Hyperpigmentation is one of the most commonly presented concerns in aesthetic practice, and one of the most frequently mistreated. The problem is almost never the product selection. The problem is the consultation: specifically, the failure to classify the pigmentation correctly before reaching for a treatment protocol.
I have been taught by patients to slow down in these consultations. A woman who presents with brown patches on both cheeks in her forties does not automatically have melasma. She might. But she might have solar lentigines, post-inflammatory hyperpigmentation (PIH), periorbital pigmentation driven by vascular change, or a combination of two or three overlapping conditions. Getting this wrong means getting the treatment wrong.
The four questions I never skip
Before I examine the skin, I ask:
- When did you first notice the pigmentation, and did it appear gradually or suddenly?
- Does it change with sun exposure, pregnancy history, oral contraceptive use, or HRT?
- Do you have a history of acne, eczema, or other inflammatory skin conditions in the same area?
- What is your ethnic background, and how does your skin respond to inflammation or injury?
These four questions establish the differential before I examine the skin. Melasma typically appears gradually in hormonally active years and worsens predictably with UV exposure and hormonal fluctuation. PIH always follows a specific precipitant: an identifiable episode of inflammation. Solar lentigines appear in UV-exposed areas with no hormonal pattern and a clear cumulative sun history.
The answer to question four shapes every treatment recommendation that follows. Patients with Fitzpatrick types III to VI carry significantly elevated risk of PIH from any aesthetic intervention, including chemical peels, laser, and energy-based devices. This assessment is not a supplementary step. It is foundational.
Clinical classification of hyperpigmentation
For treatment planning, I work with four categories:
Epidermal hyperpigmentation includes melasma (epidermal component), solar lentigines, and most PIH in lower Fitzpatrick types. Topical treatment and photoprotection are the foundation.
Dermal hyperpigmentation includes melanin that has migrated below the dermoepidermal junction, commonly seen in melasma with dermal involvement and in PIH in Fitzpatrick types IV to VI. This responds more slowly to treatment and can be worsened by aggressive surface interventions that induce further inflammation.
Mixed hyperpigmentation (both epidermal and dermal components) is common in melasma. Wood's lamp examination helps differentiate: epidermal melanin enhances under 365nm UV light; dermal melanin does not produce the same contrast enhancement.
Exogenous pigmentation includes ochronosis from prolonged hydroquinone use, drug-induced pigmentation (minocycline, antimalarials), and tattoo pigment presenting unexpectedly. These require a different clinical pathway entirely.
Wood's lamp and dermoscopy in the assessment
Wood's lamp examination remains a clinically useful tool in hyperpigmentation consultation. It adds information quickly, without cost, and without discomfort. Enhanced contrast under Wood's lamp light suggests predominantly epidermal melanin and predicts better response to topical depigmentation agents. Loss of contrast or a uniform appearance under the lamp suggests dermal involvement or a non-melanin source.
Dermoscopy adds further clinical detail, particularly when differentiating solar lentigines (structureless brown areas, often with moth-eaten borders) from lesions with atypical features. Any pigmented lesion with irregular borders, asymmetric pigment distribution, regression structures, or an appearance inconsistent with a benign cause requires referral to dermatology. Aesthetic practitioners are not dermatologists. Recognising the boundaries of our scope is a clinical competency, not a limitation.
Photoprotection is a treatment, not a caveat
No hyperpigmentation treatment produces reliable results without concurrent, rigorous daily photoprotection. I do not treat this as a side note. It is the first intervention we discuss at every hyperpigmentation consultation.
For melasma and PIH, the published evidence base consistently supports broad-spectrum SPF 50+ applied daily as the foundation of management. Tinted formulations with iron oxides offer additional protection against visible light, which drives melanogenesis through a pathway independent of UVA and UVB.
I now begin every hyperpigmentation consultation by asking about photoprotection before mentioning any active treatment. The conversation about tyrosinase inhibitors, retinoids, or peels only follows once I am confident the patient understands and will use SPF every day, regardless of the weather.
Treatment selection once the assessment is complete
Once classification is established and photoprotection is confirmed, treatment selection follows the pathway:
For melasma with an epidermal component, combination topical therapy is the evidence-based approach. This means a tyrosinase inhibitor (kojic acid, azelaic acid, tranexamic acid, or alpha-arbutin in the UK setting where hydroquinone availability is limited), combined with a retinoid and, where tolerated, an anti-inflammatory agent. Maintenance photoprotection is ongoing, not a course of treatment.
For PIH in Fitzpatrick types I to III, cautious chemical exfoliation with glycolic or mandelic acid, topical retinoids, and vitamin C serums all have supporting evidence. Treatment duration is measured in months, not weeks.
For PIH in Fitzpatrick types IV to VI, extreme caution is required with any thermal, laser, or aggressive chemical intervention. The risk of inducing further PIH from the treatment itself is real. Gentle tyrosinase inhibition, topical tranexamic acid, and extended timeframes produce safer outcomes than aggressive approaches.
For solar lentigines, IPL and laser procedures in appropriately trained practitioners offer effective treatment when Fitzpatrick selection is correct. Superficial chemical peels are a useful supportive adjunct.
The consultation is where the plan is built
A rushed consultation produces the wrong classification, the wrong plan, and a patient who does not improve. Patients who have already been treated elsewhere without improvement almost always report a consultation that moved directly from their concern to a product recommendation.
The time spent classifying correctly is the most clinically effective time in the appointment.
The full assessment and treatment framework for hyperpigmentation in UK aesthetic practice is covered in depth in the Hyperpigmentation Decoded course at aestheticsunlocked.co.uk/courses/hyperpigmentation-decoded.