Treating melasma on the face

First, make sure the patches are melasma

Melasma causes flat brown or greyish patches, commonly on the cheeks, forehead, nose, chin and above the upper lip. Patches often appear on both sides of the face. Melanin, the pigment that gives skin its colour, builds up because pigment cells become more active. Melasma itself is harmless and normally does not itch or hurt, but its appearance can cause distress.345

Persistent facial darkening deserves a medical assessment rather than an automatic melasma label. Other pigmentation conditions, and sometimes skin cancers, can resemble melasma. A dermatologist examines the skin and can use a Wood's lamp, a special light, to help assess the pigment. Occasionally, a small skin sample is needed to exclude another condition. Tell your doctor about any changing patch; pain, itching or a raised area is not the usual melasma pattern.235

What makes facial melasma worse?

Sun exposure and hormonal changes are major contributors. Melasma is associated with pregnancy, birth control pills and hormone replacement therapy, and can affect anyone. It is more common in women and people who tan easily. Family history, some medicines and thyroid disorders can also contribute. Review possible medication triggers with the prescriber rather than changing treatment yourself.567

A dark patch above the upper lip can be the same condition, sometimes called a melasma mustache. It needs the same combined approach to light protection and treatment as melasma elsewhere on the face. Excessive or improper use of hydroquinone, retinol or alpha hydroxy acids can worsen upper lip pigmentation, so adding more treatment is not automatically the answer.6

Which sunscreen helps melasma?

Choose a tinted, water resistant sunscreen with broad spectrum protection and SPF 30 or higher. Broad spectrum means protection against both UVA and UVB rays. Iron oxide adds protection against visible light, which can worsen melasma, especially in darker skin tones. SPF 50 or higher is a practical choice for stronger sun protection. Check for iron oxide rather than assuming that any tinted product provides the same protection.457

Use sunscreen every day, including cloudy days and winter. Apply it to exposed skin 15 minutes before going outside, then reapply at least every two hours outdoors and after swimming or sweating. Add shade, a wide brimmed hat and UV protective sunglasses. A hat labelled UPF 50 or higher is an option for additional protection. Avoid tanning beds and sunlamps, which can worsen melasma and interfere with treatment.456

A tinted sunscreen can avoid a white cast, which is a useful feature for a product not intended to double as face paint.1

Visible light protection does not mean avoiding your phone or laptop. There is no evidence that blue light from personal electronic devices affects the skin. Focus on outdoor light protection rather than treating every screen as another sun.2

How to apply treatment, sunscreen and makeup

1. 1Apply your melasma medication as prescribed. Follow its individual directions for frequency and time of day.
2. 2Apply sunscreen before going outdoors. When medication, sunscreen and makeup are used together, medication goes first and sunscreen goes second.
3. 3Apply camouflage makeup last, if you want coverage.
4. 4Reapply sunscreen during outdoor exposure rather than relying on the morning application for the whole day.

Choose gentle, fragrance free skincare. Stop using a skincare product that burns or stings: irritation can darken existing spots. If a prescribed treatment irritates your skin, contact the prescriber about adjusting it rather than adding exfoliants. The aim is to reduce pigment without creating more irritation.4

Which creams treat melasma?

Hydroquinone and retinoid creams need particular care because they can irritate skin. Hydroquinone is not a treatment to continue indefinitely: the course needs medical supervision to limit unwanted pigment changes. Choose the medicine, strength and schedule with your dermatologist rather than copying someone else's prescription. Sensitive skin is a reason to discuss gentler options, not to push through burning.2

What if you are pregnant or taking hormones?

Avoid hydroquinone and retinoid creams during pregnancy. Sun protection and optional camouflage are practical measures while you discuss treatment with your clinician. Pregnancy related melasma can fade over several months after delivery, so medication is not always necessary. It can return in another pregnancy. If melasma appeared after starting birth control or hormone replacement therapy, ask the prescriber whether a change is appropriate; pigmentation can fade after the trigger is removed.25

Do peels, lasers or tablets help?

Procedures are options for selected cases, not automatic upgrades from creams. Chemical peels remove superficial pigment. Microneedling creates tiny punctures and can help creams penetrate. Laser and light treatments target pigment or skin layers, but results are variable. Peels and lasers can worsen pigmentation; microneedling can cause infection or scarring. Lasers can also leave lighter patches, particularly in people of colour. Use a dermatologist with experience treating melasma and your skin tone, rather than attempting these treatments at home.27

Tranexamic acid is an off label option for stubborn melasma that has not responded to standard treatment. It can be applied to skin or taken as a tablet under medical supervision. Before prescribing it, a dermatologist reviews your health; disclose any history of blood clots. It is an addition to a treatment plan, not a replacement for light protection.16

How much improvement should you expect?

Pigment depth affects the response. Epidermal melasma, in the outer skin layer, usually responds better. Dermal melasma, deeper in the skin, responds poorly. Mixed melasma is the most common type and usually improves partly. A dermatologist's examination helps distinguish these types. Progress photographs can help track changes that are difficult to judge from memory.7

Longstanding melasma can take longer to improve, and there is no permanent cure. Continue sun protection after patches fade because summer exposure can bring pigment back. Camouflage makeup is an optional way to hide uneven colour, not a compulsory dress code for having melasma. If patches persist, discuss treatment adjustments rather than repeatedly increasing exfoliation or booking another procedure.247