Melasma is, in my experience, the pigmentation condition that frustrates patients most — because it can respond well to treatment and then quietly return. It shows up as symmetrical brown-to-grey patches, usually across the cheeks, forehead, upper lip and nose, in a fairly recognisable mask-like pattern. That symmetry is actually one of the most useful diagnostic clues: it’s rarely one-sided.

It’s seen far more often in women, particularly those with medium to deeper skin tones, and it’s strongly linked to oestrogen and progesterone — which is why it so often first appears in pregnancy (sometimes called the “mask of pregnancy”), on the combined oral contraceptive pill, or during hormone replacement therapy. UV exposure is the second half of the story: it acts as the trigger that switches on melanocytes in people who are already hormonally predisposed. A family history of melasma also raises the likelihood of developing it yourself.

What makes melasma genuinely difficult to manage is that it can sit at two depths in the skin — closer to the surface, or deeper in the dermis — and many patients have a mix of both. The deeper component is slower to respond and more prone to recurrence, which is why I’m always upfront that melasma is managed rather than “cured,” particularly without disciplined, ongoing sun protection.

PIH isn’t really its own disease — it’s the skin’s aftermath. Any inflammation or injury (a healed acne breakout, an insect bite, eczema, a burn, even a cosmetic procedure done without adequate aftercare) can leave behind a flat dark mark once the original irritation has settled. It’s not a scar in the structural sense; it’s excess melanin, deposited as a response to injury.

I see this constantly with acne — the mark that lingers for months after a pimple has actually healed. And I see it disproportionately in patients with deeper skin tones, because melanocytes in darker skin tend to be more reactive, producing melanin more readily in response to inflammation. A mark that might barely register in fair skin can become a persistent, genuinely distressing area of pigmentation in someone with a deeper skin tone. This is exactly why I’m cautious recommending aggressive laser or peel treatments to patients with richly pigmented skin without a very clear conversation about that risk first.

Freckles are the pigmentation type I most often reassure people about, because in almost every case, they need no treatment at all. They’re small, light brown or reddish spots on sun-exposed skin — the nose, cheeks, shoulders, arms — most common in people with fair skin, red or blonde hair and light eyes, linked to variants in the MC1R gene. Their signature feature is that they genuinely fade over winter and darken again in summer, which sets them apart from most other pigmentation.

Patients often ask how to tell freckles apart from sun spots. In short: freckles usually appear in childhood, are smaller and lighter, and fade seasonally. Solar lentigines tend to appear later in life, sit darker and more defined, and don’t meaningfully fade in winter. It’s common to have both at once, and occasionally something else worth a closer look — which is, again, why an in-person assessment is worthwhile if you’re unsure.

For patients who’d simply prefer fewer or lighter freckles for cosmetic reasons — and plenty of people are perfectly happy with theirs — topical vitamin C, retinoids, azelaic acid, IPL and certain laser treatments may be discussed, with suitability depending on skin type and expectations. But the single most effective thing anyone with freckles can do is protect against further sun exposure.

Dark circles are, honestly, one of the more complex things I assess, precisely because “dark circles” isn’t one condition — it’s a description that can mean several different things happening under very thin skin. Getting the cause right matters enormously, because treating the wrong type with the wrong approach won’t help, and can occasionally make things look worse.

• True pigment-based: genuine excess melanin under the eyes, often genetic or UV-related, with a brown quality — the type most responsive to topical and energy-based treatment.
• Vascular: the very thin periorbital skin allows underlying blood vessels to show through as a bluish-purple tinge. This isn’t true pigmentation, and tends to worsen with fatigue, dehydration, alcohol and poor sleep.
• Structural: volume loss around the eyes with age creates shadowing that looks like darkness but is really a contour issue.
• Post-inflammatory: conditions like eczema affecting the eye area can leave PIH behind.

Genetics play a real role too — periorbital hyperpigmentation is disproportionately common in people of South Asian, Middle Eastern, East Asian and African heritage, and tends to run in families. Systemic factors such as allergies, nasal congestion, iron deficiency, thyroid conditions and certain medications can also contribute, which is part of why I take a proper history rather than assuming it’s purely cosmetic.