: protecting yourself from ultraviolet is not enough. Visible light induces pigmentation changes in darker skins, just as ultraviolet radiation does. In a randomised, double-blind trial with 68 patients with melasma, all of them also treated with 4% hydroquinone, the group using a sunscreen that included iron oxide —a pigment that absorbs visible light— achieved at 8 weeks an improvement 15% greater in MASI and 28% greater in colorimetry than the group with a UV-only sunscreen, both with a protection factor of 50 or above.

Translated into the consulting room: the right sunscreen for melasma is not just any sunscreen with a high SPF. Those that carry pigment —the ones with colour— protect against something the transparent ones do not. It is probably the intervention with the best effort-to-result ratio on this whole page.

When we do not recommend intense pulsed light for melasma

• When it is proposed as a stand-alone treatment, without a topical approach or sun protection: the evidence does not support it.
• When the patient cannot or will not sustain the sun protection, because the result will not hold and the session can make the starting point worse.
• With tanned skin, recent sun exposure or exposure planned for the near future, or fake tan.
• In pregnancy or breastfeeding, or with the melasma in full hormonal activity: it is a time of pigmentary instability and often the sensible thing is to wait.
• When there has already been a rebound or worsening after previous light or laser treatment.
• When the diagnosis is not clear: not every symmetrical mark is melasma, and an undiagnosed pigmented lesion is not treated with light.

Saying no is a treatment too. In melasma, more so than in any other condition on this website.

What we expect, and what we do not

• Melasma is not “eliminated”. It is controlled. The realistic aim is to reduce the contrast and space out the relapses.
• The result depends more on the maintenance than on the session. A plan without sustained sun protection is incomplete from the outset.
• It can get worse before it gets better if the energy is pushed. That is why caution with the settings is not commercial timidity.
• It is a condition for years, not for one summer. Anyone promising to take it off in two sessions is describing a different disease.

Frequently asked questions

Does intense pulsed light get rid of melasma?

It does not get rid of it. The evidence supports intense pulsed light within a combined treatment, where it helps to reduce the severity index and improves satisfaction, but the broadest review available places light devices as equal or inferior to topical treatments and with more risk of adverse effects.

Can it make it worse?

It can. In melasma, an energy device used on its own or with excessive settings can inflame a skin that already produces too much pigment and cause worsening or rebound. It is the main reason it is not the first step here.

So what works best?

According to the review of 113 studies and almost 7,000 participants, topical treatment —alone or in combination— and sun protection. They are medicines prescribed by a doctor after assessing the skin, so the specific regimen is decided in consultation.

Why does it come back every summer?

Because melasma is recurring and the sun is one of the main reasons for recurrence. Without sustained sun protection the result does not hold, however good it was.

Will any sunscreen do?

No, and it is a detail that changes the result. Visible light also pigments, and transparent sunscreens do not filter it. In a randomised trial, the sunscreen with iron oxide improved MASI 15% more than a UV-only one of the same factor.

It came on during pregnancy — will it go on its own?

It can fade once the hormonal situation returns to normal, but not always, and forcing treatments during that period is not usually a good idea. The prudent course is to keep up strict sun protection and assess it afterwards.

Is it the same as sun spots?

No. A solar lentigo is an isolated mark with a defined edge and it responds well to intense pulsed light; melasma is symmetrical, blurred patches, chronic and recurring, and its management is different.

And what about the CO₂ laser, is it any use for melasma?

It is not a treatment for melasma, and the risk of making it worse is real. It is an ablative laser, and in a skin that responds to inflammation by producing pigment that works against you.

Sources

• McKesey J, Tovar-Garza A, Pandya AG. Melasma Treatment: An Evidence-Based Review. Am J Clin Dermatol. 2020;21(2):173-225. Review of 113 studies and 6,897 participants: combined topical treatment and hydroquinone remain the most effective; laser and light devices give mixed results, equal or inferior to topical treatments and with a greater risk of adverse effects; oral tranexamic acid is promising in moderate and severe recurrent melasma. https://pubmed.ncbi.nlm.nih.gov/31802394/
• Yi J, Hong T, Zeng H, et al. A Meta-analysis-Based Assessment of Intense Pulsed Light for Treatment of Melasma. Aesthetic Plast Surg. 2020. Eight studies and 215 patients: combined therapy with intense pulsed light reduces MASI and increases satisfaction. https://pubmed.ncbi.nlm.nih.gov/32055937/
• Castanedo-Cazares JP, Hernandez-Blanco D, Carlos-Ortega B, Fuentes-Ahumada C, Torres-Álvarez B. Near-visible light and UV photoprotection in the treatment of melasma: a double-blind randomized trial. Photodermatol Photoimmunol Photomed. 2014;30(1):35-42. Sixty-eight patients; the sunscreen with iron oxide (UV + visible light) achieved at 8 weeks an improvement 15% greater in MASI and 28% greater in colorimetry than the UV-only one, both with SPF ≥ 50 and with 4% hydroquinone. https://pubmed.ncbi.nlm.nih.gov/24313385/
• Jiryis B, Toledano O, Avitan-Hersh E, Khamaysi Z. Management of Melasma: Laser and Other Therapies — Review Study. J Clin Med. 2024;13(5):1468. Treating hyperpigmentation on its own can be ineffective without strict sun protection; sun exposure is one of the main reasons for recurrence. https://pubmed.ncbi.nlm.nih.gov/38592701/

Book your consultation

If you have symmetrical marks on your face that come and go with the sun or with hormonal changes, the first thing is not to choose a machine: it is to confirm that it is melasma and to set out the right order. At an assessment in person the skin is examined, the skin type is determined and what applies is explained —including the possibility that the answer is not to use light.

Clinical confirmation by the surgeon

Dr Enrique Salmerón González

Specialist in Plastic, Aesthetic and Reconstructive Surgery
Registration no. 46/4624077

Dr Elena García Vilariño

Specialist in Plastic, Aesthetic and Reconstructive Surgery
Registration no. 46/4624503

Last reviewed: 23 August 2026. This content is for information only and does not replace an individual assessment by a healthcare professional.