Melasma: Causes, Triggers and Treatment Options

Melasma is a common pattern of brown or grey-brown patches on the cheeks, forehead, nose, upper lip or chin. It is driven by sunlight, visible light and hormones on a background of genetic tendency, and heat often makes it worse. It can usually be lightened and controlled with daily sun protection and prescription treatment, but it tends to come back, so most people need a long-term plan rather than a single course.

This article covers who gets melasma, what triggers it, how sunscreen fits in, the treatments a dermatologist may discuss, the problem with unsupervised steroid creams, and why melasma recurs. It is general patient education, not a list of treatments offered at any particular clinic.

What melasma is, and who gets it

Melasma is an excess of pigment laid down by overactive pigment cells (melanocytes). It usually appears as symmetrical patches, much the same on both sides of the face, most often across the cheeks, the forehead, the bridge of the nose and the upper lip. Less often it affects the jawline, or the forearms and other sun-exposed skin.

It is far more common in women and usually starts between the ages of 20 and 40, though men get it too. DermNet's reference page on melasma describes it as most common in people with brown skin that tans easily, Fitzpatrick types III and IV, which covers a large share of Indian skin. In one multicentre study across ten centres in four regions of India, women outnumbered men by about four to one. Family history matters too: in different studies, between about a third and more than half of patients report a relative with melasma.

Dermatologists sometimes describe melasma by how deep the pigment sits. Pigment near the surface tends to respond more readily to treatment, deeper pigment responds slowly, and most people have a mix of both. Several other conditions also darken the face, including marks left after acne or a rash, pigmentation from cosmetics or creams, and some less common conditions, so it is worth having the diagnosis confirmed before starting treatment.

What causes melasma and what makes it worse

There is no single cause. Melasma appears when an underlying tendency meets one or more triggers:

• Ultraviolet (UV) light from the sun or sunbeds is the main trigger. It stimulates pigment cells directly, which is why melasma darkens in summer and after holidays.
• Visible light. Ordinary daylight, not only UV, can deepen pigment in brown skin. The British Association of Dermatologists notes that high-energy visible (blue) light may contribute, though it finds no evidence that light from phone and computer screens affects the skin.
• Hormones. Pregnancy (melasma is sometimes called the mask of pregnancy), the contraceptive pill and other hormonal contraception, and hormone replacement can all trigger or worsen it. A thyroid disorder is also linked in some people.
• Heat. Many dermatologists find that heat, from cooking over a stove, a hot commute or a sauna, makes melasma worse. The evidence for heat is weaker than for sunlight, but it fits what many people notice in a north Indian summer.
• Medicines and products. Some medicines make skin more sensitive to light, some anti-seizure medicines are linked to melasma, and perfumed or irritating cosmetics can contribute.
• Genetics, which shape how readily your pigment cells respond to everything above.

Sunscreen: the part of treatment that does most of the work

Without sun protection, melasma treatment tends not to hold. The American Academy of Dermatology (AAD) advises a broad-spectrum sunscreen of SPF 30 or higher, applied every day and reapplied through the day, along with shade and a wide-brimmed hat. DermNet goes further and recommends a very high protection (SPF 50+) broad-spectrum sunscreen containing iron oxides.

The iron oxides matter because of visible light. Most standard sunscreen filters are designed for UV and give limited protection against visible light. Iron oxides, the pigments that give tinted sunscreens their colour, reflect part of it. That is why a tinted sunscreen is often suggested for melasma, and why the British Association of Dermatologists notes that iron oxide sunscreens offer some protection against visible light.

How you use it matters as much as which one you buy:

• Use enough to cover the whole face evenly, every morning, including cloudy and smoggy days.
• Reapply after about two hours outdoors, after sweating, and after washing your face.
• Window glass lets UVA through, so a long daily drive or a desk by a window still counts.
• Choose a tint that matches your skin. A single universal shade can look grey or chalky on deeper Indian skin tones, and a sunscreen you will not wear does not help.
• Add shade, a hat or an umbrella in strong sun. No sunscreen blocks everything.

Treatments that may be discussed

Treatment is chosen once the diagnosis is confirmed, and it usually combines sun protection with a prescription cream. What follows is a general overview of what dermatologists may discuss; doses and the length of each course are always as prescribed by a doctor.

Prescription creams

Pigment-reducing creams are the usual first step. Hydroquinone is the most familiar; the British Association of Dermatologists notes that it is prescribed for limited periods, because longer use can over-lighten the skin or, occasionally, darken it. It is sometimes combined with a retinoid and a mild steroid in a triple-combination cream, used for a defined course under supervision. Other agents, such as azelaic acid, kojic acid, vitamin C, cysteamine, thiamidol and tranexamic acid applied to the skin, may be used alone, in rotation or for maintenance.

Tablets

For stubborn melasma, some dermatologists prescribe tranexamic acid tablets. The AAD notes that your health history, including any past blood clots, is reviewed first. This is a prescription decision, not something to buy and try.

Chemical peels

Superficial peels are sometimes added once the skin is used to a cream. On brown skin they are used cautiously, because the irritation from a peel can itself cause darker patches.

Lasers and light treatments

Lasers and light treatments are sometimes used alongside creams, and the AAD notes a few studies finding they can improve results when added to medication and sun protection. Results are variable, though. The BAD warns that laser can worsen pigmentation or leave lighter patches, and DermNet notes a high risk of relapse after laser, light treatments and microneedling. On darker skin they are approached with particular caution, usually only once creams and sun protection are in place; why darker skin and laser need a careful start explains the underlying problem.

Camouflage

Colour-matched cosmetic camouflage does not treat melasma, but it can cover the patches while treatment takes effect, and many people find that helpful. Be wary of dramatic before-and-after photographs of pigmentation, which lighting and camera settings change easily; how to read before-and-after photos explains the techniques, using hair as the example.

Steroid creams: a common problem in India

In India, many people with melasma first try a cream from a chemist. Some of the cheapest and most widely sold "pigmentation" and "fairness" creams contain a strong steroid, often in a triple combination, and are bought without a prescription. A multicentre study of dermatology outpatients in India found steroid creams being used on the face, most often as fairness or general-purpose creams and mostly on the advice of people who were not doctors. A later study from Jammu found that a fifth of facial steroid users were applying them for melasma or pigmentation.

Steroids lighten the skin at first, which is why these creams seem to work. Used on the face for weeks or months without supervision, they can cause:

• acne-like spots, redness and a burning sensation;
• thinning of the skin, with small visible blood vessels;
• increased facial hair;
• pigmentation that gets worse, not better;
• a flare of redness and burning when the cream is stopped, sometimes called topical steroid-dependent face.

A short course of a prescribed combination cream, under supervision, is different from months of unsupervised use. If you have been using a steroid cream on your face for a while, do not simply stop it the night before a consultation. Bring it with you: coming off suddenly can cause a flare, and the doctor can plan how to reduce it.

Why melasma comes back

Treatment lightens the pigment, but it does not remove the tendency. The pigment cells stay quick to respond, so the same triggers bring melasma back: a summer of strong sun, a beach holiday, a hot kitchen, a pregnancy or a change in hormonal contraception. DermNet notes that even people who respond well can see pigment return with summer sun, and the BAD notes that melasma often returns after treatment stops.

That is why most plans have two phases. The first lightens the patches, and the AAD says results usually take between three and twelve months to appear. The second, maintenance, keeps them light: daily sunscreen, a gentler cream used regularly or in courses, and attention to triggers. Stopping everything as soon as the skin looks better is a common reason for relapse. Over-treating causes problems too, because harsh products, scrubs and aggressive procedures irritate the skin, and irritation in brown skin can darken it.

When to see a doctor

• You are not sure the patches are melasma, or they are on one side only or irregular in shape.
• A patch is changing in size, colour or shape, is raised, bleeds or itches; it needs examining in its own right.
• The darkening started after a new medicine or cream.
• You have been using a steroid or fairness cream on your face.
• You are pregnant, breastfeeding or planning a pregnancy, as several pigment treatments are unsuitable at those times.
• There is also velvety darkening of the neck or skin folds, which can point to an internal cause worth checking.

Getting it assessed

At our clinics in Sector 39, Gurugram and Rohini, Delhi, a skin consultation with a registered medical practitioner starts with a diagnosis: the pattern of the patches, sun exposure, hormonal factors and every product you use. For melasma, the plan then centres on daily sun protection, prescription creams in courses and maintenance. Skin treatment in Gurgaon and skin treatment in Rohini explain how a consultation runs. Marks left by acne are often confused with melasma, and acne marks and scars explains the difference.