Skin Pigmentation and Hyperpigmentation Treatment in Northern Cyprus

Melasma is a chronic hyperpigmentation condition triggered by hormonal factors. It typically appears as symmetrical, irregularly bordered, brown-to-grey patches over the cheekbones, forehead, upper lip and chin. When it arises during pregnancy it is known as a "pregnancy mask" (chloasma); oral contraceptives, hormone replacement therapy and thyroid dysfunction are also recognised triggers. It is significantly more common in women than in men.

Melasma has three clinical subtypes, and treatment response differs considerably between them:

• Epidermal melasma: Pigment is located primarily in the upper skin layer (epidermis). It becomes more visible under a Wood's lamp. It responds better to depigmenting agents and superficial peels.
• Dermal melasma: Pigment has dispersed into the dermis (deeper skin). It does not become more pronounced under a Wood's lamp. It shows marked resistance to treatment; only a partial response is achieved even with laser and microneedling combinations.
• Mixed melasma: Epidermal and dermal components are both present. The most commonly encountered subtype. A combination protocol is required.

The key message: A promise of "complete clearance, never to return" is inconsistent with clinical reality in melasma. The condition follows a chronic course; the aim of treatment is to bring the pigmentation under control, reduce its prominence and delay recurrence. Sun exposure, hormonal fluctuations, stress and certain cosmetic products all trigger relapse. A realistic goal is a meaningful improvement in the skin over several months, maintained long-term with rigorous sun protection.

PIH is the brown-to-dark brown discolouration that appears after inflammation or trauma to the skin. The most common cause is acne, followed by eczema, friction dermatitis, injury and certain cosmetic procedures (aggressive peels, incorrectly applied laser). The underlying mechanism is excess melanin production during the inflammatory response, with subsequent dispersal into the dermis.

PIH differs from melasma in two important respects:

• The trigger is clear: Every PIH mark has a prior lesion behind it (an old spot scar, an old wound mark).
• It has a tendency to fade over time: With appropriate treatment, a significant improvement is expected over several months; unlike melasma, it is a reversible condition rather than a chronic one.

In Fitzpatrick skin types III–VI (medium-to-dark complexions) it appears considerably more pronounced, as baseline melanocyte activity is inherently higher. In acne patients, PIH treatment begins with controlling the active acne first; new lesions mean new PIH. For acne treatment: Acne treatment.

PIH should not be confused with acne scarring: PIH is flat — it is a colour change only; atrophic scarring (ice-pick, boxcar, rolling) involves a depression in the tissue and requires entirely different treatment.

Solar lentigo is a well-defined, brown-to-dark brown, round or oval mark that develops following years of cumulative sun exposure. It typically appears in individuals aged 40 and over on the backs of the hands, the face, the chest décolletage and the outer surface of the arms — areas chronically exposed to the sun. The popular terms "age spot" or "liver spot" are misleading; there is no direct connection to liver disease.

Solar lentigo responds better to treatment than melasma:

• The borders are well defined, making it suitable for targeted interventions (picosecond laser, Q-switched Nd:YAG, spot-based cryotherapy).
• There is no hormonal component; the risk of recurrence is low as long as new sun exposure is prevented.
• Significant lightening can be achieved in a few sessions of laser treatment.

However, not every dark, round mark is a solar lentigo. Asymmetric, colour-changing, irregularly bordered, growing or bleed-prone lesions may raise the suspicion of melanoma (skin cancer); dermoscopic examination and, where indicated, biopsy are essential. Differential diagnosis at the initial consultation is therefore thorough; a "let's remove the mark with laser" approach risks missing a melanoma.

• Freckles (ephelides): Small, light-brown marks that typically appear on the face and shoulders from childhood onwards, becoming more prominent with sun exposure. They are common in individuals with fair complexions (Fitzpatrick I–II) and red hair. Treatment is not necessary; if desired, they can be lightened with picosecond laser — however, without sun protection, no treatment is durable, and seasonal variation (fading in winter, returning in summer) is typical.
• Seborrhoeic keratosis: Raised, scaly, brown-to-black lesions with a "stuck-on" appearance, typically arising after the age of 40. They are classified as benign growths rather than pigmentation marks, and are removed by cryotherapy, electrocauterisation or CO2 laser. They do not respond to depigmenting creams or peels.
• Naevus (mole): Congenital or acquired pigmented lesions. Not suitable for laser removal; asymmetry, irregular border, colour change, diameter greater than 6 mm and growth (the ABCDE criteria) are assessed, and suspicious lesions are excised and sent for histopathological examination.
• Café-au-lait macules: Congenital, "milky coffee"-coloured flat marks. They may be associated with syndromes such as neurofibromatosis; paediatric assessment is required.
• Dermal melanocytosis (Ota naevus, Hori naevus): Deep, blue-grey dermal pigmentation. It responds only to specific Q-switched lasers (Nd:YAG 1064 nm); topical treatment is ineffective.

This diversity illustrates why treatment choice must be diagnosis-led. The first step in the clinic is to identify which condition underlies the presenting complaint of "marks"; only then is a plan formulated.

The cornerstone of pigmentation treatment is topical depigmenting therapy. These agents suppress tyrosinase — the key enzyme in melanin production — through different mechanisms; used in combination, they act synergistically.

• Hydroquinone 2–4%: The gold-standard depigmenting agent. The prescription-strength 4% concentration is significantly more effective than lower over-the-counter concentrations. Treatment duration is limited to 3–4 months; prolonged continuous use can result in a paradoxical blue-black discolouration known as exogenous ochronosis. For this reason, hydroquinone is not recommended as a "cream for ongoing use"; it is used in a defined, supervised course.
• Tretinoin (topical retinoid) 0.025–0.1%: Accelerates cell turnover, causing pigmented surface layers to shed more quickly and enhancing the penetration of other depigmenting agents. Initial redness and flaking ("retinisation") are expected. Contraindicated in pregnancy and breastfeeding.
• Triple cream (Kligman's formula — hydroquinone + tretinoin + low-potency corticosteroid): One of the most effective topical combinations for melasma. The triple action — pigment suppression + accelerated turnover + inflammation reduction — works together. Because of the steroid component, prolonged use is avoided (a typical course is 8–12 weeks); applied under medical supervision.
• Azelaic acid 15–20%: A tyrosinase inhibitor with anti-inflammatory properties. It is one of the few depigmenting agents considered safe in pregnancy and breastfeeding; the preferred choice for PIH.
• Kojic acid 1–4%: A tyrosinase inhibitor. An alternative when hydroquinone is not tolerated; mild-to-moderate effect.
• Arbutin (alpha and beta): A plant-derived analogue of hydroquinone. Better tolerated at lower concentrations; action is slower.
• Cysteine (N-acetyl cysteine, glutathione precursor): Suppresses the melanin pathway through antioxidant action. Both topical and oral options are available.
• Niacinamide 4–5%: Inhibits melanosome transfer. A supportive agent, generally well tolerated.
• Vitamin C (L-ascorbic acid) 10–20%: Antioxidant, tyrosinase inhibitor. Used in morning routines, before SPF.

Which combination is used and in what sequence depends on the pigmentation type, Fitzpatrick skin type and skin tolerance. A typical melasma plan: triple cream in the evenings (8–12 weeks) → then maintenance with tretinoin + azelaic acid in the evenings; vitamin C + high SPF in the mornings. A PIH plan is weighted towards azelaic acid, with active acne control as the priority.

A chemical peel removes the pigmented layer by controlled shedding of the skin's surface and stimulates renewal of new skin cells. In pigmentation treatment it is used in addition to depigmenting therapy; application as a standalone treatment is generally not preferred.

• Superficial peel (mandelic acid 20–40%, glycolic acid 20–50%, lactic acid): The first choice for PIH and melasma. Mandelic acid is safer in Fitzpatrick IV–VI skin types because its larger molecular size limits dermal penetration and reduces the risk of triggering PIH. Glycolic acid is effective in fair-to-medium complexions; a typical programme is 4–6 sessions at two-to-four-week intervals.
• Salicylic acid 20–30%: A good choice for PIH on an acne-prone background. It has an affinity for the sebaceous glands and provides anti-inflammatory benefit.
• Medium-depth peel (TCA 15–30%): Used in solar lentigo and selected melasma cases. However, the risk of PIH is high in medium-to-dark skin types; it is applied with careful patient selection and in experienced hands.
• Jessner's solution + TCA combination: Preferred for a deeper effect in solar lentigo.
• Deep peel (phenol): Not routinely recommended for pigmentation treatment; the risk of complications is high.

Fitzpatrick IV–VI (medium-to-dark skin types): Peel selection is critical. Aggressive peels in these skin types can trigger PIH or a flare of melasma; a superficial and gradually progressive protocol is preferred.

Detailed peel page: Chemical peel.

Laser technology works on the principle of selective photothermolysis: a specific wavelength shatters the target chromophore (the melanin pigment molecule) without damaging the surrounding tissue. The main laser platforms used in pigmentation treatment are:

• Picosecond laser (PicoWay, PicoSure, Discovery Pico): Pulses are delivered in picoseconds (trillionths of a second); this ultra-short duration mechanically shatters melanin whilst minimising heat spread. Effective for solar lentigo, lentigines, freckles, dermal melanocytosis and selected melasma cases. The risk of triggering PIH is significantly lower than with Q-switched technology; for this reason it is the preferred option in Fitzpatrick IV–VI skin types. The same platform is used for tattoo removal and acne scarring.
• Q-switched Nd:YAG 1064 nm: With its deep wavelength and selective melanin targeting, this is the classic platform considered safe in darker skin types. A low-energy "laser toning" protocol is preferred for melasma, typically 6–10 sessions at two-to-four-week intervals. High-energy application is effective for dermal melanocytosis.
• Q-switched Nd:YAG 532 nm: Preferred for superficial pigmentation (solar lentigo, freckles). The risk of PIH is higher in darker skin types.
• Alexandrite 755 nm: Can be effective for solar lentigo but the risk of burns and PIH is markedly elevated in Fitzpatrick IV–VI skin types; it is not the preferred choice in those skin types. Nd:YAG 1064 nm is favoured in darker complexions for its safety profile.
• IPL (Intense Pulsed Light): Not a pure laser; broad-spectrum light is used with filters. It can be effective for solar lentigo and superficial pigmentation. Not recommended in Fitzpatrick IV–VI skin types; it is also a risky choice for melasma.

A note of caution in melasma: High-energy laser treatment can flare melasma. A promise of "removing melasma with laser" is not consistent with clinical reality; in melasma, laser is used at low energy on carefully chosen platforms (picosecond laser toning, low-dose Nd:YAG 1064 nm), in addition to depigmenting therapy. It is not a monotherapy.

For laser options and session planning for skin pigmentation: Laser pigmentation.

Microneedling (dermaroller/Dermapen) opens controlled micro-channels, increasing the penetration of depigmenting agents into the skin whilst simultaneously stimulating the skin renewal process. It is used in addition to topical therapy particularly for resistant melasma and PIH cases.

• Microneedling + triamcinolone/tranexamic acid: A protocol popular in South Asia for melasma. Tranexamic acid (an antifibrinolytic agent) suppresses the pigment production pathway.
• Microneedling + vitamin C / glutathione: Supportive for overall skin quality.
• Microneedling + platelet-rich plasma (PRP): Used for skin renewal and quality; it does not directly target pigment but enhances the tissue's overall capacity for healing. Detail: PRP.
• Oral tranexamic acid (250–500 mg/day, 3–6 months): In recent years, an oral option showing meaningful efficacy in melasma. Risk factors for thromboembolism (smoking, contraceptive use, history of venous thromboembolism) must be assessed; where there is no contraindication and the patient is appropriately selected, it makes a significant contribution alongside depigmenting therapy.

Sun sensitivity is heightened for 24–48 hours following microneedling; strict adherence to SPF 50+ and physical sun protection measures is required. To support skin quality with mesotherapy: Mesotherapy.

The single most important component of pigmentation treatment is also the least expensive and most frequently neglected: daily sun protection. Everything else — high-end laser, triple cream, microneedling — produces only short-term results without sun protection; the pigmentation then returns to its original state and the patient walks away thinking "the treatment didn't work".

Rules specific to Northern Cyprus:

• SPF 50+ broad-spectrum (UVA + UVB), every day, year-round. Winter, overcast skies and indoor environments are not valid exceptions; UVA penetrates glass and passes through cloud.
• The two-finger rule for the face: The amount of sunscreen needed for the face fills the final two segments of the index and middle fingers. Less than this means the labelled SPF value will not be reached.
• Reapply every two hours: Especially when outdoors and in contact with water.
• Physical (mineral) sunscreens (zinc oxide, titanium dioxide) are a less irritating option for sensitive skin and patients prone to PIH. However, if a chemical-filter SPF is sufficiently effective, patient preference is the deciding factor.
• Tinted sunscreens containing iron oxide are particularly valuable for melasma, because melasma is triggered not only by UV but also by visible light (particularly blue light), and iron oxide filters this.
• In the post-treatment period (30 days after peels, laser or microneedling): Avoiding direct sun, wearing a hat, UV-protective glasses, and reapplying SPF are all mandatory.

Sun protection is not optional — it is a component of the treatment. A patient who cannot commit to this rule is not a candidate for laser or aggressive peels; any investment made will be wasted and carries the risk of new PIH.

The pathway below is an example plan for a patient with mixed melasma + PIH; an individual plan is formulated at consultation. In pure solar lentigo, laser sessions take priority; in pure PIH, depigmenting agents + azelaic acid + active acne management come first.

1. Month 0: Consultation, differential diagnosis (Wood's lamp, dermoscopy, differential diagnosis), photographic record, assessment of skin type and tolerance, sun protection education.
2. Months 0–3: Triple cream in the evenings (8–12 weeks) + azelaic acid in the mornings + SPF 50+ (tinted, containing iron oxide) + a superficial mandelic acid peel every two to four weeks (total of 4–6 sessions).
3. Month 3 review: Photographic comparison. If the response is adequate, triple cream is discontinued and maintenance is begun (tretinoin + azelaic acid in the evenings). If the response is insufficient:
   • For melasma: assessment for oral tranexamic acid (where there is no contraindication) + microneedling sessions.
   • For resistant areas: low-energy picosecond laser toning or Nd:YAG 1064 nm — every two to four weeks, 6–8 sessions.
4. Months 6–12: Maintenance protocol (tretinoin or azelaic acid in the evenings + vitamin C in the mornings + SPF 50+ daily). Photographic review at monthly-to-three-monthly intervals.
5. Month 12+: Long-term management. In the event of hormone-related recurrence, an interim peel or microneedling session can be planned.

Realistic goals: In melasma, a 50–70% reduction in prominence and controlled maintenance; in pure PIH, significant improvement over several months; in pure solar lentigo, 70–90% lightening is achievable. A promise of "complete clearance" is not a clinical reality.

• Stable PIH patients (active inflammation has resolved): Patients with acne or eczema under control and no new lesion formation. A meaningful improvement over several months is expected with topical depigmenting agents and superficial peels.
• Solar lentigo (Fitzpatrick I–III): Well-defined marks respond well to picosecond laser and superficial peel sessions.
• Stable melasma patients: No recent hormonal fluctuation (pregnancy, childbirth, new onset of oral contraceptives), and patients who can maintain strict sun protection throughout the treatment period.
• Freckle lightening requests: Patients who have an aesthetic concern and accept the cyclical lightening effect (which repeats with the seasons).
• Dermal melanocytosis (Ota/Hori naevus): A significant improvement can be achieved with Q-switched Nd:YAG 1064 nm sessions.
• PIH patients who have completed acne treatment: Active acne under control, now at the stage of treating marks and discolouration.

• Pregnancy and breastfeeding: Hydroquinone, tretinoin, oral tranexamic acid and certain peel solutions are contraindicated. The options available during this period are very limited (azelaic acid, niacinamide, physical sun protection); treatment is deferred until after delivery and the end of breastfeeding where possible. A meaningful proportion of pregnancy mask (chloasma) may fade partially of its own accord after breastfeeding ends.
• Active acne or inflammatory skin condition: Controlling the active condition is required before beginning PIH treatment; new lesions mean new pigmentation.
• Fitzpatrick IV–VI skin types: The risk of triggering PIH is significantly elevated with aggressive peels, high-energy laser (in particular Alexandrite 755 nm) and IPL. The preferred sequence in these skin types is: topical depigmenting agents + superficial mandelic acid peel → microneedling → low-energy picosecond laser toning or Q-switched Nd:YAG 1064 nm. Patient selection and parameter adjustment are critical.
• Patients without a disciplined approach to sun avoidance: A patient who says "I won't wear a hat in summer" or "I won't apply SPF at the beach" is not a candidate for pigmentation treatment — the time and cost will be wasted. Patients who will not commit to 30 days of strict post-treatment sun protection and daily SPF 50+ year-round are asked to defer the protocol.
• Melasma with an unresolved hormonal trigger: During active pregnancy, on recently initiated oral contraceptives or during hormone replacement therapy, treatment is maintenance-focused rather than aggressive. High-energy laser is not recommended until the trigger is brought under control.
• History of exogenous ochronosis: In patients who have used hydroquinone long-term and developed paradoxical pigmentation, hydroquinone is discontinued; improvement is expected gradually with alternative depigmenting agents and time.
• Suspicious lesions: Asymmetric, irregularly bordered, colour-changing, itchy or bleed-prone lesions require dermoscopic and, where indicated, biopsy assessment for melanoma or other skin malignancy. A "let's laser the mark" approach can cause this to be missed; differential diagnosis at the initial examination is thorough.
• Oral isotretinoin within the past 6 months: Medium-to-deep peels and ablative laser procedures are typically deferred (risk of atypical healing and scarring). Superficial peels and topical depigmenting agents can be continued.
• Suspected body dysmorphic disorder (BDD): Where the mark is minimal but patient satisfaction remains low, where there are repeated treatment requests, or where the patient is focused on a "mark" that others cannot see, a psychiatric assessment may be required; aggressive treatment will not achieve satisfaction in these cases.

Saying "this is not appropriate for you" or "let's address something else first" is an integral part of achieving durable patient satisfaction. Promoting an unsuitable treatment is short-term revenue and long-term complaint.

The most common mistake in pigmentation treatment is introducing a device before making a diagnosis. A patient presenting with "I have marks" should receive a thorough clinical examination — Wood's lamp, dermoscopy and biopsy where needed — before any treatment is recommended. At Nis Clinic, the diagnostic sequence is as follows:

1. Differential diagnosis — is it melasma, PIH, solar lentigo, or is there a naevus/melanoma concern?
2. Trigger analysis — hormonal status (pregnancy, oral contraceptives, hormone replacement therapy, thyroid), medications, cosmetic products, sun exposure profile.
3. Fitzpatrick grading and skin tolerance — determines the safety profile of treatment.
4. Photographic record + written plan — the objective and timeline of each stage are clearly set out.

Treatment is managed by Op. Dr. İbrahim Meyzin from a plastic surgery perspective; dermatology collaboration is brought in at every stage where it is needed. A registered member of the Cyprus Turkish Medical Association (CTMA), Registration No. 969. His plastic surgery foundation is particularly decisive in laser selection, energy parameter setting and scar biology; dermatology collaboration is engaged for depigmenting therapy and systemic treatment options. The preferred model is "the right question to the right specialist", not "one doctor solves everything".

Full doctor profile: Op. Dr. İbrahim Meyzin

The two phrases used most often in pigmentation treatment marketing are "a lasting solution in a single session" and "guaranteed results". Neither is consistent with clinical reality. The Nis Clinic approach:

• Melasma is a chronic condition — it is brought under control, not "erased". This is communicated clearly at the outset of treatment. A 50–70% reduction in prominence is a good outcome; a promise of complete clearance is not made.
• PIH is reversible but requires time. Significant improvement over several months is a realistic goal; however, active acne control must come first.
• Combination, not monotherapy. Topical depigmenting agents + chemical peel + laser (where indicated) + sun protection — all four together. The approach of "one cream is enough" or "one laser session will do it" is rejected.
• Sun protection is non-negotiable. Before treatment begins, it is confirmed that the patient will commit to this layer; patients who will not are not offered an aggressive protocol.
• Recurrence is expected. In melasma especially, hormonal fluctuations and summer months bring recurrence; the maintenance protocol is long-term. The phrase "treatment is finished, it won't come back" is never used.
• Photographic comparison. A photographic review at the same angle and lighting every three months; progress is shared in a visible, objective format. This eliminates subjective "it got better / it didn't" debate.

The plan presented to you is in writing; the objective, duration and approximate cost of each stage are clearly set out.

The staged nature of pigmentation treatment cannot be captured in a single line-item fee. At Nis Clinic, pricing is broken down by pigmentation type and the methods used. Indicative ranges:

Pricing varies according to pigmentation type, the product and device used, number of sessions and the combination plan. Blood tests, prescription medications (triple cream, tranexamic acid) and external laboratory services are generally not included in the package and are charged separately. A personalised written plan and price confirmation are shared after consultation; there are no hidden charges.

Pigmentation treatment is typically an outpatient journey that does not require a medical tourism package; monthly-to-bimonthly reviews can be carried out online (Zoom/WhatsApp video call). Attendance at the clinic is required for laser and peel sessions. Related pages: Chemical peel, Mesotherapy, PRP, Acne treatment, Laser pigmentation, Op. Dr. İbrahim Meyzin profile, Contact, Appointment.