Melasma

What melasma looks like

• flat, light to dark brown or gray-brown patches
• symmetrical, usually on both sides of the face
• common patterns: centrofacial (forehead, nose, upper lip, chin), malar (cheeks and nose), and mandibular (along the jawline)
• sometimes on the forearms, neck or chest
• no itching or pain
• worse in summer and better in winter

What causes melasma

Pigment cells (melanocytes) in the skin become overactive and produce excess melanin. Contributing factors:

• Sunlight: ultraviolet light and visible light (including blue light) are major triggers. Even brief exposure can darken melasma.
• Hormones: pregnancy, birth control pills, hormone replacement therapy.
• Genetics: many people have a family history.
• Skin type: more common in people with darker skin, including those of Latin American, Asian, Middle Eastern, North African and South Asian descent.
• Heat: cooking, saunas and hot climates may worsen it.
• Cosmetics and medicines: irritating or scented products, some anti-seizure medicines and photosensitizing drugs.
• Thyroid disease may be associated in some people.

Melasma vs other dark spots

Any single, irregular, changing dark patch should be checked by a dermatologist.

Diagnosis

A dermatologist diagnoses melasma by examining the skin. A Wood's lamp (ultraviolet light) or dermatoscope helps show how deep the pigment lies. A biopsy is rarely needed, except to rule out other conditions.

Treatment

Treatment takes months, and melasma often returns, so ongoing maintenance is needed.

Sun protection (essential)

• Broad-spectrum sunscreen with SPF 30 or higher, applied every morning and reapplied every 2 hours outdoors.
• Tinted sunscreen with iron oxides blocks visible light, which plain sunscreen does not.
• Wide-brimmed hats and shade.

Without strict sun protection, other treatments work poorly.

Topical treatments

• Hydroquinone (2 to 4%): the most established lightening agent. Use under medical guidance and usually in cycles, because long-term use can rarely cause exogenous ochronosis (blue-black darkening).
• Triple-combination cream: hydroquinone, tretinoin and a mild steroid; very effective for short courses.
• Azelaic acid, kojic acid, niacinamide, vitamin C, cysteamine and tranexamic acid creams: alternatives or maintenance options.
• Retinoids such as tretinoin.

Oral treatment

Tranexamic acid tablets taken daily can significantly improve moderate to severe melasma. They are prescription-only and not suitable for people with a history of blood clots or certain other conditions.

Procedures

• Chemical peels (glycolic or salicylic acid)
• Microneedling with lightening agents
• Lasers and intense pulsed light: used cautiously, because they can worsen melasma, especially in darker skin.

Pregnancy

Melasma that appears during pregnancy often fades within months of giving birth. Many treatments, including hydroquinone, retinoids and tranexamic acid, are usually avoided during pregnancy. Sun protection and azelaic acid are generally considered safe options; check with your doctor.

Outlook

Melasma is chronic and recurrent for many people, but it can be lightened substantially. Consistent sun protection is the most important long-term measure.

Frequently asked questions

What causes melasma?

Melasma is caused by overactive pigment cells, triggered by sunlight and visible light, hormones from pregnancy or birth control pills, genetics and heat. It is most common in women with medium to darker skin tones.

Does melasma go away?

Melasma linked to pregnancy or the pill may fade after delivery or stopping the pill. Other melasma usually lasts for years but can be lightened with treatment. It often returns with sun exposure, so maintenance is needed.

What is the best treatment for melasma?

Daily tinted broad-spectrum sunscreen plus a lightening cream such as hydroquinone or a triple-combination cream is the standard first treatment. Azelaic acid, tranexamic acid, chemical peels and other options help some people.

Is melasma dangerous?

No. Melasma is harmless and not related to skin cancer. However, a single irregular or changing dark patch should be examined to rule out other conditions.