Melasma: causes, treatment and how to lighten facial patches

Melasma is an acquired hyperpigmentation that appears as symmetrical brown patches on the face — mainly the cheeks, forehead, upper lip and chin. It results from a combination of genetic predisposition, hormones and sun exposure, and affects mostly women aged 20 to 50. It does not disappear permanently, but it lightens significantly with the right treatment and rigorous sun protection. Treatment combines topical depigmenting agents, daily sun protection and, in selected cases, oral medication or laser. Without sun protection, any treatment fails.

What is the “mask of pregnancy”?

It is one of the common names for melasma, used when it appears during pregnancy. It is also called chloasma.

They all describe the same picture: brown or brownish patches with irregular but well-defined borders, distributed symmetrically on both sides of the face. That symmetry is characteristic and helps distinguish it from other pigmentation.

What causes melasma on the face?

Three factors combine, and rarely does one act alone.

Sun. The main driver. Ultraviolet radiation and also visible light — including from screens, though to a far smaller degree — stimulate melanocytes. A single careless exposure can undo months of treatment.

Hormones. Pregnancy, oral contraceptives and hormone therapy. This explains the overwhelming female predominance and why it appears after pregnancy or after starting the pill.

Genetics. A mother or sisters with the same condition is common. It predominates in skin types III to V.

Heat also contributes — ovens, cooking, saunas — along with some photosensitising medications and previous skin inflammation.

Which types of melasma are there?

Classification depends on the depth of the pigment, and it determines the prognosis.

Epidermal. The pigment sits in the superficial layer. Patches are well-defined brown and this is the type that responds best to treatment.

Dermal. The pigment is deeper. Patches have a greyish or bluish tone with less distinct borders, and the response to treatment is slower and more limited.

Mixed. Both coexist. This is the most common.

The distinction is made in consultation, with dermoscopy and Wood's lamp. This is not an academic detail: it determines what is realistic to expect.

How do I remove melasma patches from my face?

Treatment rests on three pillars, and none works alone.

1. Sun protection. Not an accessory piece of advice — it is the foundation. SPF 50+ with protection against visible light, which tinted filters provide and transparent ones do not. Apply in the morning and reapply every four hours. Wide-brimmed hat.

2. Topical depigmenting agents. Hydroquinone, azelaic acid, kojic acid, topical tranexamic acid, niacinamide, retinoids, vitamin C. Used alone or in combined formulations, chosen according to type, stage and skin tolerance.

3. Procedures. Superficial chemical peels, microneedling with depigmenting agents, and specific lasers. These are an adjunct, never a starting point.

In resistant cases there is oral tranexamic acid, on prescription and with medical monitoring — it has relevant contraindications, particularly in anyone at thrombotic risk.

What is the best cream for melasma?

The honest answer is that it depends, and that cream alone is not enough.

On prescription: hydroquinone remains the most effective depigmenting agent, used in limited cycles and under supervision. Combined formulations with a retinoid and a corticosteroid are the reference standard for moderate to severe cases.

Over the counter: azelaic acid, topical tranexamic acid, niacinamide, vitamin C, alpha-arbutin. Slower but better tolerated in prolonged use, and well suited to maintenance.

The most common mistake is buying the cream and neglecting the sunscreen. In that order, the outcome is predictable: little or none.

Does laser treatment work for melasma?

It helps in selected cases and makes things worse in others.

Melasma is an inflammatory and vascular condition, not merely a pigmentary one. Heat and inflammation stimulate melanocytes — and a poorly chosen or poorly set laser does exactly that.

The devices with the best profile are low-fluence lasers, used at reduced energy across several sessions. Aggressive ablative lasers and intense pulsed light at high settings are contraindicated and can cause lasting worsening.

Laser is never the first step. It comes after the condition is stabilised with topicals and sun protection, and the cost depends on the number of sessions, set after assessment.

How do I treat melasma “from the inside out”?

The phrase usually refers to two different things.

Oral medication with evidence: oral tranexamic acid has shown results in resistant cases, on prescription and after assessment of thrombotic risk. It is not a supplement and is not bought over the counter.

Antioxidant supplements: Polypodium leucotomos, tranexamic acid, glutathione and oral vitamin C are used as adjuncts. The evidence is modest and none replaces topical treatment or sun protection.

What does not exist is a cure through diet. A balanced diet benefits the skin in general, but does not lighten melasma.

Do home remedies work?

Some are harmless. Others make things worse.

Do not apply to the face: lemon, vinegar, bicarbonate of soda, hydrogen peroxide or toothpaste. Lemon is the most dangerous — it is phototoxic, and combined with sun it causes a chemical burn that leaves a darker and more persistent mark than the original.

Melasma is an inflammatory condition. Anything that irritates the skin tends to aggravate it, and that includes excessive exfoliation, cleansing brushes and acids used without guidance.

Can melasma be eliminated permanently?

No. It is controlled, and control can be very good.

It is a chronic and relapsing condition. With appropriate treatment it is possible to lighten the patches substantially and keep them that way for years — provided sun protection is maintained.

Relapse is the rule once sun protection is abandoned. One summer without care undoes a year of treatment.

Melasma of pregnancy may regress spontaneously in the months after birth, but not always, and the likelihood of it returning in a subsequent pregnancy is high.

Can I use a sunbed if I have melasma?

No.

Sunbeds emit ultraviolet radiation in concentrated doses, which is precisely the main driver of melasma. Beyond markedly worsening the patches, they raise skin cancer risk and accelerate skin ageing.

There is no safe tanning for anyone with melasma — not on a sunbed, and not in the sun.

Not every brown patch is melasma

This section exists for a reason.

Brown patches on the face may be solar lentigines, smaller and asymmetrical, linked to cumulative exposure. They may be seborrhoeic keratoses, raised with a rough surface. They may be post-inflammatory hyperpigmentation, left by acne or another lesion.

And they may, in rare but real cases, be malignant lesions. Lentigo maligna is a melanoma that presents as a flat brown patch of slow growth on sun-damaged skin — and is frequently mistaken for an age spot.

A new brown patch that grows, changes colour, has an irregular border or is clearly different from the others should be examined. Applying a lightening treatment to a malignant lesion delays diagnosis.

When should I see a dermatologist?

• When brown patches appear on the face for the first time

• Before starting any lightening product, to establish what kind of patch it is

• When three months of appropriate treatment have changed nothing

• When the patches return every summer

• When one patch is different from the others, grows or changes

• When the patches are affecting self-esteem

Dr Ellene Papazis is a dermatologist accredited in Portugal and Brazil, and treats patients with melasma in Porto, Portugal.

Sources

• American Academy of Dermatology — melasma and hyperpigmentation recommendations

• European Academy of Dermatology and Venereology

• Portuguese Society of Dermatology and Venereology (SPDV)

• Pigmentary Disorders Academy — consensus on melasma classification and treatment

Written and reviewed by Dr Ellene Papazis, dermatologist accredited in Portugal and Brazil. Consultations in Porto, Portugal.

Updated 25 July 2026.