Melasma through a Toronto summer

Melasma is the condition most likely to be treated badly, and the reason is that it looks like sun damage and behaves like something else entirely.

Sun spots are discrete, they have edges, and they respond well to being targeted directly. Melasma is diffuse, symmetrical and blotchy, typically across the cheekbones, upper lip, forehead and jawline. It is influenced by hormones — pregnancy, the combined oral contraceptive pill, hormone therapy — and it is provoked by heat as well as by ultraviolet light. That last part surprises people. Infrared radiation and ordinary ambient heat can trigger a flare without any visible burn.

It is also chronic. Melasma is managed rather than cured, and the honest framing at a first appointment is that we are aiming for control, with better periods and worse ones, over years. Anyone offering to remove it permanently in a course of six sessions is not describing melasma.

Aggressive treatment makes it worse. High-energy laser, hot ablative resurfacing and enthusiastic peels can all produce a rebound darker and more stubborn than the starting point, particularly in Fitzpatrick III to V skin. The pattern we see most often is someone who got a good result from an intense treatment elsewhere, flared six weeks later, and has been chasing it since.

What actually works is unglamorous and cumulative.

Photoprotection first, daily and year-round rather than seasonal. Broad-spectrum SPF 50 reapplied through the day and — this matters specifically for melasma — a tinted formulation containing iron oxides, which block visible light that a conventional sunscreen does not. Add a wide-brimmed hat. Sit back from the fire pit and step away from the oven; heat counts.

Second, a topical routine with evidence behind it. Depending on your skin and what you can tolerate, that typically involves a tyrosinase inhibitor, a retinoid at a frequency your skin will accept, and an antioxidant in the morning. Hydroquinone has a role, in courses, under supervision, and not indefinitely. This part takes three months before it can be judged, which is where most people give up.

Third, gentle in-clinic support once the topical routine is established and stable — never as the opening move. Low energy, conservative settings, generous spacing. We photograph in standardised lighting at every visit, because month-to-month change in melasma is slow enough that memory is unreliable in both directions.

Fourth, look at the hormonal contributors with your family doctor. If a flare began within a few months of starting a hormonal contraceptive, that is worth a conversation. We do not change anyone's prescription, but we do ask the question.

The Toronto seasonal pattern is fairly consistent: things improve from November, hold through the winter, and begin to slip in May. Plan around it. Start topical work and any in-clinic course in the autumn, hold steady and protective through July and August, and do not judge the previous winter's work by how you look in mid-August.

A word on tranexamic acid, which comes up in almost every melasma consultation now. There is reasonable evidence behind it, topically and orally, and it has a legitimate place in a plan. Oral use is a prescription decision that belongs with a physician who knows your history, particularly around clotting risk, and it is not something to order from an overseas website. Ask us and we will tell you honestly whether we think it is worth raising with your doctor.

One more thing worth saying plainly. Melasma is stubborn, and the weight of it is real — patients tell us it is the thing they think about every morning. A plan that promises a fast fix nearly always ends in disappointment and often in a worse flare. A plan that is dull, protective and consistent is the one that quietly gets people to a place where they stop thinking about it every day.