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Melasma

Also known as: melasma, chloasma, pregnancy mask, mask of pregnancy

Melasma is a chronic, relapsing hyperpigmentation disorder causing symmetrical, irregular brown or grey-brown facial patches. Ultraviolet and visible light, hormonal influences and genetic susceptibility contribute, but its biology extends beyond excess melanin and no treatment reliably prevents recurrence.

Evidence status

Moderate

Diagnosis, photoprotection and short-term medical treatment have substantial guideline and trial support. Comparative studies are heterogeneous, most follow-up is short, and durable remission or recurrence prevention remains inadequately evidenced.

Definition#

Melasma is an acquired hyperpigmentation disorder characterised by symmetrical, irregular brown to grey-brown macules and patches, most often on sun-exposed areas of the face. It is chronic and relapsing: treatment may lighten it, but no current approach reliably prevents it returning.[1, 2, 3]

Melasma is not infectious, allergic or cancerous, and it does not transform into skin cancer.[1] That reassurance applies after the pattern has been assessed correctly. It is not a reason to label every facial brown patch as melasma.

Common presentation#

Typical sites include the cheeks, forehead, upper lip, nose and chin. Patterns are often described as:

  • centrofacial— central forehead, cheeks, upper lip, nose and chin;
  • malar— predominantly cheeks and nose;
  • mandibular— jawline distribution.

The patches are flat and generally asymptomatic. Itch, pain, scale, elevation, crusting or a rapidly changing focal lesion should make the practitioner reconsider the assumption.

Melasma can occur in any sex and phototype. It is more frequently reported in women and in people who tan readily, but a demographic pattern is not a diagnostic test.

More than excess melanin#

Increased melanocyte activity and melanin transfer are central, but contemporary models describe melasma as a wider skin-microenvironment disorder. Studies report altered keratinocyte signalling, basement-membrane disruption, solar elastosis, vascular change, mast-cell activity and fibroblast or senescence-related signalling.[3, 8]

This helps explain three clinical observations:

  1. Surface lightening can occur without durable control.
  2. A treatment that causes inflammation may worsen the disorder even if it targets pigment.
  3. Maintenance and trigger management matter after the initial visible improvement.

It also prevents a common overclaim: the presence of several plausible biological targets does not mean that every product aimed at one of them has proved clinical efficacy.

Established and suspected influences#

Ultraviolet and visible light

UV exposure can trigger or deepen melasma, and high-energy visible light can contribute in melanocompetent skin. UK and international guidance therefore places year-round photoprotection at the centre of management.[1, 2, 3, 5, 6]

In a randomised trial, adding visible-light protection to UV protection improved eight-week outcomes in participants also using hydroquinone. This supports the principle, but it does not prove that every tinted product provides equivalent protection. Iron-oxide content, shade, film formation and the amount actually applied all matter.

Personal electronic screens are not equivalent to sunlight. The British Association of Dermatologists notes no evidence that blue light from personal devices affects the skin in this context.[1]

Hormonal influence

Melasma can appear or change during pregnancy and is associated with oral contraceptives, hormone replacement and other hormonal contexts.[1, 2, 8] Some pregnancy-associated melasma fades after delivery; it can also persist or recur with a later pregnancy.

The association does not justify telling a client that a hormone is the sole cause or advising them to stop prescribed treatment. Medication decisions belong with the prescriber.

Genetic susceptibility

Family clustering is common enough to support susceptibility, but melasma is not inherited through a single simple pattern. Genes, light exposure, hormonal context and the skin microenvironment interact.

Heat

Heat is widely described as a major melasma trigger, often with more certainty than the clinical evidence allows. It can accompany sun exposure, inflammation and energy-based treatment, making the variables difficult to separate. Current guidelines establish UV and visible light much more clearly than everyday ambient heat.[1, 2, 8]i

It is reasonable to record individual reports and avoid unnecessary thermal or inflammatory stress during treatment. It is not evidence-led to present an ordinary-heat threshold or to rank heat beside UV as an equally quantified independent driver.

Professional assessment considerations#

Assessment begins with pattern recognition and then actively tests the assumption.

Ask about onset, pregnancy and hormonal history, medicines, family history, seasonal change, sun and visible-light exposure, previous pigment disorders, earlier treatment response and any episode of worsening after a peel, device or irritating routine.

Examine:

  • symmetry and distribution;
  • whether the area is flat and asymptomatic;
  • brown versus grey-brown or blue-grey colour;
  • background phototype and current tan as separate observations;
  • coexisting acne, dermatitis, PIH or signs of irritation;
  • any focal area that behaves differently from the rest.

Wood’s lamp and dermoscopy may add information about epidermal, dermal or mixed pigment. They should not be treated as infallible depth meters: in a 50-patient comparison the two classifications agreed only moderately (Cohen’s kappa 0.534).[12]

Medical review is appropriate when the diagnosis is uncertain; the pattern is unilateral, new or changing; there is elevation, scale, bleeding, pain or itch; pigmentation is diffuse or associated with systemic symptoms; or a prescription treatment is being considered.

Photoprotection as active management#

Photoprotection is one of the few recommendations that remains consistent across UK guidance, international consensus and systematic review.[1, 2, 3, 5, 6]

A practical plan considers:

  • broad-spectrum UVB and UVA protection;
  • visible-light protection, commonly through a suitable iron-oxide-containing tinted formulation;
  • shade, hats and exposure behaviour;
  • adequate application and reapplication rather than relying on the label alone;
  • reducing irritation so the sunscreen is tolerable enough to use consistently.

Photoprotection does not guarantee clearance. It reduces an important source of stimulation and helps other approaches work in a less reactive environment.

Medical treatment boundaries#

The strongest short-term evidence among topical medical treatments supports hydroquinone and prescription triple combination containing hydroquinone, a retinoid and a corticosteroid.[2, 4, 5, 7] In an eight-week Asian-patient RCT, triple combination outperformed hydroquinone alone and also caused more adverse effects. That is evidence for a supervised medical option, not a professional-cosmetic protocol.

In Great Britain, hydroquinone is prohibited as an ingredient in cosmetic products. Where a medicinal route is lawful it must be managed by an appropriately authorised prescriberworking within their competence — a wider category than “a doctor”, and one that excludes you unless you are in it. Irritation and paradoxical darkening are recognised risks.[1, 13]

Two precision points, because this gets stated loosely in both directions. “Completely illegal” is wrong — the prohibition is on cosmetic products, not on the molecule. And Northern Ireland follows a separate cosmetics regime, so check it rather than assuming it matches Great Britain.

Other topical and systemic agents have varying evidence. Tranexamic acid illustrates why route matters: topical use and oral medical use are not interchangeable. Oral tranexamic acid for melasma is off-label and requires prescriber-led assessment of contraindications, medication interactions and thrombotic risk.[1, 2, 4, 11]iA trial can show group-level improvement while still being inappropriate for a particular person — in the randomised study most often cited, adjunctive oral tranexamic acid lowered mean MASI by 1.8 points, yet relapse over the following three months did not differ significantly between groups (30% versus 26%).[1, 2, 5, 9, 11]

Relevant professional treatments#

Chemical peels, microneedling and energy-based devices may be used as adjuncts in selected or refractory melasma. International consensus reserves more aggressive procedural approaches for carefully assessed cases rather than routine first-line use.

The laser literature demonstrates the central trade-off. Reviews report short-term reductions in severity scores, but studies vary by device, protocol, combination treatment and outcome. Hyperpigmentation, hypopigmentation and recurrence occur, and long-term follow-up is sparse.[1, 2, 3, 9, 10] Repeated low-fluence Q-switched Nd:YAG treatment can produce persistent mottled hypopigmentation when cumulative treatment is too aggressive.

For a professional within aesthetic scope, the questions are:

  • Has melasma been confidently distinguished from PIH and other facial pigmentation?
  • Is photoprotection established and is the skin calm?
  • Has previous procedural worsening been recorded?
  • Is there a realistic maintenance plan?
  • Does the treatment fall within training, scope and device guidance?
  • Is the client being promised lightening, or being mis-sold a cure?

Procedure detail belongs in the existing MSTA chemical peels guide and IPL guide. Where microneedling is being considered, the existing microneedling guide remains the canonical technique page. This entry owns the condition and the decision logic, not duplicate procedure pages.

A cause-aware management hierarchy#

A defensible sequence is:

  1. Confirm the pattern and refer uncertainty.Do not treat “pigmentation” as a diagnosis. Where a lesion is diagnostically uncertain, the referral source for England is NICE NG12 — a weighted seven-point checklist scoring 3 or more, or dermoscopy suggesting melanoma — not a pigment-treatment review.[14] The checklist has no site criterion, so treat a new or changing lesion on a palm, sole or nail unit as needing assessment whatever it scores.[14]i
  2. Reduce established light stimulation. Build UV and visible-light protection that is realistic for the client.
  3. Set expectations.Use “control”, “lightening” and “maintenance”, not “cure”.
  4. Place medical treatments with the prescriber. Hydroquinone combinations and oral tranexamic acid are not cosmetic-salon actives.
  5. Consider adjunct procedures cautiously. Avoid stacking inflammation and plan for recurrence rather than celebrating only the immediate endpoint.
  6. Maintain and review.A return of pigment is part of the disorder’s known behaviour, not proof that the client “failed”.

Not every dark patch is melasma. For an example of site-specific differential thinking — including hair shadow, follicular PIH, friction and thickened skin that may need medical assessment — see the underarm hyperpigmentation guide.

Contraindications and cautions#

Pause aesthetic treatment or refer when:

  • the diagnosis is uncertain or the pattern is not typical;
  • pigment is unilateral, rapidly changing, raised, scaly, bleeding, painful or itchy;
  • there is active dermatitis, infection, sunburn or barrier impairment;
  • pregnancy changes the suitability of a proposed ingredient or medical treatment;
  • prescription-only or off-label medication is being considered without an appropriate prescriber;
  • a previous procedure caused worsening, hypopigmentation or scarring;
  • the client cannot adopt realistic photoprotection or expects permanent eradication;
  • the procedure or its complication management is outside the practitioner’s scope.

Melasma is benign, but the act of assuming that any facial pigmentation is melasma is not.

What the evidence currently supports#

The evidence consistently supports UV and visible-light photoprotection as foundational. It supports short-term lightening from established medical topicals, particularly hydroquinone-based triple combination under supervision.

It also supports caution. The evidence base contains many small studies, varied outcome measures and short follow-up. Across randomised topical trials, confidence in the effect estimates ranged from very low to high, and pooling was possible for only two comparisons.[5]

Laser and procedure studies show potential improvement rather than reliable durable superiority. Recurrence, PIH and hypopigmentation must remain visible in consent and treatment selection.

What remains uncertain#

  • Which combination best produces long-term control across different populations.
  • How to predict recurrence for an individual after apparently successful treatment.
  • The best maintenance regimen after medical or procedural lightening.
  • The clinical importance of each dermal, vascular, basement-membrane and inflammatory component.
  • Whether everyday ambient heat independently drives melasma and at what exposure.
  • How accurately non-invasive tools classify pigment depth in an individual.
  • The long-term balance of benefit and harm for many emerging or device-based approaches.

Common misconceptions#

“Melasma is just excess surface melanin.”

No. Melanin is central, but epidermal and dermal microenvironment changes also form part of the disorder.[3, 8]

“Melasma can be cured if the right product is strong enough.”

No current treatment reliably prevents recurrence. Stronger irritation can worsen the problem.[1, 2, 5, 9, 11]

“Every brown facial patch is melasma.”

No. PIH, solar lentigines, medication-related pigmentation, dermatitis and pigmented lesions can overlap in appearance.

“Tinted sunscreen is cosmetic camouflage, not treatment.”

Suitable visible-light protection can add clinical benefit, although not every tinted formulation has been tested equivalently.[1, 2, 3, 5, 6]

“Lasers permanently remove melasma.”

Reviews report variable short-term improvement, recurrence and risks of hyper- and hypopigmentation.[1, 2, 3, 9, 10]

“Hydroquinone is simply illegal in the UK.”

That wording obscures the important distinction: it is prohibited in cosmetic skin-lightening products, while medical use requires a doctor’s prescription.[1, 13]

Frequently asked questions#

Is melasma dangerous?

Melasma itself is benign and does not become skin cancer. A patch should only receive that reassurance after the diagnosis is reasonably secure.[1]

Why does melasma return?

Light exposure, hormonal context and an altered skin microenvironment can continue after visible pigment lightens. Most studies measure short-term change, not permanent biological reset.[1, 2, 5, 9, 11]

Is melasma the same as PIH?

No. PIH follows a specific inflammatory or injury event. Melasma is a patterned, relapsing facial pigment disorder. A person can have both, including PIH after an irritating melasma treatment.

Does visible light matter?

Yes, particularly high-energy visible light in melanocompetent skin. A controlled trial supports added benefit from visible-light plus UV protection during treatment.[1, 2, 3, 5, 6] That does not make phone and laptop screens equivalent to sunlight.[1]

Can a practitioner recommend hydroquinone in the UK?

Hydroquinone is not a professional cosmetic active. It is prohibited in cosmetic skin-lightening products, and medical treatment requires a doctor’s prescription.[1, 13]

Is oral tranexamic acid a cosmetic treatment?

No. Oral use for melasma is off-label medical treatment and requires a prescriber to assess contraindications and thrombotic risk.[1, 2, 4, 11]i

Are peels or lasers contraindicated in every case?

Not automatically. They may be considered in selected, often refractory cases with appropriate expertise and a maintenance plan. Their potential benefit must be balanced against inflammation, recurrence and dyschromia risk.[1, 2, 3, 9, 10]

References#

Each source is graded by evidence tier. Tier 4 material (manufacturer documents, expert consensus, practitioner experience) is useful for protocol and context, and is never presented as equivalent to independent clinical evidence.

  1. British Association of Dermatologists. Melasma: Patient Information Leaflet. Updated June 2024; next review June 2027.Tier 1Supports: UK guidance on presentation, light triggers, chronicity, photoprotection, treatment risk and prescription-only hydroquinone.
  2. Sarkar R, Desai SR, Sinha S, et al. Delphi consensus on melasma management by international experts and pigmentary disorders society. Journal of the European Academy of Dermatology and Venereology. 2026;40(4):680–692. doi:10.1111/jdv.70066.Tier 4Supports: Modified-Delphi consensus of 38 dermatologists from 11 countries: daily broad-spectrum photoprotection, supervised hydroquinone-based triple combination as gold standard, adjunctive peels and microneedling, laser reserved for treatment-resistant disease. TIER 4: a 38-person expert consensus process, not tier-1 systematic evidence.
  3. Passeron T, Desai SR, Abdallah M, et al. Global consensus on the management of melanin hyperpigmentation disorders. Journal of the European Academy of Dermatology and Venereology. 2026;40(5):760–772. doi:10.1111/jdv.70185.Tier 4Supports: Diagnosis-specific algorithms, pigment-depth considerations, photoprotection and cautious use of procedures. States that management must address not only melanocytes but the surrounding microenvironment including fibroblasts, mast cells and vascular components. TIER 4: this is a consensus process, not systematic evidence — the same record is carried at tier 4 in every entry that cites it.Funding / interest: 'Editorial assistance was provided by Beiersdorf. The sponsor had no role in the study design, data collection, analysis, interpretation or decision to submit the manuscript.' Nine of the ten authors report conflicts of interest — consulting honoraria, lecture payments, meeting support and investigator roles across Beiersdorf, Pfizer, Incyte, AbbVie, Janssen, L'Oréal, Pierre Fabre, Novartis and others; one author declares none.
  4. Sarkar R, Handog EB, Das A, et al. Topical and Systemic Therapies in Melasma: A Systematic Review. Indian Dermatology Online Journal. 2023;14(6):769–781. doi:10.4103/idoj.idoj_490_22.Tier 1Supports: The topical and systemic treatment evidence base, including established medical and emerging approaches.
  5. Pennitz A, Kinberger M, Avila Valle G, Passeron T, Nast A, Werner RN. Self-applied topical interventions for melasma: a systematic review and meta-analysis of data from randomized, investigator-blinded clinical trials. British Journal of Dermatology. 2022;187(3):309–317. doi:10.1111/bjd.21244.Tier 1Supports: 36 studies reporting 47 intervention comparisons. GRADE confidence in effect estimates ranged from very low to high, and pooling was possible for only two comparisons (topical tranexamic acid vs hydroquinone; cysteamine vs placebo).
  6. Castanedo-Cazares JP, Hernandez-Blanco D, Carlos-Ortega B, Fuentes-Ahumada C, Torres-Álvarez B. Near-visible light and UV photoprotection in the treatment of melasma: a double-blind randomized trial. Photodermatology, Photoimmunology & Photomedicine. 2014;30(1):35–42. doi:10.1111/phpp.12086.Tier 2Supports: Added eight-week benefit from visible-light plus UV protection versus UV-only protection alongside hydroquinone.
  7. Chan R, Park KC, Lee MH, et al. A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma. British Journal of Dermatology. 2008;159(3):697–703. doi:10.1111/j.1365-2133.2008.08717.x.Tier 2Supports: Eight-week superiority and greater adverse effects of fixed hydroquinone–tretinoin–fluocinolone triple combination versus hydroquinone alone.
  8. Gu D, Pan R, Meng X, et al. What lies behind melasma: a review of the related skin microenvironment. International Journal of Dermatology. 2025;64(2):256–265. doi:10.1111/ijd.17453.Tier 4Supports: Narrative review of multi-compartment pathogenesis: epidermal barrier dysfunction, basement-membrane damage, dermal vascular and cellular change, and systemic hormonal and oxidative contributors.
  9. Lee YS, Lee YJ, Lee JM, Han TY, Lee JH, Choi JE. The Low-Fluence Q-Switched Nd:YAG Laser Treatment for Melasma: A Systematic Review. Medicina. 2022;58(7):936. doi:10.3390/medicina58070936.Tier 1Supports: Heterogeneous short-term laser outcomes, recurrence, inflammation-related darkening and persistent mottled hypopigmentation risk.
  10. Lai D, Zhou S, Cheng S, Liu H, Cui Y. Laser therapy in the treatment of melasma: A systematic review and meta-analysis. Lasers in Medical Science. 2022;37(4):2099–2110. doi:10.1007/s10103-022-03514-2.Tier 1Supports: Severity-score changes and adverse effects across heterogeneous laser studies, including PIH and hypopigmentation risk.
  11. Lajevardi V, Ghayoumi A, Abedini R, et al. Comparison of the therapeutic efficacy and safety of combined oral tranexamic acid and topical hydroquinone 4% treatment vs. topical hydroquinone 4% alone in melasma: a parallel-group, assessor- and analyst-blinded, randomized controlled trial with a short-term follow-up. Journal of Cosmetic Dermatology. 2017;16(2):235–242. doi:10.1111/jocd.12291.Tier 2Supports: Three months of adjunctive oral tranexamic acid lowered mean MASI by 1.8 points versus hydroquinone alone (P = 0.015), but relapse over three months of follow-up did not differ significantly (30% vs 26%).
  12. Navya A, Pai V. Comparison of dermoscope and Wood's lamp as a tool to study melanin depth in melasma. Indian Dermatology Online Journal. 2022;13(3):366–369. doi:10.4103/idoj.idoj_245_21.Tier 3Supports: In 50 patients, Wood’s lamp and dermoscopic depth classification agreed only moderately (Cohen’s kappa 0.534).
  13. Office for Product Safety and Standards. Product Safety Report: GDK Akagni Skin Toning Cream (2312-0062). Published 19 March 2024.Tier 1Supports: Enforcement finding that hydroquinone “is prohibited in this type of product” (a cosmetic skin-toning cream), citing Regulation (EC) 1223/2009 and the Cosmetic Products Enforcement Regulations 2013.
  14. National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. NICE guideline NG12.Tier 1Supports: The operative suspected-cancer referral source FOR ENGLAND — pigment-treatment reviews are not. 1.7.1: refer using a suspected cancer pathway referral for melanoma if there is a suspicious pigmented skin lesion with a weighted seven-point checklist score of 3 or more. MAJOR features, 2 points each: change in size; irregular shape; irregular colour. MINOR features, 1 point each: largest diameter 7 mm or more; inflammation; oozing; change in sensation. 1.7.2: refer if dermoscopy suggests melanoma. 1.7.3: consider referral for a lesion that suggests nodular melanoma. NOTE WHAT IT DOES NOT DO: the checklist contains no site criterion, so it does not by itself prompt scrutiny of palms, soles or nail units. Wales, Scotland and Northern Ireland have their own pathways.

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Skinipedia is written by the educators at MSTA, the medic-led skincare training academy in Liverpool.