Melasma treatment explained, from causes to maintenance

The most effective melasma treatment combines strict daily protection from sunlight and visible light with a prescription lightening cream, most often hydroquinone alone or a triple combination of hydroquinone, tretinoin and a mild corticosteroid [1][2]. Melasma can be controlled and faded, but it tends to come back, so maintenance matters as much as the first course of treatment.

Melasma shows up as symmetrical, grey-brown patches on the cheeks, forehead, upper lip or chin. It is common, harmless to your general health and often frustrating, because the same triggers that cause it (light and hormones) are part of everyday life. This guide explains why it happens, how a doctor confirms it is melasma and not another type of dark spot, and what each step of treatment can realistically achieve.

The evidence base is honest about its limits. A Cochrane review of 20 randomised trials with 2,125 participants concluded that study quality was generally poor and that long-term data on how long results last are missing [1]. With that in mind, here is what the better studies show.

Key takeaways

- Melasma is driven by sunlight (including visible light), hormones such as pregnancy and the contraceptive pill, and a strong family tendency.

- Tinted sunscreen with iron oxides improved results compared with ordinary sunscreen in a randomised trial [5].

- Hydroquinone and the triple combination cream are the best-studied topical options; azelaic acid and topical tranexamic acid are gentler alternatives [1][2][7].

- Relapse is common once treatment stops, so most people need a maintenance plan.

- A doctor assesses your skin and decides which treatment is appropriate, especially during pregnancy or breastfeeding.

What causes melasma?

Melasma is a disorder of pigment cells (melanocytes) that become overactive in certain areas of the face. Several triggers work together.

Sunlight, including visible light

Ultraviolet (UV) radiation is the best-known trigger, and melasma typically worsens in summer [4]. Visible light, the part of sunlight we can see, also seems to play a role, particularly in medium and darker skin. In a double-blind trial of 68 people with melasma, all using hydroquinone 4%, those given a sunscreen with iron oxides (which blocks visible light) improved more than those given a UV-only sunscreen: about 15% more on the severity score and 28% more on colour measurements after 8 weeks [5].

Hormones, pregnancy and contraceptives

Melasma is often called the "mask of pregnancy". In a case-control study of 207 women with facial melasma and 207 without, a history of pregnancy (odds ratio 3.59) and longer use of oral contraceptives were independently linked to melasma [3]. Pregnancy-related melasma often improves in the year after giving birth, but it can persist and it often returns in later pregnancies. It also tends to persist more in women who use the pill [4].

Genes and skin type

Family history is one of the strongest signals. In the same case-control study, 61% of women with melasma reported an affected relative, compared with 13% of women without it [3]. Melasma is most frequent in intermediate skin types (Fitzpatrick III to V) and is rare at the lightest and darkest extremes [4]. Sun exposure at work, some medicines (the study found a link with antidepressants and anti-anxiety drugs) and irregular periods were also associated with a higher risk [3].

How doctors diagnose melasma and rule out other dark spots

The diagnosis is mostly clinical: a doctor looks at the pattern, the colour and the history (when it started, what makes it worse) [4]. Melasma usually appears symmetrically on both sides of the face. Several other conditions can look similar [4]:

Condition	Typical features	Why it matters
Melasma	Symmetrical, blotchy grey-brown patches on cheeks, forehead, upper lip	Chronic and relapsing; needs ongoing light protection
Solar lentigines (sun spots)	Sharply defined round spots, often on hands and face, older skin	Respond to different treatments
Post-inflammatory hyperpigmentation	Appears where acne, eczema or an injury was	Treat the underlying inflammation first
Hori's naevus	Blue-grey or brown dots on the cheeks, deeper in the skin	Lies in the dermis, so creams help little
Drug-induced pigmentation	Linked to certain medicines (for example amiodarone)	The cause needs review by the prescribing doctor

Two tools help in clinic. A Wood's lamp (a handheld ultraviolet light) highlights the borders of melasma, and patches that look more intense under the lamp tend to respond better to topical treatment [4]. Dermoscopy, a magnified skin examination, shows the pattern of pigment and the small blood vessels that are often present in melasma [4]. If you are unsure what your dark spots are, our sister article on dark spots on the face walks through the main causes.

The melasma treatment ladder, step by step

Doctors usually build treatment in layers, adding stronger options only when the gentler steps are not enough. The overview of all the conditions we look at is on our dermatology page, and the dedicated melasma page explains the topical options in more detail.

Step 1: daily photoprotection with a tinted sunscreen

Every other treatment depends on this step. Use a high-protection, broad-spectrum sunscreen every morning, reapply it when outdoors, and choose a tinted formula containing iron oxides to block visible light as well as UV [5]. Hats and shade add protection that sunscreen alone cannot offer.

Step 2: hydroquinone 2% to 4%

Hydroquinone reduces pigment production and is one of the best-studied melasma treatments [2]. In the Cochrane review, azelaic acid 20% was slightly more effective than hydroquinone 2% but not more effective than hydroquinone 4% [1]. Common side effects are irritation, itching, burning and stinging [1].

In the EU, hydroquinone cannot be sold as a skin-lightening cosmetic: the Cosmetics Regulation only allows it in narrow professional uses such as artificial nail systems at very low concentration [10]. For melasma it is usually used at 4%, which needs a prescription in Spain [12], prescribed by a doctor for a limited, supervised course, often followed by a break or a switch to a gentler maintenance cream. For more detail, see our hydroquinone cream guide and the sibling article on hydroquinone for dark spots.

Step 3: triple combination cream

The triple combination pairs hydroquinone 4% with tretinoin 0.05% and the mild corticosteroid fluocinolone acetonide 0.01%. In two 8-week randomised trials with 641 adults, 26.1% of patients using the triple combination had complete clearing, compared with 4.6% using two-ingredient combinations, and more than 70% reached a 75% reduction in pigmentation, compared with 30% [6]. The Cochrane review also found the triple combination more effective than hydroquinone alone (risk ratio 1.58) [1].

The trade-off is irritation. In a meta-analysis of topical agents, irritation was reported by about 50.9% of people using hydroquinone-containing combinations, compared with 18.7% for azelaic acid and 0.8% for topical tranexamic acid [7]. Because it contains a corticosteroid, a doctor limits how long it is used. Our combination formula guide covers how it is applied.

Alternatives: azelaic acid and topical tranexamic acid

For people who cannot tolerate hydroquinone, or as maintenance, there are gentler options. The same meta-analysis found that azelaic acid and topical tranexamic acid gave improvements comparable to hydroquinone, with lower irritation rates [7]. Azelaic acid 20% matched hydroquinone 4% in the Cochrane review [1].

Oral tranexamic acid (in person, with a dermatologist)

For moderate to severe or stubborn melasma, a dermatologist may consider oral tranexamic acid. In a placebo-controlled trial of 44 patients taking 250 mg twice daily for 3 months, the severity score fell by 49%, compared with 18% on placebo [8]. A review suggests considering it when topical hydroquinone and combination creams have not helped after about 12 weeks, and stresses careful screening for contraindications and clotting risk factors before starting [9]. It is not suitable for people with a history of blood clots or other risk factors, and it is managed in person by a dermatologist, not online.

Procedures: peels and lasers

Chemical peels and laser or light devices are sometimes added by a dermatologist. An evidence-based review of 113 studies found them equal to or less effective than topical treatment, with a higher risk of side effects such as post-inflammatory hyperpigmentation [2]. Because of that risk of rebound darkening, they are reserved for selected cases in experienced hands.

How the main options compare

Option	What studies show	Main drawbacks
Tinted iron-oxide sunscreen	Improved results with hydroquinone versus UV-only sunscreen [5]	Needs daily use and reapplication
Hydroquinone 2% to 4%	Among the most effective and best-studied topicals [2]	Irritation; supervised, time-limited courses
Triple combination	26.1% complete clearing at 8 weeks in trials [6]	Irritation in about half of users [7]; steroid limits duration
Azelaic acid 20%	Comparable to hydroquinone 4% [1]	Mild stinging
Topical tranexamic acid	Comparable improvement, very low irritation [7]	Less long-term data
Oral tranexamic acid	49% reduction in severity at 3 months [8]	Dermatologist only; clotting risk screening [9]
Peels and lasers	Equal or inferior to creams [2]	Higher risk of darkening

Relapse prevention and maintenance

Melasma is chronic. In the oral tranexamic acid trial, three months after stopping, the reduction from baseline had fallen back to 26%, close to the 19% seen with placebo and sunscreen alone [8]. The reviews agree that long-term follow-up data are lacking and that relapse is common [1][2].

Practical maintenance usually includes:

• Tinted, high-protection sunscreen every day, all year, including on cloudy days and indoors near windows [5].
• A gentler maintenance cream (for example azelaic acid) once a hydroquinone course ends, as a doctor advises.
• Avoiding heat and intense sun exposure where possible, since melasma worsens in summer [4].
• Reviewing hormonal triggers with your doctor if melasma started with the contraceptive pill [3].

Expect improvement over weeks to months, not days. Most trials measured results at 8 to 12 weeks [5][6][8].

Melasma in pregnancy and breastfeeding

Pregnancy is a common trigger. Melasma that appears then usually improves with treatment within a year of giving birth, although few cases fade completely without any treatment [4]. During pregnancy and breastfeeding, doctors usually rely on strict photoprotection first. Tretinoin is avoided in pregnancy, and hydroquinone and the triple combination are generally postponed until after pregnancy and breastfeeding; the Spanish product information for hydroquinone advises against its use in both [11]. Oral tranexamic acid is not used during pregnancy. If you are pregnant, planning a pregnancy or breastfeeding, tell the doctor so they can decide what is suitable.

Getting a doctor's opinion online

For mild to moderate melasma, topical treatment is often all that is needed. With Hi Doctor, you complete an online consultation with a doctor licensed in Spain, who replies in under 2 hours on average. The doctor reviews your case and decides whether a topical treatment is appropriate, or whether you should see a dermatologist in person. If a prescription is issued, it is issued in Spain and each pharmacy decides whether to dispense it. You can read more about how it works. Hi Doctor offers topical skin treatments only; oral options such as tranexamic acid tablets are for a dermatologist to manage in person.

When to see a doctor

See a doctor, and in some cases a dermatologist in person, if:

• A dark spot is growing, changing shape or colour, bleeding, itching or has irregular edges. Any new or changing mole needs prompt in-person review.
• The pigmentation is on one side only or appeared suddenly without an obvious trigger.
• Patches are blue-grey, which may suggest pigment deeper in the skin.
• Melasma has not improved after about 12 weeks of consistent treatment [9].
• A cream causes strong burning, blistering or darker patches.
• You are pregnant, breastfeeding or have a history of blood clots and are considering any treatment.

If you'd like a doctor to look at your case, you can start an online consultation with Hi Doctor and a doctor will assess whether a topical melasma treatment is appropriate for you.

Sources

1. Rajaratnam R, Halpern J, Salim A, Emmett C. Interventions for melasma. Cochrane Database Syst Rev. 2010;(7):CD003583. https://pubmed.ncbi.nlm.nih.gov/20614435/
2. McKesey J, Tovar-Garza A, Pandya AG. Melasma treatment: an evidence-based review. Am J Clin Dermatol. 2020;21(2):173-225. https://pubmed.ncbi.nlm.nih.gov/31802394/
3. Handel AC, Lima PB, Tonolli VM, Miot LD, Miot HA. Risk factors for facial melasma in women: a case-control study. Br J Dermatol. 2014;171(3):588-594. https://pubmed.ncbi.nlm.nih.gov/24749693/
4. Handel AC, Miot LD, Miot HA. Melasma: a clinical and epidemiological review. An Bras Dermatol. 2014;89(5):771-782. https://pubmed.ncbi.nlm.nih.gov/25184917/
5. 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. Photodermatol Photoimmunol Photomed. 2014;30(1):35-42. https://pubmed.ncbi.nlm.nih.gov/24313385/
6. Taylor SC, Torok H, Jones T, et al. Efficacy and safety of a new triple-combination agent for the treatment of facial melasma. Cutis. 2003;72(1):67-72. https://pubmed.ncbi.nlm.nih.gov/12889718/
7. Chang YF, Lee TL, Oyerinde O, et al. Efficacy and safety of topical agents in the treatment of melasma: what's evidence? A systematic review and meta-analysis. J Cosmet Dermatol. 2023;22(4):1168-1176. https://pubmed.ncbi.nlm.nih.gov/36566490/
8. Del Rosario E, Florez-Pollack S, Zapata L Jr, et al. Randomized, placebo-controlled, double-blind study of oral tranexamic acid in the treatment of moderate-to-severe melasma. J Am Acad Dermatol. 2018;78(2):363-369. https://pubmed.ncbi.nlm.nih.gov/28987494/
9. Bala HR, Lee S, Wong C, Pandya AG, Rodrigues M. Oral tranexamic acid for the treatment of melasma: a review. Dermatol Surg. 2018;44(6):814-825. https://pubmed.ncbi.nlm.nih.gov/29677015/
10. Regulation (EC) No 1223/2009 of the European Parliament and of the Council of 30 November 2009 on cosmetic products, Annex III (entry 14, hydroquinone). https://eur-lex.europa.eu/eli/reg/2009/1223/oj
11. AEMPS, Centro de Información de Medicamentos (CIMA). Ficha técnica: hidroquinona 40 mg/g crema (registration no. 81390). https://cima.aemps.es/cima/dochtml/ft/81390/FT_81390.html
12. AEMPS, CIMA. Authorised medicines containing hidroquinona, with prescription status (database query). https://cima.aemps.es/cima/rest/medicamentos?practiv1=hidroquinona