Melasma & Chloasma
What is Melasma?
Melasma is a common, harmless skin problem that causes dark patches (hyperpigmentation) on your face. It’s usually caused by sun exposure. When melasma appears in pregnant women, it’s referred to as chloasma, or “the mask of pregnancy.” Chloasma is triggered by hormonal changes that occur during pregnancy.
Melasma is much more common in women than men. People of color are also more likely to develop it, especially those of Latin, Asian, Middle Eastern, or North African descent.
What it looks like
The dark patches of melasma may be light-to-dark brown, brown-gray, or gray-blue. Sun exposure can make them even darker. Melasma is usually symmetric, meaning it occurs on both sides of your face. The condition doesn’t change the texture of your skin or cause any uncomfortable symptoms, such as itching or pain.
Common areas for melasma to occur include:
- Bridge of your nose
- Upper lip
While it most commonly affects the face, it’s possible to develop melasma in other areas of skin that are exposed to sunlight, such as your forearms and neck.
Melasma has no symptoms, no itch or pain, or has no preceding redness or inflammation, which is a good clue in differentiating from other conditions. Additionally, patients always say it gets worse in the summer months or while on a sunny vacation. —Dr. Lauren Levy
The main trigger of melasma is exposure to the ultraviolet (UV) light, whether it’s from the sun or a tanning bed. The patches appear when UV rays cause your skin to over-produce melanin, which is your natural skin pigment.
Melasma may worsen from even very brief sun exposure, like walking across a sunny parking lot from your car to a store. Your melasma may go away during the winter (when UV rays are weaker) but usually returns quickly in the spring or if you go on a trip to an area where UV rays are strong.
Lights and heat
Fluorescent light, blue light from computer and device screens, and heat (which dilates blood vessels) can also make melasma worse.
The patches may also get darker if your skin becomes irritated, such as from using a skincare product that’s too strong for your skin. This causes inflammation, which may activate the cells that produce melanin, depositing more pigment in your skin.
Hormones & pregnancy
Changes in levels of hormones such as estrogen and progesterone—can also trigger melasma or chloasma in women. This is why it may begin or worsen when you get pregnant or start taking birth control pills. You may notice it fading if you stop taking birth control pills or after you deliver your baby.
Family history of melasma also appears to play a role, since melasma often runs in families.
There are many effective treatments for melasma that can help lighten the dark patches. But they only work if you take steps to prevent additional melanin from being deposited. Using broad-spectrum sunscreen with an SPF of at least 30 daily and limiting sun exposure are the most important things you can do to improve your melasma.
People with melasma may prefer to use mineral-based sunscreens that contain zinc oxide or titanium dioxide, which are less likely to irritate the skin than chemical sunscreens. Tinted sunscreen that contains iron oxide is also helpful because it can help block blue light. Other ways to protect yourself include wearing a broad-brimmed hat and staying out of the sun during the hours when it’s strongest (10 a.m. to 4 p.m.).
Medications & creams
Hydroquinone is likely to be the first treatment your doctor recommends. It’s available in various formulations and strengths, ranging from 2% (available at the pharmacy) to 6% to 12%, which you can only get by prescription or from your dermatologist.
Hydroquinone works by blocking the enzyme tyrosinase, which is needed to make melanin. The effects of hydroquinone aren’t permanent, so the patches may get dark again if you stop using it. Maintenance treatment with sunscreen and other non-hydroquinone topical medications is usually necessary.
The main side effect of hydroquinone is skin irritation. You shouldn’t use it for long periods of time or without consulting with your dermatologist. This is because hydroquinone can lead to a condition called exogenous ochronosis, which causes blue-black discoloration of your skin that can be difficult to treat. (Your doctor will recommend taking periodic breaks from it to prevent this from happening.) Don’t use hydroquinone if you’re pregnant, trying to get pregnant, or breastfeeding.
Tretinoin (Retin-A) is a derivative of vitamin A. It’s often recommended to treat wrinkles, acne, and oiliness, but it can also lighten dark patches of skin. Tretinoin works by increasing skin cell turnover and decreasing melanin production. It’s found in a popular prescription medication for melasma called Tri-Luma, which contains tretinoin .05%, hydroquinone 4%, and a topical steroid (fluocinolone acetonide 0.01%).
Tretinoin can make you very sensitive to the sun and increase your chances of getting a sunburn, so it’s very important to use sunscreen during treatment. It may also cause dryness and irritation. Don’t use tretinoin if you’re pregnant, trying to get pregnant, or breastfeeding.
Topical steroids are a component in prescription medication for melasma, because it helps lighten skin and decrease inflammation and irritation that other ingredients (like tretinoin or hydroquinone) may cause.
Steroids shouldn’t be used on the face for long periods of time because they can cause acne, perioral dermatitis (a red, acne-like rash around the mouth), and rosacea. Always check with your dermatologist before applying an over-the-counter (OTC) steroid to your face, since some are too strong to be used there.
Azelaic acid is found in many prescription and OTC topical skin-lightening medications. It prevents the enzyme tyrosinase from working, which in turn decreases pigment formation. Azelaic acid also has anti-inflammatory effects. It can be used alone or in combination with other melasma medications, such as tretinoin or hydroquinone. This medication is safe to use if you’re pregnant.
Kojic acid fades dark patches by decreasing melanin production. It is available OTC and can be used in combination with other melasma medications or as a maintenance treatment when you’re taking a break from hydroquinone.
The main side effect of kojic acid is skin irritation (contact dermatitis). Avoid using kojic acid if you’re allergic to mushrooms because the medication is derived from fungi.
Cysteamine (Cyspera cream) is an OTC cream that works by reducing the production of melanin. You apply it to your skin and wash it off after 15 minutes. Once you’ve used it for 6 weeks, you can leave it on your skin for longer periods of time if it isn’t causing irritation. You should notice significant improvement in 8 to 12 weeks, according to a study in the Journal of Dermatological Treatment.
The main side effect of this cysteamine is skin irritation, burning, and dryness. It also has a strong odor. You should not use cysteamine if you’re pregnant or breastfeeding.
Topical vitamin C is an OTC antioxidant that lightens dark patches. Vitamin C can be used daily in combination with other topical treatments or as a maintenance treatment. The most common side effect is irritation, dryness, and acne breakouts with certain formulations of vitamin C.
Tranexamic acid can be used either topically or orally to improve melasma. Your doctor may recommend using it in combination with other topical medications or as a stand-alone treatment for maintenance therapy. It’s not clear tranexamic acid works, but it may fade dark patches by reducing the amount of molecules that stimulate the production of melanin. When used topically, it can reduce melasma, according to a study in Dermatological Surgery.
Oral tranexamic acid also works well, but melasma often returns after stopping the medication. The most common side effect is an upset stomach, but in rare cases it may cause more serious effects such as blood clots. Don’t take this medication if you have a history of blood clots, a blood clotting disorder, smoke cigarettes, or are pregnant.
Make sure you tell your doctor your medications and ask if they are contributing to the melasma. Some medications can make you photosensitive and therefore more likely to develop melasma. —Dr. Levy
Chemical peels can be helpful for lightening melasma. This is an in-office procedure that usually takes about 20 minutes, depending on the type of peel you get.
A glycolic acid peel is the most common type used for treating melasma; others include salicylic acid, trichloroacetic acid, and retinoic acid peels. There are also several peels that contain combinations of ingredients, like the Cosmelan peel and the Perfect Derma Peel. You may need 4 to 6 treatments to notice a significant improvement.
Side effects of peels include skin irritation, inflammation, and redness. Always use sunscreen and take other sun-protective measures after you have a chemical peel.
This is often used as second- or third-line treatment (after topical medications) because it doesn’t always work. Lasers that can help fade the condition include BroadbandLight therapy (BBL) or PiQo4 from Lumenis. You may need more than one session to see improvement.
Use sunscreen and take other sun-protective measures while your skin heals from laser treatments.
Microneedling with or without lightening agents is an effective treatment for melasma. The doctor makes tiny pricks in the skin with very thin needles. This boosts the production of collagen, which improves skin texture. After the treatment, your doctor may apply a topical lightening agent on your skin, such as vitamin C or tranexamic acid, because the pricks in your skin allow it to penetrate your skin more effectively.
A few days after your procedure, you can resume using your at-home lightening agents (topical medications). You may need 2 to 4 treatments for the dark patches to fade.
Do over-the-counter treatments work?
There are many over-the-counter (OTC) products that can fade melasma, though they contain lower concentrations of the ingredients in prescription medications. For example, hydroquinone can be found in many OTC products, such as AMBI Fade Cream. There are also hundreds of vitamin C serums available, which treat many types of hyperpigmentation and are an excellent addition to any skincare routine. Products containing azelaic acid are available OTC as well and can be used with prescription bleaching creams.
Since you cannot use hydroquinone constantly due to potential side effects, using one of these OTC products can be very helpful in treating melasma.
Coping with melasma
Melasma can affect your quality of life, since it may make you feel self-conscious or embarrassed. Your dermatologist will work with you to find an effective treatment to make the pigmentation less noticeable.
It takes many weeks (6 to 8) after starting a treatment to see an improvement, so during that time you may want to use a concealer to make the dark patches less noticeable. There are several effective, dermatologist-recommended foundations and concealers for melasma, such as Dermablend. You can see a makeup artist specialist who will match your skin tone for the best coverage or the Dermablend website can help you find the best shade.
Melasma is not curable. Once you have melasma you will always be prone to it, so taking sun protective measures are necessary. Also, you may be on a topical skin regimen indefinitely to help keep the melasma from coming back. —Dr. Levy
What makes melasma worse?
There are several factors that can darken patches of melasma. These include:
- Light. Spending just a few hours in the sun can worsen melasma. Tanning beds have the same effect, as do blue light and fluorescent light.
- Heat. Hot weather (and hot areas such as saunas) can stimulate pigment production. When you work out, aim a fan at your face to keep your skin cool.
- Skin irritation. If something bothers your skin (such as a skincare product), the cells that produce melanin become activated and release pigment.
- Hormones. Pregnancy and birth control pills can trigger or worsen melasma, though many patients show great improvement after giving birth or stopping birth control pills. If you’re unable to stop taking birth control pills, your doctor can develop a treatment plan to improve your melasma.
- Medications. Some medications make you sensitive to the sun and worsen dark patches, such as isotretinoin, doxycycline (an oral antibiotic), and non-steroidal anti-inflammatory drugs (NSAIDs). If you’re on any of these medications, make sure you avoid the sun and wear sunscreen with SPF 50 or above.
Melasma is frustrating and usually most likely will come back when you are exposed to sun. So even if your skin is clear during the winter, a sunny weekend vacation can bring it right back. This is because the pigment-producing cells in your skin are primed to deposit the pigment in the skin with any sun exposure. Make sure you are always wearing sunscreen on your face- a broad spectrum SPF50+ mineral sunscreen that is tinted is the preferred sun protection for melasma. Reapplication is important. Hats or gloves (if you get the conditions on your hands) are also important.