Is It Melasma, or Something Else?

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There's a version of this article that I could have written where I sound very impressive.

It would have a nice clean list. Melasma looks like this. Post-inflammatory pigmentation looks like that. Sun spots look like this third thing. Read the list, identify yours, come in already knowing the answer.

I'm not going to write that, because it isn't true to what I actually see.

Here's the honest version: most of the time, what's on your face is a mixture. Melasma with pigment from old acne sitting on top of it. Melasma alongside twenty years of accumulated sun damage. Something that began as one process and got layered over by another. And separating those layers by looking at a face — even with a dermatoscope, even after doing this for years — is genuinely difficult, because they're not sitting in tidy zones. They're on top of each other.

So let me tell you how I actually approach it, and what I do when I can't be certain.

The history is doing most of the work

Before I look closely at anything, I ask questions. Quite a lot of them.

When did it start? Not roughly — as precisely as you can manage. A patch that appeared over three months behaves differently from one that crept in over eight years.

Was there anything before it? This is the question that most often cracks a case open. A rash there. A burn. A period where the skin was irritated, peeling, reacting to something. A course of some cream a friend recommended. Pigment that follows inflammation is a different problem from pigment that arrived on its own, and it responds to different things.

Any pregnancies — and did it change afterwards? Melasma very often starts in pregnancy, and what happened in the months after delivery tells me something about how hormonally driven yours is.

Any hormonal medication? Contraception in particular.

What have you been using on it? All of it. Including things you bought online, things a relative gave you, things you stopped because they made your skin worse. Especially those.

I'll be upfront about something: a lot of this questioning is me preparing myself rather than preparing you. By the time I bring the light in close and put the dermatoscope on your skin, I've usually already formed a picture in my head, and the examination is confirming or challenging it. The examination alone, without the story, would leave me guessing far more than patients would probably like to know.

What I do when I'm not sure

I tell you.

Where something is clear, I'll name it — this is melasma, this here is pigment left over from old inflammation, that one is a sun spot. Where it isn't clear, I say so directly: I'm confident about this part, I'm not confident about that part, and here's what makes it ambiguous.

Some patients find that unsettling for a moment. I understand why. You came to a doctor for an answer and the doctor is telling you the picture is mixed.

But think about the alternative. If I pick a confident-sounding label just to fill the silence, and then treatment doesn't do what that label implied it would, you'd be right to be frustrated with me — and you'd have spent months on the wrong expectation. Whereas if we agree from the start that we're dealing with a mixture and we're aiming for improvement rather than a specific named cure, we're working on something real.

And I still treat it. That's important. Nearly everyone who comes to me about pigmentation isn't chasing a perfect diagnosis — they want their skin to look better. That's a completely reasonable thing to want. So we talk about the options, we talk about what's realistically achievable given that it's mixed, and we get started. The uncertainty changes how I set expectations. It doesn't stop us treating.

The case that taught me to keep asking

Let me give you a real example, because it shows why I don't just look and prescribe.

A woman in her forties came to see me. She'd had dark patches on both cheeks for a long time — symmetrical, on the cheeks, in a woman in her forties. If you wanted a textbook description of melasma, that's more or less it. Most people would treat it as melasma and move on.

But she also mentioned, almost in passing, that she still got acne on and off. And that made me curious, because there's a widespread assumption — including among patients themselves — that acne is something you leave behind in your twenties. You don't, necessarily. Plenty of people are still getting it in their forties. She'd half-dismissed it herself as not worth mentioning.

So I kept asking about the pigmentation. And a detail came out that changed everything: the dark spots moved. Not the overall shading across her cheeks, but individual spots — some faded over months while new ones appeared elsewhere. And when I looked carefully, the tones weren't uniform. Different spots were different shades.

That's not what pure melasma does. Melasma is relatively stable in its distribution. Spots that come and go in different locations, in varying tones, are the signature of post-inflammatory hyperpigmentation — marks left behind each time a lesion heals.

So the real picture was: a base of melasma, with a continuous rolling layer of acne-related pigmentation on top of it, constantly being renewed because the acne was never controlled.

Here's the part that matters most. We treated the acne first. And only once the acne was under control did the pigment medications actually start working, and only then did the melasma come under control.

That sequence is the whole lesson. It wasn't that fixing the acne made the pigment disappear on its own. It was that while new inflammation kept appearing every few weeks, the pigment treatment was fighting something that was being continuously replenished. Take away the source of new inflammation, and the same medications that had been getting nowhere started to do their job.

If I'd looked at her cheeks, said "melasma," and written a prescription, she would have spent a year on treatment that couldn't work, and concluded her skin was untreatable. Instead the answer came out of a conversation about something she thought was unrelated.

What this means for you

A few practical things.

Mention the thing you think is irrelevant. The acne you assume is separate. The rash you had last year. The two weeks your skin peeled after a facial. The product you used for a month in 2023 that made everything angry. That's where the answers live.

If pigment is following inflammation, the inflammation is the first target. Acne, eczema, an irritant reaction — whatever is producing new inflamed lesions has to be brought under control, or the pigment treatment is working against a tap that's still running.

Don't assume symmetrical cheek pigmentation in a woman is automatically melasma. It very often is. But "very often" is doing real work in that sentence, and the exceptions matter.

Be suspicious of your own explanation. Patients frequently arrive with a firm theory — it's hormones, it's the sun, it's a product. Sometimes they're right. But holding it loosely helps, because the firm theory can stop you mentioning the detail that would have solved it.

A note on the instruments

People sometimes ask whether there's a scan or a test that settles this definitively.

There are useful tools, and I use them. But I want to be careful not to oversell them, because the honest position is that they narrow things down rather than deliver verdicts — particularly when several processes are layered together, which is the usual situation. Anyone who tells you a machine will give you a clean, certain answer about mixed facial pigmentation is overstating what the technology does.

The history, the examination, and then watching how your skin responds to treatment over the first couple of months — that combination tells me more than any single tool. How your pigmentation behaves once we start treating it is itself diagnostic information.

If you want to sort this out properly

Come and have the conversation. My skin consultations run roughly ninety percent talking and ten percent prescribing, and this is exactly the kind of problem where that ratio earns its keep.

Bring everything you've been using — the prescription creams, the pharmacy products, the things bought online, the thing your cousin swore by. I'm not going to lecture you about any of it, and every so often one of those items turns out to be the most useful thing you tell me all consultation.

Klinik Dr Tan (Skin & Acne), Lot 27, Ground Floor, Block D, Lintas Square, Kota Kinabalu.

WhatsApp 017-234 7328. Appointments are better than walk-ins here, because rushing this particular conversation defeats the point of having it.

I'm a GP with a strong interest in skin, not a dermatologist. Where something needs specialist assessment, I'll say so and refer you on rather than persist out of pride.

Book a consultation with Dr. Tan — Book Online or WhatsApp 017-234 7328.

简要说明

我是陈医生，亚庇 Lintas Square 的 Klinik Dr Tan（皮肤与暗疮）。我是对皮肤有专长的普通科医生，不是皮肤专科医生。

脸上的深色斑，不一定就是黄褐斑。而且多数时候不只一种问题。

• 实际看诊时，脸上的色素常常是混合的：黄褐斑加上旧痘印，或再加上多年的日晒损伤，一层叠一层，即使用皮肤镜也不容易分开。

• 我会先问很多问题：什么时候开始？之前有没有发炎、烫伤、脱皮、用过什么药膏？有没有怀孕，产后有没有变化？有没有用荷尔蒙药物？现在在用什么产品？ 老实说，这些问题主要是让我自己心里先有个方向，之后的检查是在印证或推翻它。

• 不确定的时候我会告诉你。 清楚的部分我会说清楚，不清楚的部分我也会说明为什么不清楚。与其随便给一个听起来很肯定的诊断，不如一开始就讲明这是混合型，然后一起讨论实际能达到什么程度。不确定不代表不能治疗——大多数人来是想要改善，这很合理。

一个真实的例子：

一位四十多岁的女士，两边脸颊长期有深色斑——对称、在脸颊、中年女性，标准的黄褐斑样子。但她顺口提到自己还是会长痘。（很多人以为过了二十几岁就不会长痘，其实不是，四十多岁还长痘的人不少。）

我继续追问，发现关键细节：那些斑会移动——有些淡下去，新的又在别处冒出来，而且深浅不一。这不是纯黄褐斑的表现，这是**炎症后色素沉着（PIH）**的特征。

真正的情况是：黄褐斑作为底层，上面不断有新的痘印叠加，因为痘痘一直没有控制好。

重点在于顺序：我们先治疗痘痘。痘痘控制住之后，色素的药才开始真正发挥作用，黄褐斑也才受控。 不是治好痘痘色素就自己消失，而是当新的发炎不断产生时，色素治疗等于在跟一个没关掉的水龙头对抗。

给你的建议：

• 请把你觉得「无关」的事情说出来——那些你以为不相干的痘痘、去年的疹子、做完脸后脱皮的那两周。

• 如果色素是跟着发炎来的，先处理发炎。

• 不要因为是对称的脸颊色素就自动认定是黄褐斑。

• 仪器可以帮助判断，但不会给出百分百确定的答案，尤其在多种问题重叠时。

请把正在用和用过的产品都带来，我不会说教。

Klinik Dr Tan (Skin & Acne)，Lot 27, Ground Floor, Block D, Lintas Square, Kota Kinabalu。WhatsApp：017-234 7328。建议预约。

预约陈医生 — 在线预约 或通过 WhatsApp 联系 017-234 7328