Melasma: what helps and what makes it worse
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Melasma is a common, long-lasting cause of symmetric brown patches on the cheeks, forehead, nose and upper lip. What helps most is strict, year-round sun protection, including tinted sunscreen that blocks visible light, plus pigment-fading topicals such as azelaic acid or kojic acid; a dermatologist can prescribe stronger options. Sun, visible light, heat, hormones and irritating treatments make it worse, and it often returns.
What is melasma, and how do you recognize it?
Melasma (also called chloasma or the mask of pregnancy) is a skin condition that causes patches of darker skin on areas of the face exposed to the sun2. The patches are usually an even brown, often symmetrical, and most often appear on the cheeks, forehead, nose or upper lip2. It is more common in women and in darker skin types, though it can affect anyone1,2.
Dermatologists describe three facial patterns1:
- Centrofacial, the main pattern in 50% to 80% of cases, centered on the forehead, nose and upper lip1.
- Malar, limited to the cheekbones1.
- Mandibular, along the jawline and chin, which one study linked to a later age of onset, in the 40s1.
In North America, interest in melasma peaks in September, at the end of the high-sun season; MedlinePlus notes that sunlight is more intense at the beginning of summer and that melasma can come back from sun exposure, so sun protection is a year-round habit2. In the Southern Hemisphere, the same end-of-summer peak falls around March.
What causes melasma?
No single cause explains it. Light exposure, hormones and family history all play a part1. Ultraviolet light triggers and worsens melasma in clinical and laboratory studies, and visible light also produces pigmentation1. Melasma is linked to the hormones estrogen and progesterone and is common in pregnancy, with birth control pills and with hormone replacement therapy during menopause2.
Genes matter too: in some studies, 55% to 64% of people with melasma have a family history of it1. Under the microscope, the extra pigment may sit in the epidermis, in the dermis, or both1.
How common it is depends on the population. Estimates run from about 1% in the general population to 9% to 50% in higher-risk groups, and a telephone survey of 500 Latino women in the southwestern United States found a prevalence of 8.8%1.
What makes melasma worse?
Melasma responds to a wide range of everyday exposures, and a 2026 review describes how they converge on the same pigment-producing pathways4. The main ones:
| Factor | What the evidence shows |
|---|---|
| Ultraviolet light | Triggers and exacerbates melasma; prolonged UVA exposure is closely tied to recurrence and worsening1,4. |
| Visible light | Blue-violet light increases melanin in melasma patches and nearby skin, and visible-light pigmentation lasts longer than UV pigmentation4; 415 nm light caused darkening lasting up to 3 months1. |
| Heat | In a study of 1,001 patients in India, prolonged exposure to cooking fires or workplace heat was linked to more severe melasma4. |
| Hormones | Pregnancy, birth control pills and hormone replacement therapy are common settings for melasma2. |
| Air pollution and tobacco smoke | Can drive skin pigmentation through oxidative stress and a cell receptor called AhR4. |
| Stress and disrupted sleep | In 108 patients and 111 controls, stress or anxiety tendencies were reported by 61.1% of patients versus 11.7% of controls4. |
| Aggressive procedures | Ablative CO2 lasers have repeatedly been associated with post-inflammatory hyperpigmentation, especially at the edges of patches1. |
What treatments help melasma?
A 2023 systematic review of 174 controlled trials gave its strongest (grade A) recommendation to hydroquinone, triple combination cream, sunscreens, kojic acid and azelaic acid; 5% cysteamine cream received a grade B, and topical tranexamic acid and vitamin C need larger studies6. The same review gives oral tranexamic acid, a medicine, a strong recommendation where there are no contraindications, a choice to make with a clinician6.
In the United States, the only FDA-approved drug containing hydroquinone is Tri-Luma, a prescription cream for the short-term treatment of moderate to severe facial melasma5. It combines hydroquinone with tretinoin and a corticosteroid, is used together with sun avoidance and sunscreen, and is not indicated for maintenance treatment7. Hydroquinone can cause irritation, and chronic use can lead to exogenous ochronosis, a blue-black darkening of the skin1,7.
Procedures are often combined with topicals1. Superficial chemical peels may help the epidermal type, and glycolic acid peels are the most studied1. Non-ablative lasers are preferred over ablative ones because they cause less inflammation and less pigment change afterward, but recurrence is common: in one small Er:YAG laser study, melasma returned at 3 to 4 months1.
What can you do for melasma at home?
Avoiding UV and visible light is critical to preventing flares, and it is the part of treatment you control every day1. MedlinePlus advises a broad-spectrum sunscreen of at least SPF 30 that blocks UVA and UVB, reapplied at least every 2 hours in the sun and used year-round, plus hats, avoiding midday sun, and staying away from sun lamps and tanning beds2.
Add visible-light protection. In randomized trials, sunscreens that combined UV filters with visible-light blockers such as iron oxide reduced melasma relapses compared with UV filters alone1. Tinted sunscreens get their visible-light protection from iron oxide and titanium dioxide pigments3. Because UVA and visible light pass through clouds and window glass, sitting by a sunny window counts as exposure3.
Of the grade A agents in the 2023 review, kojic acid and azelaic acid are the options other than hydroquinone, and arbutin and topical tranexamic acid have supporting trials6. In the US, do not buy hydroquinone online as a cosmetic: FDA says there are no legally marketed over-the-counter skin lighteners, and unapproved products have caused rashes, facial swelling and ochronosis5. Makeup also helps: pigmented foundations and concealers can even out the patches while treatment works1.
What happens to melasma during pregnancy?
Pregnancy is one of the most common triggers. Reported prevalence during pregnancy ranges from 36.4% to 75%, depending on population and region, and patches typically appear in the second trimester3.
Pregnancy melasma often fades after delivery, typically within a year3, and MedlinePlus notes it can return in future pregnancies or with sun exposure2. Up to 30% of cases have been reported to persist even 10 years later3.
Prevention starts early. A study cited in a 2024 review found that a broad-spectrum sunscreen used from the first trimester reduced the incidence of pregnancy melasma by more than 90%3. The review's authors favor mineral sunscreens (zinc oxide, titanium dioxide) during pregnancy because some organic filters are absorbed and appear in urine and breast milk, while noting there is no evidence that sunscreens pose health risks3.
Ask your obstetrician or dermatologist before using any prescription lightening treatment while pregnant or breastfeeding. The prescribing information for Tri-Luma warns it may cause birth defects if used during pregnancy, and its safety in pregnancy and breastfeeding has not been established7.
Key takeaways
- Melasma causes symmetric brown patches on the face and is linked to sun, visible light, hormones and genes.
- Daily broad-spectrum sunscreen, tinted with iron oxide for visible light, reduces relapses better than UV filters alone.
- Hydroquinone, triple combination cream, kojic acid and azelaic acid have the strongest evidence; in the US, hydroquinone is prescription only.
- Heat, pollution and aggressive lasers can make melasma worse, and stress is linked to it.
- Pregnancy melasma often fades within a year after delivery, but it can persist and return.
References
- Melasma: an Up-to-Date Comprehensive Review
- Melasma
- Prevention of Melasma During Pregnancy: Risk Factors and Photoprotection-Focused Strategies
- The Exposome in Melasma: A Comprehensive Review of Etiology, Mechanisms, and Implications for Management
- FDA works to protect consumers from potentially harmful OTC skin lightening products
- Topical and Systemic Therapies in Melasma: A Systematic Review
- TRI-LUMA (fluocinolone acetonide, hydroquinone, and tretinoin) cream: prescribing information
Frequently asked questions
Is melasma permanent?
It is chronic and tends to recur, which is what makes it hard to manage1. Melasma often fades over several months after pregnancy ends or hormone medicines are stopped, but it can come back with sun exposure2. Traditional treatments target pigment that has already formed and have high recurrence rates4.
Can men get melasma?
How do you tell melasma from other dark spots?
Melasma's symmetric patches on the cheeks, forehead, nose and upper lip are typical, but its lookalikes include post-inflammatory hyperpigmentation, sun spots (lentigines), drug-induced pigmentation and ochronosis1. A dermatologist may use a Wood's lamp to guide treatment2. See a health care provider if facial darkening does not go away2.