Hyperpigmentation.

Sun spots and general photodamage

Flat brown spots — lentigines — plus the mottled, uneven tone that decades of sunlight leave behind on faces, necks, chests, and the backs of hands. This is the most straightforward group to treat, because the pigment mostly sits in the upper layers of the skin where light-based treatment can reach it selectively. It’s also the group most likely to return, since the cause is ongoing: new sun exposure keeps making new spots.

Melasma

Blotchy, often symmetric patches, usually across the cheeks, forehead, upper lip, or jawline. Melasma responds to hormones, heat, and visible light, not to ultraviolet alone, which is why it flares in summer, over a hot stove, in pregnancy, or with a change in hormonal contraception. It’s the kind of pigment that punishes aggressive treatment, and it gets its own section below because it deserves one.

Post-inflammatory hyperpigmentation

The flat brown or greyish marks left behind after the skin was inflamed — a breakout, an ingrown hair, a cut, a burn, a rash, or a treatment that was pushed too hard. PIH is not a scar. The skin’s architecture is intact; pigment has simply been deposited where the inflammation was, and a good deal of it fades on its own given time and shade. The work is usually threefold: settle whatever keeps causing the inflammation, protect the skin while it turns over, and treat what’s still there afterward.

Plenty of people have two of these at once, or all three. That’s ordinary, and it’s the reason a plan is worth building deliberately rather than picking a treatment off a menu.

Melasma is chronic and relapsing. It can usually be made lighter, and with consistent work it can be held lighter. What it can’t be is finished with. It’s a management problem rather than a curable one, and maintenance isn’t evidence the plan failed — maintenance is the plan. We say this at the beginning because it changes what a good outcome looks like, and because it’s much easier to hear now than six months in.

The reason melasma has to be handled differently comes down to heat and light. Melasma reacts to visible light and to warmth, not only to ultraviolet, so the same energy that lifts a sun spot cleanly can push melasma darker. That’s why we don’t use IPL on melasma. It’s also why we don’t offer RF microneedling for it: it has been tried for melasma, and the results are inconsistent enough that we don’t put it forward for that indication.

So the melasma plan here is deliberately conservative and mostly topical: tinted mineral sunscreen, which is genuinely required rather than encouraged, because the iron oxides in a tint are what block the visible light melasma responds to; prescription tretinoin; prescription-strength azelaic acid; and prescription hydroquinone used in short, supervised courses when appropriate. Low-fluence laser toning has a place in some cases, and we’ll tell you whether yours is one of them. The compounded triple-combination cream is something we refer to dermatology rather than write in-house. All of this is set out in more detail on our skincare page.

Timeline: months, not weeks. And a summer of unprotected sun can undo a winter of steady progress, which is the part most people find hardest and the part that matters most.

Nothing below is a special pigment program. These are treatments already on our menu, matched to the kind of pigment in front of us.

IPL photofacial

Our workhorse for sun spots and uneven sun-related tone on the face, neck, chest, and hands. Filtered light targets brown pigment selectively; treated spots darken over a few days, then flake away over about a week. Typically planned as a short series. Not used for melasma. Details and prices are on the IPL photofacial page.

Q-switched Nd:YAG pigment treatment

Q-switched Nd:YAG at 1064 and 532 nm for sun spots, laser toning, deep dermal pigmentation, and post-inflammatory hyperpigmentation. Different wavelengths reach different depths, which is what makes this the tool for pigment that sits deeper than IPL can address well. See laser & light.

Er:YAG resurfacing

Erbium YAG ablative resurfacing for texture, fine lines, and photodamage — from a light peel through full-field resurfacing, with the depth targeted to your goals and what your skin needs. This is the option when the sun damage isn’t only color but surface: crepiness, roughness, and thinning alongside the mottling. It’s a provider-only procedure with real downtime, discussed honestly in advance rather than after.

RF microneedling

The Rohrer PiXel8-RF delivers bipolar radiofrequency at 4 MHz through insulated or uninsulated needles, chosen for the depth and the area. It isn’t a pigment treatment — it’s for texture, atrophic scarring, and early laxity. It earns a place on this page because radiofrequency current follows tissue impedance rather than being absorbed by melanin, so the pigment risk that limits ablative resurfacing in higher phototypes largely doesn’t apply. When someone with deeper skin has both textural change and a history of PIH, this is often the safer road for the texture half of the problem. More on the RF microneedling page.

Prescription topicals and a routine you’ll actually keep

For general hyperpigmentation: strict sunscreen, nightly tretinoin, morning vitamin C, azelaic acid. Three to six months for meaningful change, and faster with in-office treatment layered on top. We write prescriptions when the situation calls for them; the medication is dispensed by a pharmacy, and the rest of what we recommend is available at a drugstore. We don’t sell skincare, so there’s nothing here we’re steering you toward.

Some pigment concerns also overlap with our other skin treatments, and rough, scaly sun spots are a different question entirely — those are covered on the actinic keratosis page.

Energy-based treatment works by putting a wavelength into a target — melanin, hemoglobin, water. In deeper skin, the melanin already present in the epidermis competes for that energy, and that competition is the mechanism behind post-inflammatory hyperpigmentation after laser treatment. So higher Fitzpatrick phototypes carry more pigment risk from these treatments. That’s a fact worth knowing, not a reason to stay away: it changes which device we reach for, how conservatively we set it, how we space sessions, and how we prepare the skin in the weeks beforehand.

What we won’t tell you is that any of our devices is safe for every skin type, because none of them is. What we will tell you at the consultation is which of our options is a reasonable choice for your skin, which one we’d pick first, and which we’d leave alone. If the honest answer is that a different kind of provider is the better fit, you’ll hear that too.

One rule holds regardless of phototype: we reschedule tanned or recently sun-exposed skin rather than treat it. A device can’t tell a tan from a target.

This is the least interesting section on the page and the one that decides whether anything else holds. Pigment treatment removes damage you’ve already collected. Only daily photoprotection stops you re-collecting it. Without that, spots return, and melasma can rebound faster than it improved.

Practically: broad-spectrum sunscreen every day, reapplied when you’re out in it, plus hats and shade in the hours that matter. For melasma specifically, tinted mineral sunscreen, because a tint blocks the visible light that untinted formulas let through. Before any laser, resurfacing, or microneedling here, we ask for strict sunscreen for two to four weeks, a pause on retinoids and other actives for roughly five to seven days, and your full medication list including any cold-sore history. If you have a melasma or PIH history, we may pre-treat with topicals to lower pigment risk before we ever turn a device on.

Our full sunscreen and topical recommendations — brand names, prices, and what to skip — are on the skincare we recommend.

Everything on this page assumes we know what a spot is. Sometimes we don’t, and that changes the order of operations completely.

A pigmented spot that is new, changing, growing, asymmetric, irregular in its border or its color, itchy, bleeding, or simply unlike your other spots needs medical evaluation before anyone treats it for appearance. Every lesion here is examined by the nurse practitioner, including under the dermatoscope, before anything is treated — and anything ambiguous goes to dermatology for a biopsy rather than to a laser. We’ll help you get that appointment.

The reason is straightforward: treating a lesion cosmetically can take away the visible clue without addressing what caused it. If you’re unsure about a specific spot, bring it up at the consultation, or get in touch and we’ll tell you whether it’s worth a dermatology visit first.