Melasma

What Is Melasma and Why Does It Happen?

Melasma is a common pigmentation disorder that causes dark, discoloured patches on the skin, most often on the face, including the upper lip, cheeks, and forehead. It is sometimes called "the mask of pregnancy" because hormonal changes during pregnancy are one of the most well-known triggers.[1] But pregnancy is far from the only cause. Hormonal factors, particularly higher levels of oestrogen and progesterone, are significant contributors, and women are far more likely to develop melasma than men.[1] The oral contraceptive pill, hormone replacement therapy, and other hormonal medications can all initiate or worsen melasma.

Excessive sun exposure is another major driver. UV light stimulates the pigment producing cells (melanocytes) in your skin, ramping up pigment output and making melasma pigmentation darker and more widespread.[4] Light in the visible spectrum also plays a role, which is why standard sunscreens alone are sometimes not enough. Even extended occupational heat exposure, like working near ovens or in hot environments, can worsen melasma.

Genetic predisposition matters too. If you have a family history of this skin condition, you are more likely to develop melasma yourself, particularly if you have darker skin tones where increased melanin production is stimulated more readily by UV rays.[1] People with deeper skin types (Fitzpatrick skin types III to VI) are especially prone to develop melasma. It is also worth noting that prolonged sun exposure without adequate protection significantly increases your risk of skin pigmentation issues and even skin cancer over time.

How Is Melasma Diagnosed?

Melasma diagnosed by a dermatologist is usually straightforward. The colour and pattern of the brown pigmentation on your face, particularly across the upper lip and cheeks, is often enough for a clinical diagnosis. In some cases, a dermatologist may use a specialised light called a Wood's lamp to assess pigmentation depth and determine whether you have epidermal melasma (pigment in the upper skin layers), dermal melasma (pigment deeper in the skin), or mixed melasma (a combination of both). Sometimes a small biopsy is necessary to confirm the diagnosis and rule out other pigmentation disorders.

Understanding your melasma type is important because it directly influences your treatment plans and how best to treat melasma in your case. Epidermal melasma tends to respond well to topical creams and chemical peels, while dermal melasma is more stubborn and may require multi-agent approaches. Mixed melasma, which is the most common form, often needs a layered strategy to treat melasma effectively across multiple levels of pigment depth.

Sun Protection: The Foundation of Every Melasma Treatment

Let me be direct about this: sun protection is the most critical element in the treatment of melasma. Without it, nothing else you do will hold. UV light and shorter wavelength light both trigger melanin production, and even brief, unprotected sun exposure can undo weeks of progress.[6][7]

Daily use of a broad spectrum sunscreen rated SPF 50+ is essential for managing melasma and preventing its recurrence after treatment. But here is the thing most people miss: standard sunscreens only block UV light. To properly protect against visible light (a major trigger), you need a tinted sunscreen.[8] Tinted sunscreens have been shown to significantly improve melasma outcomes compared to UV-only sunscreens.[6]

Beyond sunscreen, you should avoid excessive sun exposure where possible. Wear a wide-brimmed hat, seek shade during peak UV hours, and be mindful that heat itself can worsen melasma. Strict sun protection improves the effectiveness of every other treatment for melasma you may be using.

Topical Treatments: First-Line Melasma Treatment

Topical prescription creams are the first-line approach used to treat melasma and the starting point for most treatment plans. These work by reducing pigment production, promoting skin cell turnover, and gradually lightening the skin pigmentation that makes this skin condition so visible. Understanding the right ingredients to treat melasma is key to getting results.

Hydroquinone

Hydroquinone is considered the gold standard for treating hyperpigmentation. It works by inhibiting an enzyme called tyrosinase, which is essential for melanin production. This effectively slows down the pigment producing cells, helping to lighten pigmentation over time. Hydroquinone is one of the most effective treatments for reducing the appearance of melasma by decreasing pigment production.[2] It is typically used in concentrations of 2% to 4% and is available by prescription in Australia. If you are curious about the differences, check out our guide on hydroquinone 2% vs 4%.

Triple Combination Cream (Kligman's Formula)

The triple combination cream includes hydroquinone, tretinoin, and a mild corticosteroid. This combination therapy is backed by strong evidence and is more effective than using any single ingredient as a stand alone treatment.[9][10][11] The tretinoin boosts skin cell turnover and helps the hydroquinone penetrate more effectively, while the corticosteroid reduces skin inflammation and the risk of skin irritation. Studies in both Western and Asian populations have shown this triple therapy to be superior to hydroquinone alone for moderate to severe melasma.[12]

Azelaic Acid

Azelaic acid is an effective alternative for those who cannot tolerate hydroquinone or who need a longer-term option. Azelaic acid works by inhibiting tyrosinase (similar to hydroquinone) and also has anti-inflammatory properties, making it a good choice for those prone to skin inflammation or irritation.[13][14] Azelaic acid is particularly well suited for darker skin tones because it carries a lower risk of causing post-inflammatory changes. It can be used as a stand alone treatment for mild melasma or added into a broader treatment plan.

Vitamin C and Other Lightening Agents

Vitamin C (ascorbic acid) is a potent antioxidant that helps reduce pigmentation and protect against UV damage. While vitamin C alone is unlikely to clear melasma entirely, it is a valuable addition to treatment plans, helping to brighten skin tone and prevent worsening pigmentation. Vitamin C works well alongside other topical treatments and is gentle enough for most skin types.

Niacinamide is another ingredient worth considering. It helps reduce pigmentation by blocking the transfer of melanin to skin cells. Kojic acid is also commonly used to treat melasma. Kojic acid inhibits tyrosinase and can help fade melasma pigmentation, though it may cause skin irritation in some people. Kojic acid works well in combination with other topical agents and can be a good option for those looking for hydroquinone-free alternatives.

Chemical Peels for Melasma Treatment

Chemical peels can help reduce pigmentation in melasma when performed as part of a dermatologist-led melasma treatment programme.[5] They work by removing the outer layers of skin, encouraging turnover, and shifting melanin deposits upward so the skin heals with a more even skin tone. Chemical peels can speed up improvement and work particularly well alongside topical agents to treat melasma more comprehensively.

Glycolic Acid Peels

Glycolic acid is one of the alpha hydroxy acids most commonly used in chemical peels for melasma. These peels work by exfoliating the surface of the skin, improving skin texture, and helping to reduce pigmentation. Glycolic acid is generally well tolerated, though care is needed with deeper complexions to avoid post-inflammatory hyperpigmentation.

Lactic Acid Peels

Lactic acid peels are another option within the alpha hydroxy acids family. They tend to be gentler than glycolic acid, which makes them a good choice for those with sensitive or deeper complexions. They can help lighten pigmentation and improve skin texture without excessive irritation.

Salicylic Acid Peels

Salicylic acid peels are sometimes used for people with melasma who also have acne-prone skin. Salicylic acid is a beta hydroxy acid that penetrates into the pores, making it useful for addressing both acne and melasma pigmentation. It can also help improve overall skin texture.

Regardless of the type, chemical peels should always be performed by an experienced practitioner. Chemical peels can worsen melasma if the wrong type or strength is used, particularly for darker skin types. Choosing a clinic with experience in treating pigmentation concerns across different skin tones is essential.

Laser Treatments for Melasma

Laser treatments can be an effective way to treat melasma, particularly for resistant melasma that has not responded to creams and chemical peels alone. However, laser treatments need to be approached with caution. When used incorrectly, they can trigger skin inflammation and actually worsen melasma.[18]

Pico lasers are more effective for clearing melasma pigmentation compared to older fractional and Q-switch lasers. They deliver energy in ultra-short pulses, which breaks apart pigment with less heat and lower risk of worsening pigmentation or rebound. Laser works well as part of a broader treatment approach, often combined with topical agents and sun protection.

That said, laser treatments are generally not a stand alone treatment for this skin condition. Results can vary, and recurrence is common without ongoing maintenance.[18] A good practitioner will use laser as one piece of a broader melasma treatment plan, not a quick fix. This is a minimally invasive procedure, but it still requires proper assessment of your skin tone and melasma type before going ahead.

Patients should always inquire about the types of lasers used by a clinic. Laser treatments for deeper complexions require particular expertise to avoid complications. If you have a deeper complexion, look for a clinic that has specific experience with melasma treatment for your skin tone.

Tranexamic Acid: A Game-Changer for Stubborn Melasma

Tranexamic acid has emerged as an effective melasma treatment option for moderate to severe cases.[15][16] It works by reducing pigment production through a different pathway than topical agents, making it a valuable addition to treatment plans for melasma patients who are not seeing enough improvement with creams alone.

It is typically prescribed at low doses and should always be taken under medical supervision due to potential blood clot risks. It is not suitable for everyone, so your doctor will assess your medical history before prescribing. It can also be used topically, though the oral form appears to be more effective for resistant melasma cases.[17] Tranexamic acid represents a meaningful step forward in how we treat melasma, especially for those who have not responded to other approaches.

How to Manage Melasma Long-Term: Maintenance Therapy

Here is something important to understand: melasma is a chronic skin condition that cannot be permanently eliminated. It often recurs if triggers like sun exposure, hormonal changes, or hormonal medications are not managed effectively. This means that even after your melasma has faded significantly, ongoing maintenance is usually necessary to manage melasma long-term.

Maintenance therapy might include continued use of a broad spectrum sunscreen, intermittent use of prescription formulas like azelaic acid or vitamin C, and regular skin reviews with your doctor. Some patients benefit from periodic chemical peels or low-dose oral medication to keep things under control.

A personalised treatment plan is essential for effective melasma management. Your treatment plans should evolve over time as your skin responds and as your circumstances change. For example, if you are planning a pregnancy, your doctor will adjust your treatment regimen to avoid ingredients that are not safe during that time. We have a helpful guide on prescription skincare during pregnancy if that is relevant for you.

Darker Skin Tones and Melasma Treatment

Melasma is often more pronounced in individuals with darker skin tones due to increased melanin production stimulated by UV rays. Choosing the right approach to treat melasma for deeper complexions requires particular care, because many treatments carry a higher risk of post-inflammatory hyperpigmentation or uneven lightening.

It is important to consider a clinic's experience with different skin types, especially darker skin tones. Certain chemical peels, laser therapies, and even some prescription formulas need to be adjusted to avoid excessive pigmentation or skin irritation. Azelaic acid, kojic acid, and vitamin C are generally safer options, while higher-strength glycolic acid peels and aggressive laser therapies need more cautious use.

Treatment plans should always start conservatively and build up gradually, monitoring how the skin heals at each stage. Improving skin texture and reducing pigmentation is absolutely achievable, but it requires an experienced practitioner who understands the nuances.

What Melasma Patients Should Know About Treatment Timelines

Visible improvement from melasma treatment usually takes several weeks to months, depending on your treatment plan and how consistently you stick with sun protection. This is not something that clears overnight. Most people start to see a noticeable difference in their melasma pigmentation around the 12 to 16 week mark with consistent treatment.

It is also worth knowing that melasma can worsen before it gets better, especially in the early stages of treatment as cell turnover increases. Do not be discouraged. Trust the process and keep in close contact with your treating doctor so your treatment plans can be adjusted as needed. If you are just starting on prescription skincare, our guide on the first 8 weeks gives you a realistic sense of what to expect.

Camouflage makeup can mask the appearance of melasma while you are undergoing treatment, and there is absolutely nothing wrong with using it. Managing how you feel about your skin while waiting for treatments to work is just as important as the treatments themselves.

How to Fade Melasma: Building Your Treatment Plan

The best approach to fade melasma combines multiple strategies. Clinics should offer a multimodal approach to melasma treatment, combining various therapies for the best outcomes. Here is a general framework for how to treat melasma effectively:

1. Sun protection: Daily broad spectrum sunscreen (SPF 50+, tinted with iron oxide), protective clothing, and efforts to avoid excessive sun exposure.
2. Topical agents: Start with prescription topical creams. Triple combination cream is the most evidence-based first-line option to treat melasma. Alternatives include azelaic acid, kojic acid, and vitamin C.
3. Adjunctive therapies: Add chemical peels (glycolic acid, lactic acid) and consider microneedling to enhance absorption of topical treatments and further improve skin texture.
4. Oral medications: For moderate to severe or recurrent melasma, tranexamic acid may be prescribed orally.
5. Laser: For resistant melasma not responding to the above, laser (pico lasers preferred) can be considered as a minimally invasive procedure.
6. Ongoing maintenance: Sun protection, intermittent topical agents, and regular reviews to prevent recurrence.

Melasma treatment can worsen if not performed properly, which is why expert guidance matters. Consultations with a dermatologist or experienced prescribing doctor are crucial to determine the most suitable treatment for melasma. A thorough assessment of the type and depth of your melasma should happen before any treatment begins, and you should receive a clear explanation of expected outcomes and potential side effects.

Melasma can be triggered or worsened by hormonal changes, excessive sun exposure, birth control pills, hormone replacement therapy, and certain skincare products. Addressing these triggers alongside active treatment for melasma is key. If you are taking the oral contraceptive pill or birth control pills and noticing worsening pigmentation, speak with your doctor about whether switching medications might help reduce pigmentation and manage your skin condition more effectively.