Introduction
Melasma is a common acquired skin condition causing brown or gray-brown patches, usually on the face. Cheeks, forehead, bridge of nose, upper lip, and chin are typical locations. Patches are often symmetric.
Hormonal influences—pregnancy, oral contraceptives, hormone therapy—combine with ultraviolet exposure to trigger melanocyte overactivity. It affects far more women than men, especially with darker skin phototypes.
Melasma is benign—not skin cancer—but causes cosmetic concern and psychosocial distress. Sun exposure worsens pigmentation persistently.
Treatment blends strict photoprotection, topical lightening agents, and sometimes procedures. Recurrence is common if UV protection lapses.
Overview
Melasma has epidermal, dermal, and mixed pigment depths—Wood lamp or examination helps guide therapy.
Chloasma refers to melasma associated with pregnancy; many cases fade postpartum but may persist.
Differentiate from post-inflammatory hyperpigmentation, solar lentigines, and early lentigo maligna by exam and history.
- Hyperpigmented macules and patches on sun-exposed face
- Strong association with estrogen and UV exposure
- Women affected far more than men; common in Fitzpatrick III–VI skin
- Not contagious or cancerous
- Strict sunscreen essential to treatment success
- Topical hydroquinone, tretinoin, and triple-combination creams first line
- Laser and peel risks post-inflammatory hyperpigmentation in dark skin
- Chronic relapsing course—maintenance therapy often lifelong
What happens in the body
UV radiation and hormones stimulate melanocytes to produce excess melanin and transfer pigment to surrounding keratinocytes. Visible macules reflect increased melanin at epidermal or dermal level.
Inflammation from light or cosmetics can worsen pigmentation. Relapse follows new UV exposure because melanocyte hyperactivity persists subclinically.
- UV plus hormones upregulate melanogenesis
- Epidermal melasma responds better to topicals than deep dermal pigment
- Inflammatory cascades amplify pigment after skin injury
- Visible light (not just UVB) can worsen melasma—broad protection needed
Signs and symptoms
Primary feature is cosmetic pigmentation without physical illness:
- Irregular brown or gray patches on cheeks and forehead
- Symmetric facial distribution
- Darkening in summer or after sun exposure
- Minimal itching unless coexisting dermatitis
- Cosmetic distress and self-consciousness
- Makeup coverage difficulty when patches darken
- Persistence despite over-the-counter fade creams
- Worsening on oral contraceptive initiation
- Postpartum persistence after pregnancy-related melasma
- Border accentuation after irritant skin products
- Psychological impact—anxiety or reduced social engagement
- No systemic fever, pain, or rapid growth (unlike melanoma)
Causes and risk factors
Melasma arises from pigment overproduction triggers:
- Ultraviolet and visible light exposure—primary exacerbating factor
- Pregnancy hormonal changes (chloasma)
- Oral contraceptive pills and hormone replacement therapy
- Genetic predisposition—family history common
- Darker skin phototypes with active melanocytes
- Cosmetics or fragrances causing photosensitivity in some
- Thyroid disease association in some studies
- Not infectious or allergic in typical melasma
- LED screen exposure hypothesized contributor—research ongoing
- Stress may worsen via picking or inconsistent sun protection habits
Diagnosis and evaluation
Diagnosis is clinical; exclude mimics:
- Characteristic symmetric facial hyperpigmentation pattern
- Patient history of pregnancy, hormones, sun, and cosmetics
- Wood lamp exam distinguishing epidermal vs dermal pigment accentuation
- Dermoscopy to exclude lentigo maligna and nevi
- Skin biopsy rarely needed if diagnosis clear
- Differentiation from post-inflammatory hyperpigmentation after acne or eczema
- Assessment of Fitzpatrick skin type guiding procedure risk
- Thyroid screening if clinically indicated—not routine for all
Treatment and management
Sun protection plus topical therapy is foundation:
- Daily broad-spectrum SPF 30+ with iron oxide for visible light—reapply outdoors
- Topical triple combination (hydroquinone, tretinoin, fluocinolone) short-term under supervision
- Non-hydroquinone agents—azelaic acid, kojic acid, tranexamic acid topically or oral
- Chemical peels (glycolic, TCA) in selected skin types with specialist
- Microneedling and low-fluence lasers with caution in dark skin
- Discontinue or switch hormonal contraception when feasible and desired
- Cosmetic camouflage makeup for immediate psychosocial relief
- Maintenance regimen after clearance to prevent relapse
- Treat underlying acne or dermatitis to avoid post-inflammatory darkening
Prevention, self-care, and lifestyle
Not every condition is fully preventable, but the steps below may lower risk or recurrence:
- Strict lifelong photoprotection—even brief exposure retriggers melasma
- Wide-brim hat and shade during peak sun hours
- Non-hormonal contraception if melasma linked to OCPs and recurrence unacceptable
- Gentle skin care avoiding irritants that inflame skin
- Continue maintenance topicals and sunscreen after successful treatment
Possible complications
Delay, missed care, or unsafe self-medication can raise the chance of complications in some cases:
- Persistent cosmetic disfigurement affecting quality of life
- Post-inflammatory hyperpigmentation from aggressive peels or laser in dark skin
- Depression or social anxiety related to appearance
- Frustration from recurrence after stopping maintenance
- Ochronosis rare from prolonged high-concentration hydroquinone misuse
- Misdiagnosis delay if lentigo maligna not considered on sun-damaged skin
When to see a doctor or seek emergency care
Seek prompt medical advice or emergency care if any of the following apply—it is safer not to wait and see:
- Pigment lesion with irregular border, rapid growth, or bleeding—exclude melanoma
- Melasma not improving after 3–6 months of prescribed therapy and sun protection
- Desire for pregnancy-safe treatment planning
- Need for procedure with dermatologist experienced in skin of color
- Psychological distress requiring counseling referral
Living with the condition
Treat sunscreen like toothpaste—daily application rain or shine, indoor near windows too.
Photograph patches monthly in same lighting to judge treatment response objectively.
Set realistic goals—melasma control is goal; perfection may be unrealistic with hormonal triggers ongoing.
Frequently asked questions
Will melasma go away after pregnancy?
Some cases fade within months postpartum; many persist and need treatment and sun protection.
Is melasma cancer?
No. It is benign pigmentation. New changing dark lesions still need evaluation to exclude melanoma.
Can men get melasma?
Yes, though less common. Sun exposure and genetics still play roles.
Are lasers safe for dark skin?
Special settings and experienced providers are essential; wrong lasers cause worsening pigmentation.
Does SPF in makeup suffice?
Usually not enough quantity applied—dedicated sunscreen layer recommended.
Can I use hydroquinone forever?
Long-term continuous hydroquinone is discouraged due to irritation and ochronosis risk—cycl under dermatologist supervision.
Important caution
This page is general dermatology education, not a personal treatment prescription.
Melasma management requires consistent photoprotection and professional guidance for topicals and procedures.
Seek prompt dermatology evaluation for any pigmented lesion that changes asymmetrically or bleeds.