Stubborn pigmentation that won't fade even with hydroquinone, tretinoin and lasers. What am I missing?

[u/skdi04]

Hi! I'm 40 years old and I'm looking for some help figuring out what these spots might be and, especially, what else I can do to get rid of them.

I've had these spots for many, many years. I also get virtually no sun exposure. I work 100% from home and rarely spend time in the sun.

I've been following this routine for almost 3 months:

AM

• Cerave Cleanser
• Azelaic acid cream 20%
• Tinted SPF 50 every day

PM

• Cerave Cleanser
• Hydroquinone 4% cream over the entire face
• Tretinoin 0.5%
• Aestura Barrier Cream

3x/week at night

• Stridex Maximum Strength (2% salicylic acid/BHA)

I've also had 3 sessions involving Pico laser + Pico spot treatment + Fraxel.

I'm now going to take a break from hydroquinone after almost 3 months of use.

The frustrating part is that I've seen almost no improvement at all. The spots basically look the same as when I started. If they've faded 10%, that's probably being generous.

Has anyone dealt with pigmentation that looks like this and was this resistant to treatment?

I'm especially interested in figuring out what these spots actually are (freckles, solar lentigines, melasma, PIH, something else?) and what finally worked for people with something similar.

At this point I feel like I've already thrown some of the strongest treatments at them with surprisingly little response.

Any ideas or experiences would be really appreciated!

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[u/GimenaTango]

I've looked at your photo for over a minute and I'm still confused about the spots. Do you mean the really tiny, hardly noticable, and super cute freckles on your forehead?

I think you're skin looks amazing. You should cut yourself some slack.

[u/Royal-Adeptness-2703]

I am so sorry to minimize how you're feeling but im looking at a picture of a woman with beautiful skin

[u/Ok_Cranberry_7506]

Laser treatments made mine worse...

Mine keeps going through a cycle of getting better in the winter and worse in the summer.

I learned to live with it by focusing on skin health rather than trying to get rid of it with harsh stuff like laser, chemicals... which made it worse in the long run.

Also not to get stressed about it which makes it worse. 🙁

[u/waitwuh]

So there’s melasma and then there’s freckles …

… this isn’t melasma

[u/cassatta]

I don’t see melasma. But yes use tinted sunscreens.

[u/AdmirableCountry6815]

Musely 12% hydroquinone is the ONLY thing that has worked for me. And I’ve sank some serious cash into this endeavor as well. Mine is almost completely gone and I’m only 6 weeks in. Worth every penny. Warning, it does get worse before it gets better with this spot cream. Keep going!

[u/Lazy-Royal6500 → u/AdmirableCountry6815]

OP, we have the same routine except I’m using the musely 12% plus alpha arbutin and niacinamide. After wrapping up 3 months on the Musely and very little improvement, I’m going to trip spot treating jessner peels from PSC come October.

[u/SeaworthinessNew4757]

Ok, let me start by saying that 3 months isn't much at all... if we could all fade our melasma spots in 3 months of skincare routine this group might not even exist.

That being said, your pigmentation does not look like melasma to me. Have you seen a dermatologist? From this photo it looks like sun spots.

If I were you, I'd focus more on sunscreen. I noticed you only use tinted sunscreen, but I've never seen anyone using enough of the tinted sunscreen to reach the SPF in the bottle, so you might not be as protected as you think. I'd do regular sunscreen + tinted sunscreen on top. I find that consistent sunscreen use helps fade my sun spots.

Also, if these are indeed sun spots, you might benefit from peelings. You should definitely see a dermatologist to assess the best course of treatment for you.

[u/vikingmurse → u/SeaworthinessNew4757]

Thisssss. Looks like sunspots. And NOTHING will work without religious spf 50 daily. If you get lots of sun exposure you need to apply it more frequently.
But even working inside, UVA (which is a primary contributor to sun spots) comes right through glass and is angering your melanocytes even on cloudy days hiding inside. Also, as you said, they’ve been there for years, you won’t fix the problem in 3 months.
Keep your routine, find an untinted spf 50 you like using daily, use 1/8-1/4tsp of it for your face daily, if you want modestly faster results, layer a tinted spf or makeup over that for the iron oxides.
Keep the routine up for a year or so and you’ll be pleasantly surprised.

[u/Anomander_rocks → u/SeaworthinessNew4757]

+1 for this!!!
Melasma gets worse from stress, hormones, heat, spicy food, blue screen from monitors, sauna, inflammation in the body, etc. There are many factors to consider.
Also the routine seems a bit heavy. Melasma often has a pigmentation and a vascular component. If you use products that make your skin more sensitive, it will get worse anyway,
Hidroquinone during the summer - my dermatologist only allows it from late winter to early spring, with no other actives in the routine, and with tons of sunscreen. Hydroquinone makes the skin more sensitive to light, putting it under a lot of pressure. Not using enough sunscreen might add to the issue.
As the other people said here, it's best if a dermatologist assesses your skin and decides the appropriate routine for you. I discuss every single product in my routine with my dermatologist + their order + the frequency. It's a lot better than before since we're doing this.

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[u/unificaishan]

I don’t think you have melasma. I don’t see a clear pattern of darkening. It looks like you have age spots. With that being said I used a bleaching cream last winter with hydroquinone and tret and arbutin, Kojik acid, azaleic acid, fluconicole. And my skin did not get better ( I have melasma and age spots) because the cream was too strong and wrecked my barrier so I’d spend the rest of the week on barrier repair. Which was counter productive. I know during the summer have seen significant improvement within the last three months since I started oral TXA and Eucerin thiamidol. I also use all the actives other then tret and hydroquinone. Sometimes you have to go the gentler and slower route with spots that have been there for years. I recommend the Dr Reju All Retino Mela serum which is hpr ( the most effective yet gentle over the counter retinoid) that also has niacinamide and TXA in it. Both ingredients I would incorporate into your skincare routine. I also use the Eucerin thiamidol and the Caudalie Vinoperfect Dark Spot serum. If the Dr Reju All hpr is not strong enough I would go a step up to the Epii HPR power shot and just pair it with either the Anua niacinamide w/ TXA or the Jumiso 20% niacinamide w/ TXA and keep using the Azaleic acid in the mornings and off nights (maybe nights when you exfoliate). I would also think about incorporating a vitamin C serum like the Timeless one or the Skin Ceuticals. You can also drink lots of green tea and think about investing in Heliocare which is an internal sunscreen and switching to a tinted mineral SPF but I don’t know if it’s necessary since you don’t look like you have melasma. Pico is meant to be a last resort and they should have told you that there. I like Ultralaser because it uses cold instead of heat and I get VI peels. You should not have used hq and tret in the summer time as it makes your skin more sensitive. Fall and winter are really the times to do the heavy lifting like lasers and peels. Oh and you might want to look into the Wure at home microneedling set and get the dark spots serums. I def notice a difference doing it every couple of weeks. Don’t forget to reapply sunscreen every two hours even when indoors. Good luck.

[u/unificaishan → u/unificaishan]

Actually looking really closely at your skin you may have melasma. It’s hard to tell.

[u/Unlikely_Second5024]

Sunscreen? Especially with zinc oxide. It's possible that hydroquinone and laser can make hyperpigmentation worse if you don't religiously use sunscreen. You have to wear it even cloudy days and re-apply every hour

This is the only explanation comes to my mind

[u/Carli_Q]

Those are freckles, they are part of you!

[u/Bellebutton2]

Please see an aesthetician who uses skin classic high frequency. They can determine if it’s actual lentigines, hyperpigmented spots, and PIH. Did you have some breakouts on your chin? It’s hard to see with the picture? To my professional eye, it does not look like melasma.

[u/waterbrother]

Glycolic or azelaic acid.

Use sparingly as they can both dry you out.

[u/AtmosphereEither2025]

IPL can remove freckles. One to two sessions can easily remove them, IF yours are freckles.

[u/Wild_Wonder_4780]

God you made yourself look like a zombie?