Melasma is an acquired, symmetrical hypermelanosis that settles on the cheeks, forehead, upper lip and jaw in a recognisable pattern. What makes it a distinct clinical problem is not how dark it looks but how it behaves: it is driven by ultraviolet and visible light, by hormonal influence and by dermal inflammation, and it returns when the drivers are still present.
Key Facts
- 1064 nm — the wavelength used for laser toning in melasma, chosen for its deeper penetration to dermal pigment
- 1–3 J/cm² — the low fluence range that defines the toning technique, as opposed to conventional higher-energy laser settings
- 5–10 Hz — the repetition rate typically described, delivered with a collimated large-spot beam
- 8–10 mm — spot sizes suggested to reduce the risk of mottled hypopigmentation, with intervals lengthened to around two weeks
- 9–10 sessions — the course length used in most published monotherapy studies, weekly or biweekly
- Up to 81% — recurrence reported after discontinuing low-fluence Q-switched Nd:YAG laser used as monotherapy
- Fitzpatrick IV–V — the skin types in which mottled hypopigmentation and rebound hyperpigmentation are reported more frequently
- 250–500 mg twice daily — the oral tranexamic acid range described in review literature — prescription-only, off-label for melasma, and not appropriate for everyone
Why melasma is not treated like a sunspot
A solar lentigo is a discrete, bounded lesion. Remove the pigment and, with adequate sun protection, the lesion is gone. Post-inflammatory hyperpigmentation follows an identifiable injury — a spot, a burn, a friction site — and settles as the injury resolves. Melasma does neither. Histologically it shows features of photoageing and dermal inflammation alongside active melanocytes: solar elastosis, increased dermal vascularisation, raised mast cell counts and an altered basement membrane.
That last finding is the clinically consequential one. A disrupted basement membrane allows pigment and melanocytes to sit deeper than they should, and it is also why aggressive thermal injury can make the presenting problem worse rather than better. The tissue is already inflamed. Adding more inflammation is not a neutral act.
What laser toning actually is
The technique most often used for melasma in Asia is low-fluence Q-switched Nd:YAG at 1064 nm, generally described as laser toning. The parameters are the definition: fluences of roughly 1 to 3 J/cm², a collimated large-spot beam, a repetition rate around 5 to 10 Hz, and faint erythema as the treatment endpoint. Most published monotherapy studies run around nine to ten sessions, weekly or biweekly.
The 1064 nm wavelength is preferred over shorter wavelengths because melasma pigment is frequently dermal or mixed, and the longer wavelength penetrates further. The low energy is not a compromise or a gentler option for nervous patients. It is the mechanism: sub-cellular disruption of melanosomes without the thermal injury that would provoke the inflammatory cascade the condition is already running.
Melasma is not a stain to be removed. It is a melanocyte that has been switched on — and pigment cleared without addressing the switch is a result with an expiry date.
The number that matters is the recurrence rate
Clearance figures are the ones usually quoted. The more useful figure is what happens afterwards. Reviews of low-fluence Q-switched Nd:YAG for melasma report improvement across studies, and in the same breath report that recurrence after discontinuation runs as high as 81% when the laser is used on its own.
Read plainly, that is not an argument against laser. It is an argument against laser as a standalone plan. A modality that clears pigment reliably and holds it poorly needs to sit inside something that addresses melanogenesis continuously — topical, oral where appropriate, and photoprotection — rather than being sold as a course with a finish line.
The two ways laser toning goes wrong
The first is mottled hypopigmentation: pale macules developing after repeated low-fluence, large-spot treatments. Case series have documented this after laser toning, and published guidance suggests it can be reduced by using larger spot sizes in the region of 8 to 10 mm and lengthening intervals to around two weeks rather than treating frequently.
The second is rebound hyperpigmentation. Both are reported more often in Fitzpatrick IV and V skin, which describes a substantial proportion of the population presenting in Singapore. This is the reason the treatment interval and the session count are clinical decisions rather than scheduling convenience, and the reason a plan that treats every patient at the same cadence is not adjusting for the skin in front of it.
Where tranexamic acid fits
Tranexamic acid is an antifibrinolytic that reduces plasminogen binding to keratinocytes and blunts ultraviolet-induced plasmin activation — the upstream step that drives tyrosinase activation and inflammatory mediator release. It also appears to have an antiangiogenic effect through reduced plasmin-mediated VEGF and endothelin-1, which speaks to the vascular component of melasma rather than the pigment alone.
Review literature describes oral dosing in the range of 250 to 500 mg twice daily. Two qualifications matter more than the number. It is prescription-only and off-label for this indication, and its duration is commonly limited to three to six months because long-term safety data are scarce and thrombotic risk is a genuine consideration. Personal or family history of thromboembolism, hormonal contraception and pregnancy all change the calculation. This is a medical decision made after history-taking, not a supplement.
The photoprotection gap
The part of melasma management most often underdone is also the cheapest. Both ultraviolet and visible light induce pigmentation, and conventional sunscreen filters address the ultraviolet portion. Consensus guidance now explicitly incorporates visible-light protectants containing iron oxide — the reason tinted formulations are recommended for melasma where an untinted one would be adequate for general photoprotection.
In an equatorial city with year-round high ultraviolet index, indoor lighting and screen exposure on top, this is not a footnote. A treatment plan that includes laser and omits daily visible-light protection is spending effort at the wrong end of the process.
What else sits alongside
Melasma responds to being treated from several directions at once rather than escalated in one. Topical agents that inhibit tyrosinase, chemical peels, and gentler energy-based approaches all appear in the literature as components rather than replacements for one another. Where a picosecond device is used, the same principle applies as with nanosecond toning — parameters are set to avoid provoking inflammation, and the technique is discussed on our pico laser page and in the pico laser guide.
What melasma does not need is the strongest available setting. Where pigment is post-inflammatory rather than melasmic — a distinction that changes the plan entirely — the approach differs again, and is covered in our pigmentation treatment guide.
When treatment is deferred
Pregnancy and the immediate postpartum period, recently started or changed hormonal medication, active inflammation in the treatment area, and unprotected sun exposure that cannot yet be modified are all reasons to wait or to start with the non-procedural components only. Treating pigment while the driver is running produces a short improvement and a fast return, and each cycle of clearance and rebound is not free.
An assessment that concludes the timing is wrong is a legitimate outcome. It is more useful than a package of sessions that cannot hold.
What assessment establishes
Fitzpatrick skin type, the pattern and symmetry of the pigmentation, whether it is epidermal, dermal or mixed, the presence of a vascular component, hormonal and medication history, and what photoprotection is realistically in place. Fluence, spot size, session interval and whether laser belongs in the plan at all follow from that — not from a fixed menu.
References
- Lee YS, Lee YJ, Lee JM, et al. The Low-Fluence Q-Switched Nd:YAG Laser Treatment for Melasma: A Systematic Review. Medicina. 2022;58(7):936. PMC9323185
- Optimizing Q-switched lasers for melasma and acquired dermal melanoses. Indian Journal of Dermatology, Venereology and Leprology. IJDVL
- AlJabr A, AlAnazi AMI, AlEtebi RAA, et al. Tranexamic Acid for Hyperpigmentation Disorders: A Literature Review on Efficacy and Safety in Melasma and PIH. Journal of Cosmetic Dermatology. 2026;25:e70692. PMC12848551
- Lam K, Mansour D, Sutton A. Oral tranexamic acid treatment beyond 6 months for melasma patients — a retrospective case series. JAAD International. 2024;15:195. PMC11066674
- Ocampo-Candiani J, Alas-Carbajal R, Bonifaz-Araujo JF, et al. Latin American consensus on the treatment of melasma. International Journal of Dermatology. 2024;64(3):499–512. PMC11840225
If you are unsure whether your pigmentation is melasma, an in-person assessment is the way to establish it.
Book My AppointmentFrequently Asked Questions
Because laser removes pigment that has already been made, not the tendency of the melanocyte to make more. Reviews of low-fluence Q-switched Nd:YAG monotherapy report recurrence after discontinuation as high as 81%, which is why laser is generally discussed as one component of a maintained plan rather than a course with an end date.
No. Sunspots are discrete, bounded lesions. Post-inflammatory hyperpigmentation follows an identifiable injury and fades as the injury resolves. Melasma is symmetrical, patterned, hormonally and light-influenced, and characteristically persistent — and the three are not treated the same way.
Melasma skin shows features of photoageing and dermal inflammation, including basement-membrane change. Excessive thermal injury can provoke inflammation and worsen the presenting problem, which is why the toning technique uses low fluence over multiple sessions rather than high energy in few.
Small pale macules that can develop after repeated low-fluence laser toning, reported more frequently in Fitzpatrick IV–V skin. Published guidance suggests larger spot sizes and longer intervals between sessions to reduce the risk.
It is the part of the plan most often underdone. Both ultraviolet and visible light drive pigmentation in melasma, and conventional filters address the ultraviolet portion only; consensus guidance now includes visible-light protectants containing iron oxide.