The Definitive Guide to Melasma

Who gets melasma?

Melasma affects about 5% to 10% of people, depending on ethnic background. Women make up about 75% to 95% of sufferers, most commonly from 25 to 35 years of age. It is more common in those with darker skin.¹Ogbechie-Godec OA, Elbuluk N. Melasma: an Up-to-Date Comprehensive Review. Dermatol Ther (Heidelb). 2017;7(3):305-318. doi:10.1007/s13555-017-0194-1^,2Tamega Ade A, Miot LD, Bonfietti C, Gige TC, Marques ME, Miot HA. Clinical patterns and epidemiological characteristics of facial melasma in Brazilian women. J Eur Acad Dermatol Venereol. 2013;27(2):151-156. doi:10.1111/j.1468-3083.2011.04430.x^,3Ortonne JP, Arellano I, Berneburg M, et al. A global survey of the role of ultraviolet radiation and hormonal influences in the development of melasma. J Eur Acad Dermatol Venereol. 2009;23(11):1254-1262. doi:10.1111/j.1468-3083.2009.03295.x^,4Hexsel D, Lacerda DA, Cavalcante AS, et al. Epidemiology of melasma in Brazilian patients: a multicenter study. Int J Dermatol. 2014;53(4):440-444. doi:10.1111/j.1365-4632.2012.05748.x^,5Yalamanchili R, Shastry V, Betkerur J. Clinico-epidemiological Study and Quality of Life Assessment in Melasma. Indian J Dermatol. 2015;60(5):519. doi:10.4103/0019-5154.164415

There are risk factors that increase the chance of developing of melasma:⁶Ortonne JP, Arellano I, Berneburg M, et al. A global survey of the role of ultraviolet radiation and hormonal influences in the development of melasma. J Eur Acad Dermatol Venereol. 2009;23(11):1254-1262. doi:10.1111/j.1468-3083.2009.03295.x^,7Espósito ACC, Cassiano DP, da Silva CN, et al. Update on Melasma-Part I: Pathogenesis. Dermatol Ther (Heidelb). 2022;12(9):1967-1988. doi:10.1007/s13555-022-00779-x^,8Tamega Ade A, Miot LD, Bonfietti C, Gige TC, Marques ME, Miot HA. Clinical patterns and epidemiological characteristics of facial melasma in Brazilian women. J Eur Acad Dermatol Venereol. 2013;27(2):151-156. doi:10.1111/j.1468-3083.2011.04430.x^,9Passeron T. Melasma pathogenesis and influencing factors – an overview of the latest research. J Eur Acad Dermatol Venereol. 2013;27 Suppl 1:5-6. doi:10.1111/jdv.12049

• Genetics plays a role, with 50% of first-degree relatives having melasma.
• It tends to occur in skin with several features of photoaging, including elastosis, senescent fibroblasts, and increased vascularisation. As such, chronic, daily sunlight exposure contributes to melasma. In particular, it seems that UVB light is the main contributing factor. To a lesser extent, UVA, visible light, and possibly infrared can also contribute.
• Hormonal influences, in particular oestrogen, are involved in the development of melasma. This can occur during pregnancy and while taking oral contraceptive medication. Other hormones either have a small role or the mechanism is unknown. These include progesterone, hypothyroidism, and low testosterone (for males).
• Oxidative stress is associated with melasma, although the exact mechanisms are unknown. Common causes of oxidative stress include ultraviolet light, pollution, exercise, and sleep deprivation. This may explain why several anti-oxidant treatments can help with the treatment of melasma. These include vitamin C, nicotinamide, and kojic acid.

Symptoms and signs of melasma

Melasma normally presents as symmetrical mottled patches of hyperpigmentation on the face. It is normally asymptomatic (i.e., not itchy, sore, etc). Extrafacial melasma refers to discolouration that develops in areas outside the face, which is much less common, develops later, and is more difficult to treat.

Melasma tends to be a chronic condition that often gets worse with sun exposure and other triggers. It can improve when rigorous sun protection is practiced and when other triggers are removed.

Significant psychological distress can result from melasma significantly impacting quality of life. Many people report depression, embarrassment, frustration, and impacts on their relationships.¹⁰Yalamanchili R, Shastry V, Betkerur J. Clinico-epidemiological Study and Quality of Life Assessment in Melasma. Indian J Dermatol. 2015;60(5):519. doi:10.4103/0019-5154.164415

Melasma treatment

General measures

Strict sun protection is essential for the treatment of melasma. Broad-spectrum sunscreen, with the highest SPF available, should be used. Many studies have confirmed the importance of sun protection.¹¹Grimes PE. Management of hyperpigmentation in darker racial ethnic groups. Semin Cutan Med Surg. 2009;28(2):77-85. doi:10.1016/j.sder.2009.04.001^,12Ogbechie-Godec OA, Elbuluk N. Melasma: an Up-to-Date Comprehensive Review. Dermatol Ther (Heidelb). 2017;7(3):305-318. doi:10.1007/s13555-017-0194-1^,13Cestari T, Arellano I, Hexsel D, Ortonne JP; Latin American Pigmentary Disorders Academy. Melasma in Latin America: options for therapy and treatment algorithm. J Eur Acad Dermatol Venereol. 2009;23(7):760-772. doi:10.1111/j.1468-3083.2009.03251.x^,14Grimes PE, Ijaz S, Nashawati R, Kwak D. New oral and topical approaches for the treatment of melasma. Int J Womens Dermatol. 2018;5(1):30-36. Published 2018 Nov 20. doi:10.1016/j.ijwd.2018.09.004^,15Boukari F, Jourdan E, Fontas E, et al. Prevention of melasma relapses with sunscreen combining protection against UV and short wavelengths of visible light: a prospective randomized comparative trial. J Am Acad Dermatol. 2015;72(1):189-90.e1. doi:10.1016/j.jaad.2014.08.023 As visible light can also contribute to the condition a tinted sunscreen should be used. The most effective tinted sunscreens for melasma have an iron oxide concentration over 3%. They can also help prevent the recurrence of the condition after successful treatment.¹⁶Kohli I, Chaowattanapanit S, Mohammad TF, et al. Synergistic effects of long-wavelength ultraviolet A1 and visible light on pigmentation and erythema. Br J Dermatol. 2018;178(5):1173-1180. doi:10.1111/bjd.15940^,17Austin E, Geisler AN, Nguyen J, et al. Visible light. Part I: Properties and cutaneous effects of visible light. J Am Acad Dermatol. 2021;84(5):1219-1231. doi:10.1016/j.jaad.2021.02.048^,18Geisler AN, Austin E, Nguyen J, Hamzavi I, Jagdeo J, Lim HW. Visible light. Part II: Photoprotection against visible and ultraviolet light. J Am Acad Dermatol. 2021;84(5):1233-1244. doi:10.1016/j.jaad.2020.11.074^,19Lyons AB, Trullas C, Kohli I, Hamzavi IH, Lim HW. Photoprotection beyond ultraviolet radiation: A review of tinted sunscreens. J Am Acad Dermatol. 2021;84(5):1393-1397. doi:10.1016/j.jaad.2020.04.079^,20Dumbuya H, Grimes PE, Lynch S, et al. Impact of Iron-Oxide Containing Formulations Against Visible Light-Induced Skin Pigmentation in Skin of Color Individuals. J Drugs Dermatol. 2020;19(7):712-717. doi:10.36849/JDD.2020.5032

Specific melasma treatments

Please note this section may seem vague as we have avoided naming some specific medications. Regulators, particularly Medsafe don't allow us to write about the Off-Label Use of medications. However, these are permitted to be discussed during your consultation, so you are welcome to ask.

Prescription skin lightening creams are the normal first-line treatment for melasma. It is often combined with an exfoliating agent and other ingredients when they are referred to as triple combination cream (TCC). Skin-lightening creams can suppress the production of melanin by melanocytes. These creams have been reported to clear or almost clear the skin condition in about two-thirds of people.²¹Chan R, Park KC, Lee MH, et al. A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma. Br J Dermatol. 2008;159(3):697-703. doi:10.1111/j.1365-2133.2008.08717.x Care needs to be taken as they can cause a disfiguring condition called ochronosis when used for too long.

Some acne creams have also been shown to be effective, with some studies suggesting they are almost as effective as lightening creams.²²Baliña LM, Graupe K. The treatment of melasma. 20% azelaic acid versus 4% hydroquinone cream. Int J Dermatol. 1991;30(12):893-895. doi:10.1111/j.1365-4362.1991.tb04362.x

While less effective, other skin-lightening creams include kojic acid and nicotinamide.

Chemical peels have also been shown to be effective for melasma. They work by removing epidermal pigment. Their effect is enhanced by the concomitant use of skin-lightening creams. A course of five to six peels is normally required.²³Sarkar R, Bansal S, Garg VK. Chemical peels for melasma in dark-skinned patients. J Cutan Aesthet Surg. 2012;5(4):247-253. doi:10.4103/0974-2077.104912

A tablet medication was recently discovered to be very effective for melasma. However, because it can promote clotting, it should not be used in those at risk of blood clots such as DVTs.²⁴Del Rosario E, Florez-Pollack S, Zapata L Jr, et al. Randomized, placebo-controlled, double-blind study of oral tranexamic acid in the treatment of moderate-to-severe melasma. J Am Acad Dermatol. 2018;78(2):363-369. doi:10.1016/j.jaad.2017.09.053^,25Colferai MMT, Miquelin GM, Steiner D. Evaluation of oral tranexamic acid in the treatment of melasma. J Cosmet Dermatol. 2019;18(5):1495-1501. doi:10.1111/jocd.12830^,26Zhang L, Tan WQ, Fang QQ, et al. Tranexamic Acid for Adults with Melasma: A Systematic Review and Meta-Analysis. Biomed Res Int. 2018;2018:1683414. Published 2018 Nov 6. doi:10.1155/2018/1683414

Laser treatments are also effective for melasma, although they need to be used with care. Non-ablative fractional and picosecond lasers are probably the most effective options. ²⁷Trivedi MK, Yang FC, Cho BK. A review of laser and light therapy in melasma. Int J Womens Dermatol. 2017;3(1):11-20. Published 2017 Mar 21. doi:10.1016/j.ijwd.2017.01.004