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Melasma

Melasma is a skin disorder causing blotchy pigmentation. There is no cure but it can be managed. Read on to find out more.

Melasma

Melasma


Melasma is a pigment problem due to sun and light damage causing brown patches of skin. 


It mainly affects the face but can also occur on the forearms and back (sun-exposed areas).


Melasma is called a “relapsing” pigment condition, meaning it comes and goes.


How common is melasma?


Melasma affects about 1 in 100 people worldwide.


It tends to start between the ages of 20 and 40 years.


Effects of melasma


As a result of melasma frequently involving the face, melasma has a significant impact on day-to-day life.


People affected by melasma report feelings of shame and reduced self-confidence. It can also negatively impact relationships and work.


As yet, there is no cure, so it has to be managed. It is also likely to return.


What causes melasma?


The cause of melasma is unknown. It is more common in women.


What are the risk factors for melasma?


The main risk factors for melasma include:


Sun exposure


Avoiding the sun is vital if you suffer from melasma.


Pregnancy


Melasma can start during pregnancy due to the effect of changing hormone levels.


Certain skin types


People with darker skin tones tend to be at more risk.


Race


People from Asia (40%) and Latin America (9-30%) get melasma more.


Family history


It is common for melasma to run in families, with over half having someone else affected. This suggests there are genes or genetics involved.


Hormones


The hormones oestrogen and progesterone may also cause melasma.


The risk increases during pregnancy and if you are taking the Oral Contraceptive Pill.


Thyroid disorders are also linked to the condition.


Medicines


Certain medications can trigger melasma, even ingredients in soaps and cosmetic products.


Heat


Exposure to heat may also be linked to the development of melasma.


How common is melasma?


Melasma is, unfortunately, very common and affects between 10% and 40% of people, depending on where you live.


What areas does melasma affect?


Melasma usually affects both sides of the face equally, such as the cheeks, upper lip, forehead and jawline.


Will melasma go away?


Sometimes melasma does go away on its own. If you have melasma, however, expect it to last 20 years or more.


What is the best treatment for melasma?


Improvement of melasma tends to be slow. So there is no quick fix.


The longer someone has had melasma, the less likely it will respond.


Treatments are often disappointing, and the pigmentation usually returns, meaning an ongoing maintenance programme (and avoiding the sun) is necessary.


Treatment often requires multiple approaches. 


General management measures


There are many rules to self-manage melasma.


  • Always use sun protection strategies such as wearing a broad-brimmed hat when outdoors.

  • Limit exposure to the sun during the peak hours.

  • Use a broad-spectrum SPF 50+ sunscreen with protection rom ultraviolet A (UVA), UVB and visible light, applied to the whole face daily, year-round. 

  • Sunscreens containing iron oxides are preferred, as they screen out some visible light and ultraviolet radiation. All tinted makeup products contain iron oxide. 

  • Decreasing heat exposure at home and work.

  • Use a mild cleanser. If the skin is dry, use a non-perfumed moisturiser.

  • Use cosmetic camouflage to disguise the pigment.

  • Concealers can be used as thick, more opaque foundation makeup.

  • Colour correctors can be used to tone down pigmentation.

  • Consider discontinuation of hormonal contraception.


Sun protection using iron oxide sunscreens


Melasma requires strict sun avoidance.


Protection against UVB, UVA, and blue-violet visible light using a broad-spectrum tinted sunscreen is essential.


Treatments for Melasma


Other treatments are the same as other causes of pigmentation, which are discussed on our pigmentation treatment webpage.


Most treatments aim to reduce pigment formation.


Hydroquinone


Hydroquinone (HQ) has been used extensively to treat melasma.


HQ remains the gold standard in treating melasma, although its use has become restricted and must be prescribed. 


Mequinol is a new derivative of hydroquinone.


Triple Combination therapy.


This is effective in 60-80% of people.


The combination used most is “Kligman's formula” which contains hydroquinone, tretinoin and dexamethasone (a steroid).


Hydroxy Acids (HAs)


Hydroxy acids are also useful in treating melasma and can be used in topical skin products.


Examples include:


  • Azelaic acid

  • Kojic acid


Antioxidants


These stop harmful oxygen free radicals which cause the inflammation associated with pigmentation.


Vitamin E (α-Tocoferol acetate)

Vitamin C (Sodium ascorbyl phosphate, Ascorbyl Palmitate, Ascorbyl Glucoside)


Tranexamic acid


Tranexamic acid (TXA) has good evidence of effectiveness in treating melasma.


It can be given by mouth, as a drip or topical product. 


How it works is unknown.


Glutathione


Glutathione is an antioxidant and usefully switches the conversion of eumelanin (dark brown) to pheomelanin (lighter brown).


Glutathione is used topically (cream, face wash, soap, lotion) as a chemical peel, by intradermal injection  (mesotherapy), and orally.


Tretinoin (retinoids)


Tretinoin (0.05%– 0.1%) treats melasma but needs at least 24 weeks for clinical improvement.


Retinoids increase skin turnover and prevent pigment formation but can be irritating, which is why they are combined with steroids.


Steroids


Steroids are used in combination with other treatments.


The mechanism for their skin-lightening effect remains poorly understood.


Cysteamine


Cysteamine is a new skin-lightening treatment with few adverse effects.


Cysteamine works as an antioxidant and stops the transfer of pigment to the surrounding skin.


Chemical peels


Almost all types of chemical peel have been used to treat melasma, such as:


  • Glycolic acid

  • Trichloroacetic acid (TCA)

  • Jessner's

  • Salicylic acid 

  • Lactic acid 


When using peels in darker skin types, caution is needed to prevent post-inflammatory pigmentation (PIH or PIPA).


See our page on PIPA.


Other treatments that help with melasma


Microneedling 

Chemical peels

LED


References

Mahajan, VK, Patil, A, Blicharz, L, et al. Medical therapies for melasma. J Cosmet Dermatol. 2022; 21: 3707- 3728. doi: 10.1111/jocd.15242

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