Melasma: causes, triggers and treatment

Melasma causes brown or gray patches on the face, most often on both cheeks, the forehead or above the upper lip. It is common, harmless and often linked to hormones and sun. It can also be stubborn. This guide explains what triggers it, how to protect your skin, and the treatments dermatologists use. It is part of Skinli's guide to hyperpigmentation.

What melasma is

The American Academy of Dermatology (AAD) describes melasma as a skin condition that causes patches and spots, usually on the face, that are darker than your natural skin tone. MedlinePlus says it appears on areas of the face that get sun. It is a type of hyperpigmentation, which means skin with extra melanin, the pigment that gives skin its color.

Melasma does not hurt or itch. The AAD says you will not feel anything on your skin. MedlinePlus says the only symptom is a change in skin color. The AAD adds that melasma can affect how people feel, and that studies show it can lower self-esteem.

What melasma looks like

The AAD lists the places melasma appears most often:

• Cheeks
• Chin
• Forehead
• Nose
• Above the upper lip

Less often, it appears on the jawline, neck or arms. The AAD says melasma on the cheeks shows on both cheeks. The patches have uneven shapes, can join into larger areas, and can include small spots that look like freckles.

The color depends on skin tone. The AAD says most people see shades of brown. On darker skin, melasma can look bluish gray. Its color list includes tan, brown, grayish brown and bluish gray.

Melasma or another dark spot?

Feature	Melasma	Marks after acne	Sun spots
Where	Both sides of the face, in patches	Where pimples were	Face, hands, shoulders and other sun-exposed skin
Shape	Blotchy patches and freckle-like spots	Small spots the size of old pimples	Small flat spots, often oval
Main triggers	Hormones, sun, visible light	Inflammation from acne	Years of sun
Guide	This page	Dark marks after pimples	Sun spots

The AAD says melasma can be mistaken for other skin conditions, so a dermatologist visit is worth it before starting treatment. A dermatologist can often tell by looking. Some use a Wood's lamp, a special light, or a dermatoscope, a magnifier held on the skin, to see how deep the pigment goes. If needed, a small skin sample, called a biopsy, can rule out other conditions.

What triggers melasma

The AAD says the cells that make skin color are more active in people with melasma, and that something seems to trigger them. Its list of possible triggers:

• Sunlight. Sun makes skin produce more melanin, which the AAD says explains why melasma appears on skin that gets the most sun.
• Pregnancy. The rise in estrogen and progesterone during pregnancy is thought to trigger melasma.
• Some medicines. Birth control pills, anti-seizure medicines, and medicines that make skin more sensitive to sunlight. The AAD names retinoids, some antibiotics and some blood pressure medicines in that group.
• Stress. Some research suggests stress may trigger melasma through the hormone cortisol. The AAD calls this link controversial.
• Tanning beds. They tend to give off stronger ultraviolet rays than the sun.
• Thyroid disease. A thyroid problem may raise the risk, and treating it sometimes clears the melasma.

MedlinePlus adds hormone replacement therapy during menopause to the list, and says melasma is more common in tropical climates.

Do not stop a prescribed medicine because you think it causes melasma. Ask the doctor who prescribed it about other options first.

Who gets melasma

The AAD says you have a higher risk if you:

• Are a woman between the ages of 20 and 40. Melasma is more common in women, though some men get it.
• Have a medium or dark skin tone. It is more common in women of Latin, Asian, Black or Native American heritage.
• Have a blood relative with melasma. In one study of 324 people with melasma, 48% had a blood relative with it.

Melasma and pregnancy

The AAD says melasma is so common during pregnancy that it is sometimes called the mask of pregnancy. MedlinePlus says it often fades over several months after the pregnancy ends, and may come back in a later pregnancy.

If you are pregnant, the AAD advises waiting until after the baby is born to treat melasma. It says the safety of non-prescription melasma products in pregnancy can be hard to know, and melasma may fade after birth anyway. Retinoids should not be used during pregnancy, per the AAD. Sun protection is safe to keep up the whole time.

Protecting your skin every day

The AAD calls sun protection one of the most common treatments for melasma. Its self-care steps:

• Protect your skin every day, including cloudy days.
• Use a broad-spectrum, water-resistant sunscreen with SPF 30 or higher on all skin that clothing does not cover. Put it on 15 minutes before going outside and reapply at least every two hours.
• Choose a tinted sunscreen that contains iron oxide. The AAD says visible light has been shown to worsen melasma, especially on darker skin, and iron oxide helps protect against it.
• Wear a wide-brimmed hat and seek shade.
• Stay out of tanning beds and never use sunlamps. The AAD says they can worsen melasma and stop treatment from working.
• Choose gentle, fragrance-free skin care. A product that burns or stings is irritating your skin, which the AAD says may darken dark spots.

For patients with melasma, the AAD says dermatologists often recommend a sunscreen with zinc oxide, titanium dioxide or iron oxide.

How dermatologists treat melasma

The AAD says there is no one best treatment. The most effective plans combine sun protection with medicine applied to the skin, and sometimes a procedure.

Treatment	What it is
Hydroquinone	A common prescription cream that evens out skin tone. The AAD says it is no longer sold without a prescription
Tretinoin with a mild steroid	A retinoid plus a medicine that calms inflammation
Triple cream	Tretinoin, a steroid and hydroquinone in one cream. The FDA says Tri-Luma, the only FDA-approved drug with hydroquinone, is approved for short-term treatment of moderate to severe melasma of the face
Gentler creams	Azelaic acid, kojic acid or vitamin C
Procedures	Chemical peel, microneedling, laser or light treatment, and platelet-rich plasma
Tranexamic acid	A cream or pill for hard cases. Tell your dermatologist if you have ever had a blood clot

The Tri-Luma label says it is for short-term use and not for keeping melasma away, and that melasma usually returns after it is stopped. In its trials, people used it once a day for 8 weeks.

Retinoids need care. A 1993 trial found that 0.1% tretinoin improved melasma in 68% of women after 40 weeks, compared with 5% on a plain cream. Improvement was slow and first showed at 24 weeks, and 88% of the tretinoin group had redness and peeling. The AAD also says some melasma treatments can irritate darker skin, which can make melasma darker. A dermatologist knows how to avoid that.

For the evidence on each ingredient, see azelaic acid, vitamin C, niacinamide and retinol and tretinoin.

How long treatment takes

The AAD says it usually takes 3 to 12 months to see results, and longer if you have had melasma for a long time. It advises treating melasma sooner rather than later, because long-standing melasma is harder to fade. On darker skin, results usually take longer.

The AAD sets one clear limit for home treatment: use a non-prescription melasma product for no longer than three to six months. If it has not helped by then, see a dermatologist. MedlinePlus also says to contact your provider for darkening of the face that does not go away.

While treatment works, makeup can cover the patches. The AAD's order is melasma medicine first, then sunscreen, then makeup. A dermatologist can give tips for a natural result. The AAD also suggests asking about cost before you start, because melasma treatment is not considered medically necessary and most insurers will not pay for it.

Melasma can come back

The AAD says treatment cannot make melasma go away forever. It often returns after time outdoors without sun protection. Daily sunscreen and a hat are part of the plan for good, even after the patches fade. For more on the role of sunscreen, read how to get rid of dark spots on your face.