Melasma: Diagnosis and treatment

How do dermatologists diagnose melasma?

Dermatologists can diagnose most patients by looking at their skin. To see how deeply the melasma penetrates the skin, your dermatologist may look at your skin under a device called a Wood’s light.

Sometimes melasma can look like another skin condition. To rule out another skin condition, your dermatologist may need to remove a small bit of skin. This procedure is called a skin biopsy. A dermatologist can safely and quickly perform a skin biopsy during an office visit.

How do dermatologists treat melasma?

Melasma can fade on its own. This usually happens when a trigger, such as a pregnancy or birth control pills, causes the melasma. When a woman delivers her baby or stops taking the birth control pills, melasma can fade.

However, some people have melasma for years, or even a lifetime. If the melasma does not go away or a woman wants to keep taking birth control pills, melasma treatments are available. These include:

  • Hydroquinone: This medicine is a common first treatment for melasma. It is applied to the skin and works by lightening the skin. You will find hydroquinone in medicine that comes as a cream, lotion, gel, or liquid. You can get some of these without a prescription. These products contain less hydroquinone than a product that your dermatologist can prescribe.

  • Tretinoin and corticosteroids: To enhance skin lightening, your dermatologist may prescribe a second medicine. This medicine may be tretinoin or a corticosteroid. Sometimes a medicine contains three medicines (hydroquinone, tretinoin, and a corticosteroid) in one cream. This is often called a triple cream.

  • Other topical (applied to the skin) medicines: Your dermatologist may prescribe azelaic acid or kojic acid to help lighten melasma.

  • Procedures: If medicine you apply to your skin does not get rid of your melasma, a procedure may succeed. Procedures for melasma include a chemical peel, microdermabrasion, dermabrasion, laser treatment, or a light-based procedure. Only a dermatologist should perform these procedures.
    New skin problems can occur when the person who gives the treatment does not tailor it to the patient’s skin type.

Ask your dermatologist about possible side effects (health problems that can result from the treatment).

If you notice any of the following after getting treatment for melasma, be sure to call your dermatologist:

  • Skin irritation

  • Darkening of the skin

  • Other problems


Under a dermatologist’s care, many people with melasma have a good outcome. Melasma can be stubborn, though. It may take a few months of treatment to see improvement. It is important to follow your dermatologist’s advice. This ensures that you get the most benefit from treatment. It also can help avoid skin irritation and other side effects.

After your melasma clears, you may need to keep treating your skin. Your dermatologist may call this maintenance therapy. Maintenance therapy can prevent melasma from returning.

You can help prevent your melasma from returning by wearing sunscreen and a wide-brimmed hat every day.

Recently, a friend mentioned to me that her skin had suddenly developed a weird, blotchy, brownish rash when she was on vacation. “It looked like a bunch of acne scars above my lip and on my forehead,” she said. “It was like a dark shadow that wouldn’t go away.” But, when she finally went to the dermatologist after three weeks of my daily, annoyingly pushy reminders, she discovered that the splotches were not, in fact, scars, but melasma—a skin condition that can happen to literally anyone (cue scary music).

Just kidding; melasma is not, in fact, the kiss of death—it’s just incredibly annoying to deal with. “Melasma is a complex condition that causes hyperpigmented patches on the skin,” says skin wizard, Annie Chiu, M.D., dermatologist at The Derm Institute. And the reason most derms approach melasma with a weary eye is because it really is complex, solely because it’s can be caused by a variety of factors, including “genetic tendency, increased estrogen, and skin type,” she says.

Getty Images

Basically, anyone with skin is at risk for developing melasma, but Dr. Chiu says you’re especially susceptible if:

  1. You’re pregnant (melasma so common in pregnant women, thanks to hormonal fluctuations, that it’s earned the name “pregnancy mask”)
  2. You have naturally darker skin (Fitzpatrick skin types IV and V are predisposed to melasma)
  3. You were born biologically female (again, hormones)
  4. You love hanging outdoors (UV rays from sun exposure stimulate skin cells to create excess pigment)
  5. You stare at a computer all day (the visible light from your computer, tablet, and cell phone can all trigger melasma)

See? That’s pretty much the majority of the population. Which means there’s also no true, one-and-done way of preventing melasma (although sun protection in the form of hats and SPF of at least 35 can help decrease, though not totally prevent, its impact on your face).

So if you do notice brown marks on your upper lip, upper cheeks, and/or on the forehead that look “patchy and widespread, rather than just a spot or two,” says Chiu, then it’s likely melasma (though, of course, go to your derm for an actual diagnosis).

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But before you freak out, here’s the good news: It’s treatable. The bad news? It’s kind of a pain to get rid of, solely because it requires you to be vigilant about your at-home treatments. “In office, we use peels and very specific low-level lasers to break up the pigment,” says Dr. Chiu, “and we also have patients treat their melasma at home with a mix of prescription-strength hydroquinone, kojic acid, retinol, and vitamin C products, as well as be meticulous about applying UVA- and UVB-protecting sunscreen.”

So, yeah, sorry—you’re going to have to go to the derm at least once if you want your melasma treated, but after that, you can at least keep the pigmentation at bay with the best of the best spot-fading products, below. Just remember that each of them absolutely needs to be used in conjunction with daily sunscreen, or your melasma will get worse. So let’s avoid that, shall we?

4 Best At-Home Melasma Treatments

For Sensitive Skin

Ole Henriksen Truth Serum, $72


Massage a vitamin C serum, which gently stimulates collagen production to reduce dark spots, over your clean, dry skin every morning, before moisturizing.

For Combo Skin

Peter Thomas Roth Retinol Fusion PM, $65


Apply a thin layer of retinol, which slowly resurfaces your skin to fade and brighten discoloration, every other night 20 minutes after you moisturize.

For “Normal” Skin

La Roche-Posay Mela-D Serum, $53


Before moisturizing, use a serum with glycolic acid and kojic acid (both of which can be irritating on sensitive skin) to exfoliate dark spots faster than vitamin C and even retinol.

For Tough Skin

Glytone Dark Spot Corrector, $38

If you’ve never once had sensitivity or irritation, try hydroquinone, the most heavy-duty lightener that decreases the production of pigment in your skin, every other day.

Chloe Metzger Senior Beauty Editor Chloe Metzger is the senior beauty editor at Cosmopolitan, obsessively writing about new makeup launches, the best hair products (curly girl here; whattup), and the skincare formulas that really work for every skin type (follow her on Instagram to see behind-the-scenes pics of that magazine life).

Here’s How Ginger Zee Got Rid of Her Melasma – and Everything Else You Need to Know About the Common Skin Issue

Image zoom Noam Galai/Getty

If you’re pregnant, on birth control pills or spend a lot of time in the heat or sun, there’s a chance you have or will experience a pesky skincare problem called melasma, a series of large brown spots on your face that are tricky to get rid of. The good news? You’re not alone in the struggle, and with the right products and strategy, you’ll have a clear complexion in just a few months.

Case in point: When Good Morning America‘s Ginger Zee noticed the spots after her pregnancy, she turned to dermatologist Dr. Whitney Bowe to help her get rid of them. And now, after sharing her skincare success story on GMA, Dr. Bowe is filling us in on her secrets. Below, learn everything you need to know about the skin issue from Dr. Bowe.

Image zoom Dr. Whitney Bowe

What is melasma?
“Melasma consists of tan to brown patches that occur primarily on the forehead, temples, cheeks and the upper lip. It’s affects up to 70% of pregnant women, and is extremely common among women of color. Melasma tends to be appear as larger patches which may have jagged borders, and can look like a map, a mask, or that somebody took brown paint and splattered it on the skin.”

What causes it?
“Hormones play a major role in melasma. Ginger noticed hers during her pregnancy — about half of all cases begin during pregnancy. But birth control pills can trigger melasma also. Melasma occurs much more commonly in women as opposed to men, specifically because hormones are such a key factor.”

“Aside from hormones, UV exposure is really the strongest factor, and the number one reason why melasma treatments fail. If you don’t have strict avoidance of sunlight, no matter what your treatment is or how good it is, you’re doomed to fail.”

For more tips from Dr. Bowe and Ginger, watch our Facebook Live!

Will staying out of the sun make it fade?
“If you have melasma, it’s not just about wearing sunscreen. It’s about wearing a hat, trying to avoid direct sunlight between the hours of 11am and 2pm, and using SPF 50 or above. If it’s a cloudy day, you’re still getting a significant amount of UV rays coming through the clouds. If you’re in the car, UVA rays are going to come through the window. If you work near a window, you’re getting UV exposure all day long. If you have melasma, you’re wearing sunscreen whether you’re indoors or outdoors, whether it’s winter or summer, you have to be wearing it year round, and ideally reapplying it during the day with a Colorescience SPF brush or a spray that you can layer over your makeup.”

Image zoom Dr. Whitney Bowe

So all I need to do is wear sunscreen?
“No. Another trigger is heat. So hot yoga, saunas, steam rooms, cooking – if you’re in and out of the oven, that can trigger it. Any exposure to heat can make melasma worse. Infrared beds and infrared saunas, they also create heat. Basically if you feel warmth on your skin, it can trigger melasma. You have to be really careful.”

Is it genetic?
“Family history definitely plays a role in melasma, so if anyone in your family has struggled with it, you’re much more likely to get it.”

RELATED PHOTOS: The Beauty Launches That We’re Living For in 2017

How do you get rid of it?
“You want to be really gentle when It comes to melasma. It’s all about a slow and steady approach. In people who have melasma, the pigment cells are exquisitely sensitive. Any injury to those cells, and they’ll start pumping out melanin which will stain the skin, which is why less is more. For Ginger, I used a combination of in-office treatments, prescription medications and and over-the-counter skincare. I rotate through a series of superficial peels, using different ingredients like glycolic acid one time, salicylic acid the next, and resorcinol every 3-4 weeks, and it’ll slowly lift the pigment out of the skin.”

“Number two, I customize a melasma emulsion. I select a blend of prescription strength ingredients, and recommend putting them on the brown spots only a couple times a week. I mix Retin-A, kojic acid and hydroquinone, which is the most powerful lightening ingredient and has to be used under very close supervision by a doctor”

“And then there’s the daily skincare regimen. With Ginger, she uses a gentle cleanser like Cetaphil (wash with fingertips only, meaning scrubs or exfoliating devices) in the morning, then an antioxidant serum like a few drops of Skinceuticals CE Ferulic mixed into a La Roche Posay sunscreen for her morning regimen. The antioxidants neutralize free radicals that are thought to trigger melasma. Every other night, she was using the melasma emulsion, and on the other nights she used CE Ferulic.”

“I also told her no hot yoga, saunas, steam rooms, sun bathing, tanning salons. She wore a hat when she was walking outside.”

Image zoom Dr. Whitney Bowe

Do lasers help?
“Ginger used to do hot yoga, and originally saw a dermatologist who recommended she use lasers to get rid of her melasma, which is actually one of the biggest myths around it. A lot of people think the more powerful the laser the sooner they’ll see results, and it’s the opposite. If the laser is too strong or creates too much heat, it can make your melasma worse. Photo facials are one of the worst things you can do for melasma, but a lot of people think it’s the best thing. I’ve seen melasma be made so much worse because people think all brown spots are created equal, and your brown spots will get better, but most people get worse. I would say avoid lasers altogether.”

Can I fight it without seeing a dermatologist?
“Yes. You want to look for ingredients with Vitamin C, kojic acid, licorice or soy – there are a lot of brightening ingredients out there. And then you have to be really, really careful about your sunscreen. You can use all the right lightening ingredients, but if you’re not using SPF, you’ll be fighting an uphill battle.”

Is it true that DIY treatments with citrus will help?
“No. If you Google home remedies for melasma, you’ll find all these recipes with lemon, lime, or orange juices, which can absolutely make your melasma 100x worse. Do not use lemon juice in a home remedy.”

How long does it take to go away?
“It takes time. I always tell people it’s going to take at least three months to lighten it. We can’t cure it – we can keep it under control – but there’s no cure, so it’s a lifelong commitment to your skin.”

Melasma (Chloasma)

Medically reviewed by Last updated on Mar 4, 2019.

  • Health Guide
  • Care Notes
  • Medication List

What Is It?

Melasma is a condition in which areas of the skin become darker than the surrounding skin. Doctors call this hyperpigmentation. It typically occurs on the face, particularly the forehead, cheeks and above the upper lip. The dark patches often appear on both sides of the face in a nearly identical pattern. The darker-colored patches of skin can be any shade, from tan to deep brown. Rarely, these dark patches may appear on other sun-exposed areas of the body.

Melasma occurs much more often in women than in men, and usually is associated with hormonal changes. That is why the dark patches develop often during pregnancy, or if a woman is taking hormone replacement therapy (HRT) or oral contraceptives. Melasma during pregnancy is relatively common. Sometimes it is called the “mask of pregnancy” or “chloasma.” The dark patches typically last until the pregnancy ends.

The most important factor in the development of melasma is exposure to sunlight. Using medications that make you sensitive to the sun (photosensitizing) can increase your risk of developing melasma. These can include some cosmetics and medicines used to treat ovarian or thyroid problems. Protection from the sun is a necessary part of treatment of melasma. For example, women who are pregnant or who take a hormone medication and avoid the sun are less likely to develop melasma than are those who spend a lot of time in the sun.


Darker patches of skin appear on the forehead, temples, cheeks or above the upper lip. The symptoms are strictly cosmetic — you won’t feel ill, and the darker skin won’t be sore.


A doctor will diagnose melasma simply by looking at your skin. Your medical history will help to determine any factors that may have caused the disorder.

Your doctor may use a special lamp that gives off ultraviolet light. This allows the doctor to see patterns and depth of skin discoloration more clearly.

Expected Duration

The dark patches typically last until the pregnancy ends or you stop taking the hormonal medications and protect from the sun. The patches gradually fade over many months. In some people, the discoloration never entirely disappears.


The best way to prevent melasma is to limit skin exposure to the sun. If you go out in the sun, take these preventive measures:

  • Wear a hat with a brim to shade and protect your face.

  • Apply sun block (such as zinc oxide or titanium dioxide) to vulnerable areas.

  • Use sunscreen that protects against both ultraviolet A and ultraviolet B radiation. The sunscreen should have a sun protection factor (SPF) of at least 30.


As hormones stabilize, the dark patches of melasma usually fade. Women who develop melasma as a result of pregnancy often see the patches fade months after the baby is born. Women who take oral contraceptives or hormone replacement therapy often see the patches fade once they stop taking the medications.

A few options may help fade or treat dark patches:

  • Hydroquinone is a cream that takes pigment out of the skin. It blocks the natural chemical process that leads to the creation of melanin, the substance that makes skin dark.

  • Tretinoin is a type of vitamin A that helps to increase the rate at which dead skin cells fall off and new ones appear. This makes the melasma patch fade more quickly as the pigmented cells are shed.

  • Azelaic acid cream appears to work by slowing down or stopping the production of pigment, the substance that makes the skin darker.

  • Chemical peels are liquid solutions applied to the skin to provide a mild chemical burn, similar to sunburn. Over time, the burned layers peel off, leaving fresh, new skin. Chemical peels vary in strength. Glycolic acid is among the mildest, and therefore has a lower risk of causing scarring or skin discoloration. Chemical peels may be used if melasma does not respond to other treatments.

  • Intense Pulsed Light therapy utilizes certain wave lengths of light to target and remove pigmented areas of skin.

When To Call a Professional

See your doctor if you develop any unexplained discoloration of the skin. Although melasma does not require treatment, a doctor can distinguish melasma from other skin disorders that may need to be treated.


Much of the discoloration will fade or disappear once hormones stabilize and you stay out of the sun. For people who find the discolorations unsightly, treatment may help to fade stubborn patches. You also can use cosmetics to even out the skin color.

Learn more about Melasma (Chloasma)

Associated drugs

  • Melasma

IBM Watson Micromedex

  • Melasma

External resources

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Medical Disclaimer

Why do I have dark spots on my lips?

Many of the causes listed below are easy to manage at home or require simple treatment:

1. Vitamin deficiency

Share on PinterestBlack spots can appear on the lips for various reasons.

Vitamins such as B-12 help to give the skin an even tone.

If the body is deficient in these vitamins, the skin may change. Dark spots on the lips or an uneven skin tone can indicate a vitamin deficiency.

Deficiencies should be diagnosed by a doctor, who may recommend adding vitamin-rich foods to the diet or taking a multivitamin supplement, depending on the severity of the deficiency.

In extreme cases, a doctor may recommend vitamin injections.

2. Dehydration

Dehydration can have many harmful effects on the body. Where the face is concerned, a lack of water in the diet can lead to chapped, irritated skin and lips.

The lips may become rough, and layers of skin may peel off, leading to small injuries. These could cause scabs, scars, and other changes of color in the lips.

Drinking plenty of water and eating liquid-rich foods throughout the day will usually prevent or treat minor dehydration.

3. Too much iron

An excessive intake of iron can lead to discolored skin.

A person may have too much iron in their body because they are taking too many iron supplements or receiving multiple transfusions of iron-rich blood.

Or, a person may have a hereditary condition called hemochromatosis. This causes the body to absorb too much iron from food, which may lead to changes in skin color.

If a person has an excess of iron, a doctor will carefully monitor and regulate levels over time. The doctor may recommend that they donate blood on a regular basis. Prescription medications may also help to remove the iron.

4. Medications

Chemical medications can also cause skin color changes and the formation of black spots on the lips.

Most of these medicines fall into the following categories:

  • cytotoxic drugs used during cancer treatment
  • antipsychotic drugs, such as chlorpromazine
  • antimalarial drugs, such as quinine sulfate
  • anticonvulsants, such as phenytoin
  • antiarrhythmic medications, such as amiodarone

Anyone taking these medications should contact a doctor if black spots form on their lips. The doctor may recommend a change in medication or a different treatment option.

5. Hyperpigmentation

Hyperpigmentation, or melasma, is a common and harmless skin issue.

Melasma occurs when patches of skin become discolored and appear brown or greyish. These can appear anywhere, including the lips.

Hormones may play a role in hyperpigmentation, and the pregnant women are often affected.

Protecting skin from the sun will often stop areas of hyperpigmentation from becoming more distinct. The patches may fade over time, and dermatologists may recommend topical medications to lighten the dark spots.

6. Allergies

An allergic reaction may be responsible for dark spots on the lips. This allergy is called pigmented contact cheilitis.

Potential irritants include:

  • lipstick or lip balm that may have expired
  • face makeup
  • toothpaste
  • hair dye or hair-lightening creams
  • green tea, which may irritate sensitive skin

Anyone with an allergic reaction should stop using products they suspect may be responsible and contact a doctor.

7. Hormone disorder

Dark or black spots on the lips can indicate a hormone disorder. Levels of thyroid hormone that are either low or high can cause spots or hyperpigmentation to occur on the body.

Contact a doctor to receive a diagnosis and develop a treatment plan.

8. Venous lake

A dark spot on the lip may be a venous lake.

This will look like a single, dark purple spot that is raised and feels soft when pressed. They can vary in size and usually appear in areas exposed to sun, such as the lips or ears.

Venous lakes are associated with sun exposure, though the direct cause is unknown. They usually do not indicate skin cancer.

Laser therapy can remove a venous lake if the person finds it unsightly. Protecting lips from the sun may help to prevent their development.

9. Sunspots

Share on PinterestIt is advisable to have a doctor check all sunspots.

These are areas of discolored skin that may feel hard or scaly. The medical community refers to sunspots as actinic keratosis.

Sunspots can appear on any skin that is exposed to sun.

They may have:

  • a flat or raised surface
  • a tone that matches the rest of the skin, or they may be slightly pink, red, or dark brown
  • a rough and dry surface
  • a crusty or flaky texture
  • a size ranging from very small to about 1 inch across

Actinic keratosis is considered a form of precancer, as the affected areas contain abnormal cells that could progress into cancer over time.

A doctor should inspect all sunspots. They may recommend freezing any abnormal cells, scraping or cutting them away, or removing them with chemical peels.

10. Angiokeratoma

An angiokeratoma is a skin lesion. Angiokeratomas vary in size, shape, and color, but they are usually dark red or black and hard to the touch. They may have an uneven surface.

These lesions tend to appear in older adults and may look like warts. Though they are usually harmless, a doctor should carefully inspect each angiokeratoma to ensure that it is not cancerous.

If a person wants an angiokeratoma removed, this is usually achieved with a laser or by freezing.

11. Dental fixtures

Any fixture in the mouth that does not fit well can cause pressure sores to appear on the lips or gums. Braces, dentures, and retainers are often responsible.

After a sore heals, it may leave behind a dark spot, and these may darken further if they are not protected from sunlight.

Treatment involves having an orthodontist correct the fit of the device and protecting the spots from sunlight as they heal.

12. Smoking and alcohol

Harmful chemicals and toxins in tobacco products can damage the lips and mouth.

Drinking too much alcohol can also disrupt the balance of toxins in the body and cause dark spots to appear on the lips.

Quitting or limiting consumption of these products can help to prevent this symptom.

13. Cancer

Cancerous growths on the lips have a variety of appearances. Look out for the following symptoms:

  • a growth with an irregular shape
  • a growth that has rapidly increased in size
  • an open or bloody sore
  • a shiny growth
  • a growth with an unusual color
  • scaly red patches of skin
  • scar-like tissue

Cancerous growths on the lips are usually removed surgically, or by freezing or radiation.

Is There Any Way to Treat Upper Lip Discoloration?

Q: I have a faint, dark discoloration on my upper lip; what is it, and how can I get rid of it?
A: My six least favorite words from any doctor: “I don’t know what this is.” Lucky for you, Deborah Sarnoff, MD, clinical associate professor of dermatology at New York University Medical Center, has some ideas about what might be causing your problem. It may be hormone related: Circulating estrogen, either your own or from estrogen replacement therapy, when combined with sun exposure, can cause the kind of discoloration you describe. Or it may be caused by inflammation on your upper lip if you’ve had acne or a hair removal treatment (like waxing or tweezing), which can cause darkening of the skin when exposed to sunlight, especially in people with darker skin.
Bottom line: A cream containing hydroquinone or kojic acid (such as La Roche-Posay Mela-D Dark Spots, $45) along with a topical retinoid (like prescription Renova) and mild over-the-counter hydrocortisone cream can fade the discoloration after about six weeks of nightly use. But nothing will work unless you also use sunblock religiously.

Unmasking the causes and treatments of melasma

This challenging skin condition causes dark patches on the skin that can last for years.

Published: October, 2018

By October, your summer tan is probably almost gone, but a glance in the mirror may still show some darkened patches on your skin that seem to be sticking around. These brown or grayish-brown blotches, typically on the forehead, chin, cheeks, upper lip, or nose, may signal a condition called melasma.

Melasma is sometimes referred to as the mask of pregnancy, because it is sometimes triggered by an increase in hormones in pregnant women. But while the condition may be common among pregnant women, it isn’t limited to them.

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What is melasma?

Melasma is a chronic skin disorder that results in symmetrical, blotchy, brownish facial pigmentation. Melasma can also affect the arms and back. It can lead to considerable embarrassment and distress.

This form of facial pigmentation is sometimes called chloasma, but as this means green skin, the term melasma (brown skin) is preferred.

Melasma / chloasma

See more images of melasma.

Who gets melasma?

Melasma is more common in women than in men; only 1-in-4 to 1-in-20 affected individuals are male, depending on the population studied. It generally starts between the age of 20 and 40 years, but it can begin in childhood or not until middle age.

Melasma is more common in people that tan well or have naturally brown skin (Fitzpatrick skin types 3 and 4) compared with those who have fair skin (skin types 1 and 2) or black skin (skin types 5 or 6).

What causes melasma?

The cause of melasma is complex. The pigmentation is due to overproduction of melanin by the pigment cells, melanocytes, which is taken up by the keratinocytes (epidermal melanosis) and deposited in the dermis (dermal melanosis, melanophages). There is a genetic predisposition to melasma, with at least one-third of patients reporting other family members to be affected. In most people, melasma is a chronic disorder.

Known triggers for melasma include:

  • Sun exposure and sun damage — this is the most important avoidable risk factor. Visible light and ultraviolet rays contribute to abnormal pigmentation
  • Pregnancy — in affected women, the pigment often fades a few months after delivery
  • Hormone treatments — oral contraceptive pills containing oestrogen and progesterone, hormone replacement, intrauterine devices and implants are a factor in about a quarter of affected women
  • Certain medications (including new targeted therapies for cancer), scented or deodorant soaps, toiletries and cosmetics may cause a phototoxic reaction that triggers melasma, which may then persist long term
  • Hypothyroidism

Melasma commonly arises in healthy, non-pregnant adults. Lifelong sun exposure causes deposition of pigment within the dermis, and this often persists long-term. Exposure to ultraviolet radiation (UVR) deepens the pigmentation because it activates the melanocytes to produce more melanin.

Research is attempting to pinpoint the roles of stem cell, neural, vascular and local hormonal factors in promoting melanocyte activation.

What are the clinical features of melasma?

Melasma presents as macules (freckle-like spots) and larger flat brown patches. These are found on both sides of the face and have an irregular border. There are several distinct patterns.

  • Centrofacial pattern: forehead, cheeks, nose and upper lips
  • Malar pattern: cheeks and nose
  • Lateral cheek pattern
  • Mandibular pattern: jawline
  • Reddened or inflamed forms of melasma (also called erythrosis pigmentosa faciei)
  • Poikiloderma of Civatte: reddened, photoaging changes are seen on the sides of the neck, mostly affecting patients older than 50 years
  • Brachial type of melasma affecting shoulders and upper arms (also called acquired brachial cutaneous dyschromatosis).

Melasma is sometimes separated into epidermal, dermal, and mixed types. A Wood lamp that emits black light (UVA1) may be used to identify the depth of the pigment.

Epidermal melasma

  • Well-defined border
  • Dark brown colour
  • Appears more obvious under black light
  • Responds well to treatment

Dermal melasma

  • Ill-defined border
  • Light brown or bluish
  • Unchanged under black light
  • Responds poorly to treatment

Mixed melasma

  • The most common type
  • Combination of bluish, light and dark brown patches
  • A mixed pattern is seen under black light
  • Partial improvement with treatment

How is melasma diagnosed?

The characteristic appearance of melasma means the diagnosis is usually straightforward and made clinically. Other disorders that may be considered instead of melasma or as well as melasma include:

  • Postinflammatory pigmentation
  • Solar lentigines and other forms of lentigo
  • Drug-induced pigmentation, e.g. due to minocycline or nonsteroidal anti-inflammatory drugs
  • Lichen planus
  • Naevus of Ota and naevus of Hori
  • Guttate hypomelanosis, in which pale spots are prominent.

Occasionally, a skin biopsy may be performed to make or confirm the diagnosis of melasma. Histology varies with the type of melasma. But some degree of each of the following features is usually found.

  • Melanin deposited in basal and suprabasal keratinocytes
  • Highly dendritic (branched) intensely pigmented melanocytes
  • Melanin in the dermis within melanophages
  • Solar elastosis and elastic fibre fragmentation

The extent and severity of melasma can be described using the Melasma Area and Severity Index (MASI).

What is the treatment of melasma?

Melasma can be very slow to respond to treatment, especially if it has been present for a long time. Treatment may result in irritant contact dermatitis in patients with sensitive skin, and this can result in post-inflammatory pigmentation.

Generally, a combination of the following measures is helpful.

General measures

  • Discontinue hormonal contraception.
  • Year-round life-long sun protection. Wear a broad-brimmed hat.
  • Use broad-spectrum very high protection factor (SPF 50+) sunscreen applied to the whole face daily, year-round. It should be reapplied every 2 hours if outdoors during the summer months. Sunscreens containing iron oxides are preferred, as they screen out some visible light as well as ultraviolet radiation. Alternatively or as well, use a make-up that contains sunscreen.
  • Use a mild cleanser, and if the skin is dry, a light moisturiser.
  • Cosmetic camouflage (make-up) is invaluable to disguise the pigment.

Topical therapy

Tyrosinase inhibitors are the mainstay of treatment. The aim is to prevent new pigment formation by inhibiting the formation of melanin by the melanocytes.

  • Hydroquinone 2–4% as cream or lotion, applied accurately to pigmented areas at night for 2–4 months. This may cause contact dermatitis (stinging and redness) in 25% of patients. It should not be used in higher concentration or for prolonged courses as it has been associated with ochronosis (a bluish grey discolouration similar to that seen in alkaptonuria).
  • Azelaic acid cream, lotion or gel can be applied twice daily long term and is safe in pregnancy. This may also sting.
  • Kojic acid or kojic acid dipalmitate is often included in formulations, as it binds copper, required by L-DOPA (a cofactor of tyrosinase). Kojic acid can cause irritant contact dermatitis and less commonly, allergic contact dermatitis.
  • The mechanism of action of cysteamine cream is unclear but is thought to involve inhibition of tyrosinase. A study of 50 patients with melasma found cysteamine cream to be significantly more effective than a placebo cream.
  • Ascorbic acid (vitamin C) also acts through copper to inhibit pigment production. It is well tolerated but highly unstable, so is usually combined with other agents.
  • Methimazole (antithyroid drug) cream has been reported to reduce melanin synthesis and pigmentation in hydroquinone-resistant melasma.
  • New agents under investigation include zinc sulfate mequinol, arbutin and deoxyarbutin (from berries), liquorice extract, rucinol, resveratrol, 4-hydroxy-anisole, 2,5-dimethyl-4-hydroxy-3(2H)-furanone and/or N-acetyl glucosamine

Other active compounds used for melasma include:

  • Topical corticosteroids such as hydrocortisone. These work quickly to fade the colour and reduce the likelihood of contact dermatitis caused by other agents. Potent topical steroids are best avoided due to their potential to cause adverse effects.
  • Soybean extract, which is thought to reduce the transfer of pigment from melanocytes to skin cells (keratinocytes) and to inhibit receptors.
  • Tranexamic acid has been used experimentally for melasma as a cream or injected into the skin (mesotherapy), showing some benefit. It may cause allergy or irritation.

The superficial or epidermal pigment can be peeled off. Peeling can also allow tyrosinase inhibitors to penetrate more effectively. These must be done carefully as peels may also induce post-inflammatory pigmentation.

  • Topical alpha hydroxyacids including glycolic acid and lactic acid, as creams or as repeated superficial chemical peels, remove the surface skin and their low pH inhibits the activity of tyrosinase.
  • Topical retinoids, such as tretinoin (a prescription medicine) are effective. Tretinoin can be hard to tolerate and sometimes causes contact dermatitis. Do not use during pregnancy.
  • Salicylic acid, a common peeling ingredient in skin creams, can also be used for chemical peels, but it is not very useful in melasma.

The most successful formulation has been a combination of hydroquinone, tretinoin, and moderate potency topical steroid. This has been found to result in improvement or clearance in up to 60–80% of those treated. Many other combinations of topical agents are in common use, as they are more effective than a single agent. However, these products are often expensive.

Oral treatment of melasma

Oral medications for melasma are under investigation, including tranexamic acid. Tranexamic acid is a lysine analogue that inhibits plasmin and is usually used orally to stop bleeding. It reduces the production of prostaglandins, the precursors of tyrosine. In a low dose, tranexamic acid has been reported to be effective and safe in the treatment of melasma, providing patients have been carefully selected and are at low risk of thromboembolic disease.

Glutathione is also under investigation as a systemic skin whitening agent but has potentially severe adverse effects.

Devices used to treat melasma

The ideal treatment for melasma would destroy the pigment while leaving the cells alone. Unfortunately, this is hard to achieve. Machines can be used to remove epidermal pigmentation, but with caution—over-treatment may cause postinflammatory pigmentation. Patients should be pretreated with a tyrosinase inhibitor (see above).

Fractional lasers, Q-switched Nd:YAG lasers, picosecond lasers and intense pulsed light (IPL) appear to be the most suitable options. Several treatments may be necessary, and post-inflammatory hyperpigmentation may complicate recovery.

Carbon dioxide or erbium:YAG resurfacing lasers, pigment lasers (Q-switched ruby and Alexandrite devices) and mechanical dermabrasion and microdermabrasion should be used with caution in the treatment of melasma.

What is the outcome of treatment of melasma?

Results take time, and the above measures are rarely entirely successful.

Unfortunately, even in those that get a good result from treatment, pigmentation may reappear on exposure to summer sun and because of hormonal and endogenous factors. New topical and oral agents are being studied and offer hope for effective treatments in the future.

Treatment is not always necessary for melasma.

If hormonal changes, such as those that occur during pregnancy or while taking birth control pills, have caused melasma, it will fade after delivery or once a person stops taking the pills.

For other people, melasma can last for years or even for the rest of their lives. If melasma does not fade over time, a person can seek treatment to help remove or fade the patches.

However, not all treatments work for everyone, and melasma may come back even after successful treatment.

Treatment options for melasma include:


Share on PinterestA person can apply hydroquinone lotion directly to melasma to lighten the skin.

Doctors often use hydroquinone as the first line of treatment for melasma. Hydroquinone is available as a lotion, cream, or gel.

A person can apply the hydroquinone product directly to the patches of skin that are discolored.

Hydroquinone is available over the counter, but a doctor can also prescribe stronger creams. Hydroquinone works by lightening the color of the skin patches.

Corticosteroids and tretinoin

Corticosteroids and tretinoin come in creams, lotions, or gels. Both corticosteroids and tretinoin can help lighten the color of the melasma patches.

Combined creams

In some cases, a dermatologist may choose to prescribe combination creams that may contain hydroquinone, corticosteroids, and tretinoin in one. These are called triple creams.

Additional topical medications

In addition to or instead of other medicated creams, a dermatologist may also prescribe azelaic acid or kojic acid. These acids work to lighten the dark areas of skin.

Medical procedures

If topical medications do not work, a dermatologist may recommend procedures such as:

  • microdermabrasion
  • chemical peel
  • laser treatment
  • light therapy
  • dermabrasion

Some of these treatment options have side effects or may cause additional skin problems. It is best to speak with a doctor or dermatologist about all the possible risks.

If a person has had melasma before, they can try to avoid triggers by:

  • limiting sun exposure
  • wearing a hat when outside
  • using sunscreen

Acne scarring. Sun damage. Inflammation lingering from an eczema flare-up. Hyperpigmentation, a broad term that refers to a skin condition in which the skin is discolored or darkened, can be brought on by many different factors.

But, as it turns out, there’s a type of hyperpigmentation that you may have never heard of until now. It’s known as melasma, and it’s a pigmentary condition that affects more than five million Americans, most of them being women. Much like general hyperpigmentation, melasma appears in the form of discoloration on the skin and is exacerbated by exposure to the sun. However, there are actually quite a few differences that set it apart from your run-of-the-mill hyperpigmentation (which we’ll get into, don’t worry).

While no one should ever feel like they have to hide a skin ailment, it’s important to know the differences between the two conditions if you choose to treat them. Ahead, a definitive breakdown of melasma and hyperpigmentation, the differences between the two, and how to treat them — as detailed by four trusted dermatologists.

Hyperpigmentation can refer to any darkening of the skin.

Whether you have post-blemish scarring from a stubborn breakout, freckles that expanded into full-blown sun spots from excess exposure, or discoloration caused by a condition like eczema or psoriasis, the discoloration usually all falls under the umbrella of hyperpigmentation. This is because acne, sunlight, skin rashes, and the like have the potential to stimulate melanocytes, the pigment-making cells in the skin, to make a surplus of pigment, “causing them to dump their pigment into lower levels of the skin, like tattoo pigment, where it doesn’t belong,” explains Adam Friedman, an associate professor of dermatology at George Washington University Medical Faculty Associates in Washington, D.C. The deeper the pigment, the tougher it is to treat. Put it this way: A section of skin that’s been consistently exposed to harmful UV rays without the proper protection will be harder to diminish than say, a dark spot leftover from a pimple that you’ve been careful to shield from the sun. In other words, the level of severity varies, but if you spot discoloration on your skin that wasn’t there before, it’s safe to assume it’s hyperpigmentation. But always consult your doctor to be sure, of course.

Melasma is in a league of its own.

Melasma is a form of hyperpigmentation that’s more commonly seen in women (especially in those with darker skin tones) and is thought to be triggered by UV exposure, as well as hormonal influences. The latter is what distinguishes it from traditional hyperpigmentation and makes it tougher to treat. “Hormonal influences play a significant role here, as seen by the increased prevalence of pregnancy, oral contraceptive use, and other hormonal therapies,” says Friedman. “The problem is preventing its worsening, especially from the hormonal angle, as it can be hard to remove the instigating factors.”

You can usually tell if you have melasma based on its appearance alone. ” typically appears as symmetric blotchy hyperpigmented patches on the face, usually the cheeks, bridge of the nose, forehead, chin, and upper lip,” says Sejal Shah, a dermatologist and founder of Smarter Skin Dermatology in New York City. While less common, melasma can appear on other parts of the body — especially those more prone to sun exposure (like the neck and forearms) — and many people say their melasma worsens in the summer and improves in the winter. “It may appear during pregnancy or after starting birth control or other hormonal treatments,” Shah says. (Something to consider if you’ve seen discoloration appear shortly after switching up your birth control or undergoing a hormonal change.)

Finally, there are a couple of factors that can contribute to the spreading of melasma: visible light and heat. For the former, New York City-based dermatologist Shari Marchbein recommends using makeup that contains iron oxide to help block visible light. Unfortunately, steering clear of infrared heat proves more difficult, as it can be generated just by being in hot environments such as a sauna, a steamy kitchen, or even the gym.

Most treatments are the same, but melasma is harder to get rid of.

As mentioned above, melasma is difficult to treat. This is because, unlike traditional hyperpigmentation, which responds to a variety of over-the-counter products that contain brightening agents like vitamin C, kojic acid, niacinamide, hydroquinone, and azelaic acid, melasma hasn’t seen the same rate of success or consistency.

Dark Spots? Here’s How to Treat and Control Melasma, According to Dermatologists

While interviewing a dermatologist for a story last year, I shamelessly took the opportunity to ask about something that had been bothering me. “What is this on my forehead?” I asked, pulling my hair back. He leaned in to inspect my brown-speckled skin. “It looks like melasma,” he said.

The dark spots on my face had only appeared a few years earlier. I thought back to a hiking trip I took in my 20s; I’d made sure to wear sunscreen, since I knew I’d be at a higher altitude in the mountains and that the sun would be strong. But I forgot to reapply, and ended up sunburned. Ever since, I’d been plagued by these brownish-gray patches.

According to New York-based dermatologist Rachel Nazarian, MD, you can develop these annoying brown spots on your skin at any point in your life, but they can suddenly crop up in adult women due to changes in hormones. Below, we asked dermatologists for their best tips to treat and prevent skin pigmentation caused by melasma.

Melasma is dark brown or gray discoloration of the skin that typically affects sun-exposed parts of the face, such as the forehead, cheeks, and upper lip. The greater the baseline melanin is in skin, the more likely you are to experience melasma—which means those with darker skin tones are more likely to have it, says Dr. Nazarian.

Certain health conditions can also make you more sensitive to sunlight and more prone to developing melasma, Dr. Nazarian explains, such as thyroid problems and being on birth control pills. It’s also thought to be hereditary, she adds, so if one of your parents has melasma, you might develop it, too.

Pregnancy can up your risk as well. In fact, melasma is often referred to as the “mask of pregnancy” and can occur in up to 50% of pregnant women, Debra Jaliman, MD, a New York City-based dermatologist, tells Health. Because hormones change during pregnancy, skin is more sensitive to sunlight, which can cause your complexion to go from clear to a little spotty.

Prevention is seriously easy

To avoid melasma (or at least control dark pigmentation you already have), the best preventative measure is to use SPF on your face every single day, rain or shine. A few derm-approved favorites include EltaMD UV Clear Tinted Facial Sunscreen Broad-Spectrum SPF 46($35;,Neutrogena Ultra Sheer Dry-Touch Sunscreen SPF 55 ($12; and Drunk Elephant Umbra Sheer Physical Daily Defense Broad Spectrum Sunscreen SPF 30 ($34;

It’s smart to avoid too much sun and heat, but if exposed, be sure to cover with a wide-brimmed hat. As I learned firsthand, melasma can crop up from sunburn. Dr. Nazarian points out that some oral medications and supplements, such as Heliocare ($19; may make you less sensitive to sunlight and, if taken daily, could lessen your chances of getting melasma.

Best treatments for melasma

Once you have them, it can be challenging to rid yourself of these freckly brown spots. Melasma rarely goes away on its own, experts say, but there are treatments you can try to ease their appearance.

In addition to wearing sunscreen religiously, Dr. Jaliman says products that contain niacinamide (vitamin B3), a potent antioxidant, can help even skin tone. Try InstaNatural Niacinamide 5% Face Serum ($15;, which boasts niacinamide and ultra-moisturizing hyaluronic acid.

Also good: Vitamin C inhibits an enzyme called tyrosine from converting into melanin (the pigment that darkens skin), so skin gets brighter. Investing in a topical vitamin C serum can help improve dark discoloration. We like Mad Hippie Vitamin C Serum ($28;

It may require a combination of different treatments, but getting rid of melasma is not impossible. If you aren’t having luck with topical treatments, book an appointment with your dermatologist to learn more about in-office procedures. Dr. Nazarian recommends Vi Peels (a chemical peel) and light treatments such as IPL combined with resurfacing lasers such as Fraxel to combat melasma.

“These should only be done by a board-certified dermatologist, as they have the risk of making melasma worse if not done properly,” Dr. Nazarian warns. She stresses the importance of continuing to wear a high-SPF sunscreen and avoiding heat to prevent reoccurrence.

How best to conceal melasma

When I first started noticing darker pigmentation in my forehead, I found myself a little self-conscious. What began as severe sunburn faded into grayish spots that made me look, well, old. But I’ve since learned that there are a few affordable and effective ways to conceal dark pigmentation caused by melasma.

Dr. Jaliman suggests trying over-the-counter products with ingredients like kojic acid, licorice extract, topical vitamin C, white mulberry extract, or bearberry extract, which all work to lighten skin and improve dark discoloration. Tinted moisturizers and sunscreen primers provide good melasma coverage (try It Cosmetics Your Skin But Better CC Cream, which is has an A-list stamp of approval from reality star Whitney Port).

For more severe dark spots, consider makeup from CoverFx to camouflage discoloration. Dr. Nazarian likes CoverFX Power Play Foundation ($44;, because it works well to cover many skin conditions, including melasma.

Q. Does melasma go away on its own?

A. Melasma is a skin condition that typically develops slowly and, in some cases, may disappear on its own. However, with the right treatment combination and sun protection, it’s possible to achieve comprehensive results much faster.

How Can Nashville Skin Help?

All of our skin care professionals at Nashville Skin have extensive expertise in the latest and most effective medical dermatology methods for treating patients with pigment issues. Nashville Skin specializes in treatments for melasma that are non-invasive and require little recovery time, yet provide robust long-term results.

If you have melasma and are searching for an effective treatment, contact us today at one of our three convenient Nashville locations (21st avenue S., Southern Hills Medical Center, Centennial Medical Center or St. Thomas Medical Center – Lennox Village ), and our Clarksville office to schedule a formal evaluation to determine your unique melasma treatment needs.

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