Melasma keeps coming back — here’s what actually holds it

Melasma is not a stain you scrub off. It is an active, relapsing condition — and the reason it keeps returning is almost always that the plan treated the colour and ignored the triggers.

Why it comes back

Melasma sits at the meeting point of three things: sun and visible light, hormones, and an intrinsic tendency of the pigment cells to over-respond. Creams and lasers can clear what is already there. None of them switch off the tendency. So when the sun exposure resumes, or the hormonal driver continues, the pigment returns — and patients conclude the treatment “didn’t work” when in fact it was never designed to be permanent on its own.

What the evidence actually supports

Oral tranexamic acid

This has become one of the better-supported systemic options. Reviews describe meaningful reductions in melasma severity scores (MASI) at doses in the region of 500–1500 mg per day over roughly 8–12 weeks, and a network meta-analysis of updated data found oral tranexamic acid produced the largest decrease in severity scores compared with injected and topical routes.

It is a prescription medicine with genuine contraindications — a personal or family history of clotting disorders being the important one — so it is assessed case by case, never dispensed casually.

Low-fluence Q-switched laser toning

Used gently and correctly, low-fluence Q-switched 1064 nm treatment can lighten melasma in darker skin types. Used aggressively, it can make melasma worse and cause new pigment problems. This is the treatment where the doctor’s restraint matters more than the machine’s power.

Combination beats monotherapy for staying power

One of the more useful findings for patients: recurrence at six months was substantially lower in a combination-treated group (about 4.8%) than in a group receiving tranexamic acid alone (about 21%). The lesson is not which specific combination — it is that layered treatment plus maintenance outperforms any single agent over time.

What we do at The Derm Edit

1. Diagnose properly first. Melasma, post-inflammatory pigmentation and tanning look similar and behave completely differently. Treating one as the other is why so many people plateau.
2. Control the triggers before escalating. Broad-spectrum sunscreen reapplied through the day, tinted formulations with iron oxide for visible-light protection, heat exposure, and a review of any hormonal contributors.
3. Layer treatment to the depth involved — topicals and medical peels, systemic therapy where appropriate, gentle laser toning on the Fotona StarWalker MaQX, and depigmenting programmes such as Cosmelan or Dermamelan for stubborn cases.
4. Build maintenance into the plan from day one, not as an afterthought when it relapses.

The honest part

Melasma is managed, not cured. Anyone promising permanent clearance in a fixed number of sessions is either misinformed or selling. What we can offer is steady, safe lightening appropriate to Indian skin, a plan you understand, and the maintenance rhythm that keeps the result — reviewed with photographs, not impressions.