Melasma

Melasma Treatment at Prescription Skin

Melasma is a common pigment condition that causes patchy brown or grey-brown marks on the cheeks, forehead, nose and upper lip. It is more frequent in women and in medium to deeper skin tones. Sunlight (including some indoor light), heat and hormones are important triggers. Melasma tends to ebb and flow rather than “cure,” so steady prevention and maintenance are key [1],[2].

What causes melasma?

The risk of developing melasma increases with increasing sun exposure. We know this because melasma is less prevalent in winter months and non-tropical areas. It is therefore believed that the underlying changes that occur with persistent sun exposure also underly the onset of melasma. The condition is believed to be caused by the overproduction of melanin by hyperfunctional melanocytes. Melanin is a skin pigment that gives us our skin and hair colour. Increased amounts of melanin are produced in response to sun exposure as it provides a natural defence against ultraviolet rays. This is the mechanism of developing a tan. Sometimes the melanin can be distributed unevenly throughout the skin, leading to blotchy pigmentation such as melasma. [1]–[5]

Aside from sun exposure, other risk factors for melasma include autoimmune thyroid disorders and medications that make your skin more sensitive to the sun. Family history appears to be a strong risk factor for melasma. Melasma can affect the epidermal layer, the dermal layer, or both. When it affects the dermal layer, it can be difficult to treat. In women, who are about 5–6 times more likely to develop melasma than men, pigmentation may fade slowly or incompletely after childbirth or when contraceptive medications are discontinued. In men, melasma can be extremely stubborn and resistant to treatment. Low testosterone levels in men may be a contributing factor. [1],[2]

Why is it worse in some people?

Severity reflects both biology and exposure. People who tan easily or spend time in strong sun or heat, or who have hormone shifts (for example during pregnancy), tend to show more colour. Visible light (the part we see) and infrared heat can deepen pigment in melasma even when UV is blocked, which is why tinted sunscreens that also block visible light can help [9]–[11].

Practical skincare and trigger management

The mainstay of melasma treatment is strict sun protection all year round. We recommend using a sunscreen with a sun protection factor (SPF) that is 30 or higher. Other methods of sun protection include wearing protective clothing and hats and avoiding direct sun exposure, especially during the critical hours of 10 AM and 2 PM when the UV index is at its highest.

There are a number of medications that can increase your risk of developing melasma, which is why it is important to provide a full list of your medications to your doctor. Oral contraceptive pills containing oestrogen are known to contribute to melasma. This is because melanocytes are responsive to circulating levels of oestrogen, leading to higher amounts of melanin secretion and increasing the risk of blotchy pigmentation such as melasma. Alternative contraception medications that don’t contain oestrogen might therefore be helpful. Additionally, a medication used to treat seizures may also increase your risk of developing melasma. [1],[2]

There is a range of topical treatments available for melasma. With the right treatments, up to 80% of people will see an improvement or complete clearance of their melasma. Most treatments are used in combination, rather than individually. As a first-line treatment solution at Prescription Skin, we typically prescribe triple topical therapy comprising hydroquinone, tretinoin and a topical corticosteroid. Used short term, topical corticosteroids are a safe and highly effective treatment. They act to block the synthesis and secretion of melanin. This treatment regimen may need to be altered if one or more of the medications are contraindicated, such as during pregnancy. A newly studied oral treatment for moderate-to-severe melasma is tranexamic acid, which also requires a prescription. [12]–[19]

NOTE: Chemical peels and lasers should be used with caution, as they can make the melasma worse or cause hyperpigmentation [20],[21].

Treatments that actually make a difference

Hydroquinone and the “triple cream”

Hydroquinone (HQ) remains a cornerstone for fading patches. The best-studied prescription option is a triple therapy option, available only by prescription. It performs better than hydroquinone alone and is available at Prescription Skin. Any regimen containing hydroquinone is used in limited courses, then stepped down to maintenance to reduce rebound or irritation [12]–[15].

Other helpful topicals

Azelaic acid and retinoids support fading and maintenance, and they feature in guidelines and systematic reviews. Consistency over weeks to months matters more than any one single product [2],[16],[17].

Tranexamic acid (TXA)

TXA can lower pigment signals. Studies and network meta-analyses support oral TXA as a useful short-term option for suitable adults under medical supervision. Topical and intradermal forms are also studied. Because TXA can affect clotting pathways, screening for risk factors is essential before use [18],[19].

Why Prescription Skin works better

Prescription plans deliver proven actives at therapeutic strength and combine them in ways that improve results while limiting irritation and relapse—typically a time-limited fade phase (for example, triple combination) followed by gentler maintenance (for example, azelaic acid or retinoid plus strict photoprotection). Because melasma relapses with light and heat, a maintenance plan is as important as the initial fade [2],[12]–[17],[20],[21].