Melasma: Why Dark Patches
Appear and What Fades Them

Melasma is a common pigment condition that causes symmetrical tan or brown patches on the cheeks, forehead, upper lip, and chin. It is driven by three things working together: hormones, sun and visible light, and a genetic tendency, which is why it is most common in women, often starts during pregnancy or with birth control pills, and worsens every summer. Melasma is not dangerous, but it is stubborn. Daily tinted mineral sunscreen is the foundation of every treatment plan, and prescription lightening creams and oral tranexamic acid fade most cases over two to four months. Belaray Dermatology treats melasma at its Hicksville and Stony Brook offices.

What Does Melasma Look Like?

Melasma appears as flat patches of tan, brown, or gray-brown color with irregular but fairly symmetrical borders. The most common pattern covers the cheeks, bridge of the nose, forehead, and upper lip, giving a mask-like appearance that is sometimes called the “mask of pregnancy.” A second pattern affects the cheeks and jawline, and a less common one affects the forearms and shoulders. The patches do not itch, scale, or hurt. They darken within hours of sun exposure and fade somewhat in winter.

What Causes Melasma?

• Sunlight and visible light. Ultraviolet light is the strongest trigger, but high-energy visible light (the blue part of daylight, which also comes from screens at much lower intensity) and heat darken melasma too. This is why ordinary sunscreen is not enough and why melasma returns every summer.
• Hormones. Estrogen and progesterone stimulate pigment cells. Melasma commonly begins during pregnancy, with oral contraceptives, or with hormone therapy, and about 90 percent of patients are women.
• Genetics and skin type. Melasma runs in families and is most common in people with olive, brown, or tan skin that tans easily, including patients of Hispanic, Asian, Middle Eastern, and African descent.
• Other triggers. Thyroid disease, some seizure and photosensitizing medications, and irritating skincare or waxing that inflames the skin can all contribute.

Melasma vs. Sun Spots vs. Post-Inflammatory Hyperpigmentation

Three common causes of brown marks on the face are often confused, and they are treated differently.

• Melasma: larger, symmetrical, blotchy patches on the central face in a woman of child-bearing age; worsens with sun, heat, and hormones; fades and returns.
• Sun spots (solar lentigines): small, round, sharply defined brown spots on sun-exposed skin, including the hands and shoulders, that accumulate with age and do not come and go. These respond well to laser and light treatment.
• Post-inflammatory hyperpigmentation: a brown or gray mark left behind by a pimple, rash, cut, or procedure, in the exact shape of the original injury. It fades on its own over months, faster with sunscreen and lightening creams. See dermatology for skin of color.

A dermatologist can usually tell these apart on examination. A Wood’s lamp helps show whether melasma pigment sits in the upper skin layer (epidermal, which responds well to creams) or deeper (dermal, which is slower to respond).

How Is Melasma Treated?

1. Sun and Light Protection, Every Day

No melasma treatment works without it. Use a tinted mineral sunscreen containing zinc oxide or titanium dioxide plus iron oxides, SPF 30 or higher, every morning, year-round, indoors and out. The iron oxides give the tint and block visible light, which clear sunscreens do not. Reapply when outdoors, wear a wide-brimmed hat, and avoid peak sun. Sun protection alone lightens melasma over a few months in many patients. See our sunscreen guide.

2. Topical Lightening Treatment

• Hydroquinone (prescription, usually 4 percent) is the most effective single lightening agent. It is used nightly for a limited course, typically three to four months, then stopped or cycled to avoid side effects. It is not used during pregnancy or breastfeeding.
• Triple-combination cream (hydroquinone, tretinoin, and a mild corticosteroid, sold as Tri-Luma or compounded) is the most effective prescription cream for moderate to severe melasma and is used in the same cycled way.
• Non-hydroquinone options for maintenance, pregnancy, or sensitive skin: azelaic acid (safe in pregnancy), topical tranexamic acid, cysteamine cream, kojic acid, niacinamide, and vitamin C serums. These work more slowly but can be used long term.
• Retinoids (tretinoin, adapalene) speed cell turnover and improve the penetration of lightening agents; they are started at low strength because irritation can darken melasma.

3. Oral Tranexamic Acid

For melasma that does not respond to sunscreen and topical treatment, low-dose oral tranexamic acid, taken for two to four months under a dermatologist’s supervision, reduces the signals that drive pigment production and is one of the most effective additions available. It is used off-label for melasma and is not prescribed to patients with a history of blood clots, clotting disorders, or certain other conditions, so screening comes first.

4. Procedures, Used With Caution

Lasers and intense pulsed light (IPL) can worsen melasma by inflaming the skin and are used only selectively, at low settings, and after medical treatment has stabilized the pigment. Superficial peels and microneedling are sometimes combined with lightening agents in resistant cases. Any procedure for melasma must be followed by strict sun protection or the pigment returns darker than before.

Can Melasma Be Prevented?

• Tinted mineral sunscreen every morning, including in winter and on cloudy days.
• A wide-brimmed hat outdoors from May through September on Long Island, when the UV index is highest.
• Avoid heat exposure to the face where possible: saunas, steam, and hot yoga darken melasma.
• Gentle skincare only. Scrubs, harsh acids, and waxing the upper lip inflame the skin and deepen pigment.
• If you are starting birth control or hormone therapy and have had melasma, discuss options with your prescriber.

When Should I See a Dermatologist?

See a dermatologist to confirm that facial patches are melasma rather than sun spots, post-inflammatory marks, or, rarely, a pigmented growth that needs a closer look. A dermatologist can prescribe hydroquinone and triple-combination creams, screen for and prescribe oral tranexamic acid, and build a maintenance plan that keeps the pigment from returning. Over-the-counter products alone rarely clear established melasma.

Frequently Asked Questions

Does melasma go away on its own?

Sometimes. Melasma that begins in pregnancy often fades within a year after delivery, and melasma triggered by birth control pills may improve after stopping them. Melasma that has been present for years rarely clears without treatment. Daily tinted sunscreen and prescription lightening creams fade most cases within two to four months, with maintenance to keep it from returning.

What is the best cream for melasma?

Prescription hydroquinone 4 percent, or a triple-combination cream containing hydroquinone, tretinoin, and a mild corticosteroid, is the most effective topical treatment and is used in cycles of three to four months. For maintenance, pregnancy, or sensitive skin, azelaic acid, topical tranexamic acid, cysteamine, kojic acid, and vitamin C are slower but safe for long-term use. No cream works without daily sunscreen.

Why does my melasma come back every summer?

Because ultraviolet light, visible light, and heat all stimulate the pigment cells in melasma, and Long Island’s UV index is high from May through August. Clear sunscreens block UV but not visible light. A tinted mineral sunscreen containing iron oxides, worn every day and reapplied outdoors, along with a hat and shade, is the most effective way to prevent the summer return.

Is melasma a sign of a health problem?

Usually not. Melasma is a cosmetic pigment condition driven by hormones, light, and genetics, and it is not dangerous. It can be associated with pregnancy, hormonal contraception, hormone therapy, and occasionally thyroid disease, so a dermatologist may ask about these. Any dark patch that is raised, changing in shape, or asymmetrical should be examined to rule out other causes.

Can laser remove melasma?

Not reliably, and it can make melasma worse. Lasers and IPL inflame the skin and often deepen melasma pigment or cause rebound darkening. They are reserved for selected resistant cases, used at low settings after medical treatment has stabilized the pigment, and always followed by strict sun protection. Sunscreen, lightening creams, and oral tranexamic acid are the main treatments.

Is tranexamic acid safe for melasma?

Low-dose oral tranexamic acid is effective for stubborn melasma and is generally well tolerated when prescribed for two to four months by a dermatologist. Because it affects clotting, it is not given to patients with a history of blood clots, clotting disorders, certain heart conditions, or who use estrogen-containing contraception without review. Topical tranexamic acid is an alternative with no clotting concern.

Is melasma the same as sun spots?

No. Melasma forms larger, symmetrical, blotchy patches on the central face, worsens with sun, heat, and hormones, and comes and goes. Sun spots are small, round, sharply defined brown spots on sun-exposed skin that accumulate with age and stay put. Sun spots respond well to laser and light treatment, which can worsen melasma, so the diagnosis changes the plan.

Related reading: our sunscreen guide, dermatology for skin of color, BBL and IPL photofacials for sun spots, and the patient education hub.