Melasma Treatment in Bangalore: Why It's Difficult and What Works

Melasma is the pigmentation condition we see most frequently in Bangalore, and it is also the most frequently undertreated — not because effective treatments don't exist, but because the condition's chronic, relapsing nature is poorly communicated to patients.

What Makes Melasma Different

Melasma is not simply sun damage. It is a hormonally-driven disorder of melanocyte regulation. This is why it disproportionately affects women (particularly during pregnancy and while on oral contraceptives), why it worsens with heat as much as UV exposure, and why it returns even after successful treatment if triggers aren't controlled.

Histologically, melasma has two components: epidermal pigment (which responds to treatment) and dermal pigment (which does not). The ratio of each varies between patients, which is why some respond dramatically to peels and others show minimal improvement.

Sun Protection Is Treatment, Not Just Prevention

This cannot be overstated: broad-spectrum SPF 50+ with iron oxide is the single most important intervention in melasma. Iron oxide protects against visible light — including the blue-light from screens — which drives dermal melasma independently of UVA/UVB. Most pharmacy sunscreens do not contain iron oxide.

Patients who are meticulous about treatment but inconsistent with sun protection will see minimal results.

What the Evidence Supports

**Topical triple combination therapy**: The combination of a retinoid, a corticosteroid, and hydroquinone remains the most studied first-line treatment. However, hydroquinone carries risks of ochronosis (permanent blue-black discolouration) with prolonged use, so it should only be used under medical supervision in treatment cycles.

**Tranexamic acid**: Either as a topical, oral, or injectable, tranexamic acid has emerged as one of the most effective non-hydroquinone treatments. Oral tranexamic acid (250mg twice daily) has strong evidence in Asian skin.

**Chemical peels**: Superficial peels (glycolic, lactic, mandelic) can accelerate epidermal clearance, but must be done conservatively to avoid PIH. Trichloroacetic acid (TCA) peels are generally avoided in melasma.

**Laser toning**: Q-switched Nd:YAG laser at low-fluence settings can address dermal melasma but must be done by an experienced operator. Aggressive settings cause paradoxical darkening.

Managing Expectations

Melasma requires long-term management, not a single treatment course. Most patients achieve significant improvement within 3–6 months, but maintenance therapy and strict sun protection are required indefinitely. We discuss this clearly at the first consultation, so patients aren't surprised by recurrence.