Introducing: Literally Everything You Ever Wanted to Know About Melasma

Main image – Lubyaburakova/Stocksy

If you’ve noticed your skin showing up brown or greyish patches that just won’t quit, you may have a skin condition called melasma.

But don’t worry, you are definitely not alone. Because melasma is extremely common. Unfortunately it is also extremely stubborn. So stubborn in fact that experts confess the condition isn’t completely fixable and can even be made worse by simply stepping into the sunshine. Sigh.

So it’s no wonder melasma sufferers feel frustrated when it comes to this chronic skin condition, particularly if they don’t have access to private dermatologists or medical grade treatments and skincare.

Thanks to a team of brilliant experts though, the journey to understanding your melasma a little bit better starts here.

Dermatologists Dr Sina Ghadiri, Dr Hannah Kopelman, Dr Shereene Idriss, and Dr Jeanine Downie, as well as Dr Dan Marsh and Dr Mo Akhavani of The Plastic Surgery Group, are here to debunk everything you ever wanted to know about melasma and make you feel a little less worried/alone/confused/all of the above.

What is melasma? What causes it? How can you keep it under control? And what should you be doing day to day to help maintain the benefits of what you’re treating it with? Keep scrolling to find out.

 

---

What is melasma?

“It is severe hyperpigmentation that typically affects the face, neck, chest and arms,” explains Dr Downie. “While it is more common in women, it can also appear in men. The dark patches look like tea stains on the skin.”

 

 

Dr Marsh adds “It’s sometimes called ‘the mask of pregnancy’ and it occurs when the body has overactive melanocytes, these are the cells that produce melanin pigmentation.”

Dr Kopelman keeps it simple. “I often describe it as your skin being extra sensitive to light and hormones—it just wants to pigment,” she says. “It’s not dangerous, but it can be really emotionally frustrating, especially when it feels like it shows up overnight.”

 

---

What causes it?

Stress can be a trigger for melasma but it’s mainly hormonal fluctuations and/or big lifestyle changes like pregnancy that actually cause it.

“Melasma loves to make a dramatic entrance on women in their reproductive years, especially those with medium to darker skin tones,” warns Dr Idriss.

It can depend hugely on genetics too. “Unfortunately, if you’ve got a family history of melasma, you may already be genetically predisposed – thanks, Mom,” Dr Idriss adds.

There are also things that can trigger a melasma flare up. “Melasma is multifactorial, and sun always makes it worse,” warns Dr Downie. “Even hot ovens can exacerbate melasma. So, it is sun, heat, and stress that mainly aggravate it.”

 

---

How do you know if you have it?

Melasma is one of the sneakiest skin conditions. “The biggest clue is that melasma is totally asymptomatic—you don’t feel anything. No itching, no burning, no bumps. It’s just these flat patches of pigment that often look symmetrical on the face,” says Dr Kopelman.

“I’ve had so many patients come in thinking it’s sun damage or post-acne discolouration, but melasma has a kind of soft, patchy look to it. I always tell people: if the pigmentation seems to darken in the summer or after a hot yoga class, that’s a big hint it could be melasma.”

 

 

Try not to jump to conclusions though. “I still always recommend a proper diagnosis by a dermatologist – there are a few lookalikes that require a different approach,” she adds.

 

---

Can you ever really get rid of it permanently?

Unfortunately melasma is as stubborn as it is sneaky.

“Melasma is one of those chronic conditions that tends to wax and wane,” says Dr Kopelman. “I’m always honest with my patients: We can absolutely lighten it and manage it well, but there’s no true ‘cure.’”

So, despite treatment, it often reappears. “This is due to the fact that it is caused by a number of factors including hormonal changes, sun exposure, genetic predisposition and even certain medications,’ adds Dr Marsh. 

 

---

The OTC skincare solutions

So, whilst melasma isn’t something you can fix, it is something you can treat. If the thought of a prescription or an in-office treatment doesn’t appeal, there are over the counter options available. 

The first step is to up your SPF game. “Wear sunblock every day with an SPF of 30 or more and reapply it,” advises Dr Downie. “Broad-spectrum protection, including UVA, UVB, blue light protection, and infrared protection, is critical.”

“Using skincare products that contain antioxidants such as Vitamin C and E can also help to protect the skin against damage, and avoiding harsh scrubs and peels is advisable as these can make melasma worse,” says Dr Marsh. 

 

 

Whilst Dr Downie believes that over-the-counter medications don’t treat melasma as well as in-office treatments, he has a few recommendations in case this is your preferred method. 

“Cyspera 5% and 7% are some of my main treatments for melasma,” he says. “I recommend patients use it every other night for 15 to 30 minutes on unwashed skin when they get home from work. Afterward, they should rinse it off, reapply sunscreen regardless of the time, and continue with their usual skincare routine.”

Other treatments he recommends are, “topical tranexamic acid as found in ZO brightalive, Alastin A-LUMINATE and SkinMedica Even & Correct. And ZO Pigment Control and Blending Creme, the Obagi C-Clarifying Serum and the AlphaRet Exfoliating Peel Pads” (although Dr Marsh advises against peels in general so do a patch test first and proceed with caution).

Dr Idriss believes combining an over-the-counter routine with prescription is key. “You need a targeted over-the-counter routine in addition to prescription treatment – that combo is the gold standard,” she says. 

“Prescription creams like hydroquinone can be incredibly effective, but they’re not meant for long-term use. You’ll need to cycle off, which is exactly why your at-home routine matters so much.”

 

 

She suggests using the Dr Idriss Major Fade Solution System which contains 12 brightening ingredients.

Dr Akhavani adds, “actives such as niacinamide treat it by reducing the melanosome transfer in the skin. Because melanosomes are the cells that transport and create melanin, when their processes are impacted then dark spots can be lightened.” So, how long can we expect to see results? “These can start to take effect within as little as four weeks, however noticeable results tend to take longer, for example a few months until you will notice significant visible signs of change.’

 

---

The prescription solutions

The middle ground is to ask for a prescription but, like most prescriptions, they can’t last forever.

“Of course, the duration of prescription melasma treatments can vary depending on the severity of the condition and the specific product/regimen used,” says Dr Ghadiri. Here are your options:

Tretinoin

Dr Ghadiri says you can use tretinoin to treat melasma, however “it is generally less effective as a standalone treatment,” he says.

“While tretinoin is often included as part of a combination regimen for initial clearance, it is most commonly used long-term as a maintenance therapy to help sustain results. When used alone, it may gradually improve melasma, but the effects tend to be modest and progress more slowly, making it less suitable as a sole treatment for moderate to severe cases.” 

How long should you use it for? “For ongoing maintenance, tretinoin is often well-tolerated and can be continued at least a few times per week. This can be effectively paired with agents like azelaic acid for long-term pigment control,” Dr Ghadiri explains.

 

Oral tranexamic acid

“Oral tranexamic acid is complicated and if you have any blood issues, platelet problems, blood clotting problems or cancer it is not recommended,” says Dr Downie. It’s different for everyone though. “I only recommended on a case-by-case basis.” 

“I actually do use oral tranexamic acid for certain patients with stubborn or relapsing melasma, especially when topical options haven’t been enough,” says Dr Kopelman.

“It works by reducing the vascular component of melasma and suppressing melanocyte activity through its antifibrinolytic mechanism. When used appropriately, it can be quite effective, often improving pigmentation within a few months.” 

So how much should you take? “I typically prescribe a low dose – usually 250 mg twice daily – and monitor for side effects like headache or menstrual irregularities,” she explains.

And she agrees with Dr Downie. “It’s not for everyone: I avoid it in patients with a personal or family history of clotting disorders. It’s most effective when paired with a strong topical routine that includes sunscreen, vitamin C, and a pigment-regulating agent like hydroquinone or cysteamine.”

 

Hydroquinone (HQ)

“Hydroquinone remains one of the most studied and reliable topical depigmenting agents for melasma,” explains Dr Kopelman.

“On its own, it works by inhibiting the enzyme tyrosinase, which limits melanin production in the skin. Patients often see improvement within 8–12 weeks when using a 4% concentration. The benefit of using it alone is that it gives you a clear sense of how it’s working without other variables.”

But be warned, taking HQ on its own can cause quite severe side effects, particularly in the first few weeks. “Common reactions include irritation, such as redness, stinging, dryness, and peeling. Some individuals may also develop allergic or contact dermatitis – particularly to the constituent metabisulphite,” warns Dr Ghadiri. 

 

 

“If applied incorrectly or too aggressively, HQ can lead to post-inflammatory hyperpigmentation (PIH), and with prolonged use, especially at concentrations above 4% or in individuals with darker skin tones, there is a rare risk of developing ochronosis, a bluish-black discolouration of the skin – and this is something we counsel patients on extensively as it is extremely hard to improve.” 

“I typically prefer combining it with other agents (like tretinoin and a mild steroid) to reduce inflammation and enhance results while minimising side effects,” Dr Kopelman adds.

“Still, even as monotherapy, hydroquinone can offer significant visible improvement — especially in patients who are also diligent with sun protection.”

 

Triple combination cream – hydroquinone, tretinoin and steroids

According to Dr Ghadiri, HQ can be used as part of a triple combination that includes tretinoin and a corticosteroid, however the risks listed above “may be compounded by steroid-related side effects,” he says.

“These can include skin thinning (atrophy), the appearance of visible blood vessels (telangiectasia), acne-like breakouts, and perioral dermatitis.

“Additionally, improper or abrupt discontinuation of the cream may lead to rebound hyperpigmentation, making careful and supervised use essential.”

The triple combination is more effective than using just tretinoin and HQ individually though.

“Triple combination remains a gold standard at present for melasma management,” explains Dr Ghadiri. “The addition of a corticosteroid plays a key role by reducing inflammation and irritation, which in turn improves skin tolerance to both hydroquinone and tretinoin,” he continues. 

“As a result, patients often experience faster and more complete clearance of melasma compared to using hydroquinone and tretinoin alone. However, due to the potential side effects associated with prolonged corticosteroid use, triple therapy is best used as a short-term treatment under medical supervision.”

So how short is short term? “I generally trial triple combination cream for around 8 weeks at a time to minimise the aforementioned risks of chronic use,” he says.

And there are things you’ll need to avoid when doing the triple combination too, starting with basking in the sun.

“First and foremost, sun exposure should be minimised, as even brief unprotected exposure can reverse progress, daily use of a broad-spectrum SPF 50+ with protection against the visible light spectrum and frequent reapplication is essential,” says Dr Ghadiri.

“It’s also best to avoid other potentially irritating skincare products, such as exfoliants (like AHAs and BHAs), scrubs, or benzoyl peroxide, unless specifically advised by a professional.

“Hair removal methods like waxing or threading can cause irritation and worsen pigmentation, so gentler alternatives are preferable. Hydroquinone and tretinoin are also not recommended during pregnancy.”

 

---

The in-office treatments

Dr Ghadiri says it could be beneficial to combine in-office procedures with prescription topical treatments, for moderate to severe treatment-resistant melasma.

“Topical therapy remains the foundation of care and should always be part of the regimen,” he says. Here are the in-office options.

• Lasers:

Dr Idriss says that lasers should be approached with caution. “The wrong one can actually make melasma worse,” she warns.

“Doing lasers without a solid skincare foundation is like getting liposuction and skipping the gym, it’s just not going to stick.” 

 

 

But how can lasers help? “They can help in carefully selected cases – particularly low-fluence lasers or fractional devices that target vascular and pigmentary components,” explains Dr Kopelman. “But I always caution my patients. Lasers are never a first-line treatment, and they are not a cure,” she warns.

“The risk with more aggressive lasers is that the heat can trigger rebound pigmentation, sometimes worse than the original melasma. That said, in-office treatments like low-fluence Q-switched Nd:YAG lasers, when used conservatively and combined with topical therapy, can offer a benefit. But the results are usually temporary unless maintenance strategies are in place.”

• Microneedling:

“This can accelerate improvement, target deeper dermal pigmentation and enhance the absorption of topical agents,” explains Dr Ghadiri.

“However, these procedures must be performed with great care and by a skilful practitioner, particularly in individuals with darker skin tones (Fitzpatrick types IV-V1) to minimize the risk of post-inflammatory hyperpigmentation.

• Chemical peels:

“Chemical peels can be a great adjunct for melasma, especially when we’re trying to accelerate results or break through a plateau,” explains Dr Kopelman.

“The pros are that peels can exfoliate superficial pigment, stimulate cell turnover, and improve skin texture overall. I like using peels that are specifically formulated for melasma — usually ones with azelaic acid, kojic acid, or lactic acid.”

And the cons? “If the skin isn’t properly prepped, or if the patient isn’t strictly avoiding sun afterward, it can actually worsen pigmentation,” she says. “There’s also a risk of post-inflammatory hyperpigmentation in patients with deeper skin tones, so I approach peels cautiously and always pair them with a strong at-home regimen.”

 

---

Melasma maintenance tips

There’s no rest for the wicked when it comes to melasma and you need to keep up the good work between your chosen treatments.

“A consistent and gentle maintenance routine is key,” says Dr Ghadiri. We’ve said it once and we will say it again – sunscreen!

“The most important step is strict sun protection – use sunscreen daily and complement it with physical barriers like wide-brimmed hats and sunglasses,” he says.

 

 

And what about your skincare regime? “Incorporate agents such as azelaic acid, niacinamide and topical tranexamic acid into your regular routine as maintenance,” Dr Ghadiri adds. “Stick to gentle skincare, including hydrating cleansers and barrier-repair moisturisers, to keep the skin healthy and resilient.”

Dr Marsh adds, “Vitamin C and E can also help to protect the skin against damage, and avoiding harsh scrubs and peels is advisable as these can make melasma worse,” he says. “It’s also important to speak to your doctor about any medication you are taking as some medications can impact melasma.”

It’s important to maintain a healthy lifestyle too. “Diet is the cornerstone of skin health,” explains Dr Akhavani. “It’s vital to ensure you are eating a healthy balanced diet, maintaining good hydration and also getting enough sleep, as all of these support skin health and regeneration.”

 

---

The takeaway

If ever there was a stubborn skin condition, melasma is it. But, according to the experts, there are plenty of options to keep it under control.

Strict sun protection is your first port of call, along with staying out of the heat and wearing a hat and sunglasses to protect your skin in the hot summer sun. Next, you could consider a melasma-friendly skincare regime, incorporating ingredients like niacinamide and vitamin C and avoiding harsh scrubs and peels.

A prescription is your next option, with things like tretinoin and hydroquinone (HQ) near the top of your list – although, be aware of their side effects. The most effective prescription though, according to the experts, is the triple combination of tretinoin, HQ and steroids which, again, come with their fair share of pros and cons. 

If you go down the in-office route, you can choose between things like laser and microneedling but ensure you go to a reputable dermatologist who can give your skin the best outcome possible and make sure you study the warnings first.

Don’t forget to do the proper maintenance in between treatments – a consistent skincare routine, eating a balanced diet and using sun protection – and your stubborn melasma might just get the hint. 

 

Meet the experts

Dr Sina Ghadiri is a consultant dermatologist and the founder of Sinaesthetics

Dr Hannah Kopelman is a dermatologist and chief medical officer at DermOnDemand

Dr Shereene Idriss is a board certified dermatologist and the founder of Idriss Dermatology

Dr Jeanine Downie is a board-certified dermatologist, and founder of image Dermatology ® P.C. in Montclair, NJ 

Dr Dan Marsh is a plastic surgeon and co-founder of The Plastic Surgery Group

Dr Mo Akhavani is a Consultant Plastic and Cosmetic Surgeon and co-founder of The Plastic Surgery Group