Melasma is a common skin condition that causes patches of dark discoloration on the face, typically appearing as tan, brown, or grayish-brown marks on the cheeks, forehead, nose, upper lip, or chin. It affects more than 5 million people in the United States alone and is especially common in women with medium to dark skin tones. The patches are flat, not raised, and while they’re harmless from a medical standpoint, they can be persistent and frustrating to treat.
What Melasma Looks Like
Melasma patches are symmetrical, meaning they usually appear in roughly the same pattern on both sides of the face. The color ranges from light tan to deep brown, and in some cases the patches can look bluish-black when pigment sits deeper in the skin. The borders tend to be irregular but relatively well-defined against surrounding skin.
The discoloration follows one of three common patterns. The most frequent is centrofacial, covering the forehead, cheeks, nose, upper lip, and chin. The malar pattern affects just the cheeks and nose. The least common is mandibular, appearing along the jawline. Some people have a combination of these patterns, and the darkness can fluctuate with the seasons, getting worse in summer and fading slightly in winter.
Why It Happens
Melasma develops when the pigment-producing cells in your skin become overactive and deposit too much melanin in certain areas. This isn’t a simple on-off switch. It involves a cascade of signals between your skin’s surface cells, the pigment cells underneath, and even the blood vessels and connective tissue deeper in the skin. Sun exposure is the primary trigger: UV rays cause surface skin cells to release a flood of chemical signals that tell pigment cells to ramp up production.
But sun damage does more than just stimulate pigment. Chronic UV exposure breaks down the basement membrane, a thin layer that normally acts as a barrier between the outer skin and the tissue below. Studies of melasma patients with darker skin tones found this membrane was disrupted in over 80% of skin samples. When that barrier is damaged, pigment cells can drop down into deeper layers of skin, making the discoloration harder to treat. The affected skin also has significantly more blood vessels than surrounding normal skin, with one study finding a 69% increase in the area covered by blood vessels in melasma patches compared to nearby unaffected skin.
Hormones, Sun, and Risk Factors
Hormones are the other major driver. Estrogen and progesterone both appear to stimulate pigment production, which is why melasma shows up so often during pregnancy (earning the nickname “the mask of pregnancy”) and in people taking hormonal birth control. Between 15% and 50% of pregnant women develop melasma, typically during the third trimester when hormone levels peak. Postmenopausal women taking progesterone have also been observed developing it, and people with melasma who aren’t pregnant often have elevated estrogen receptors in their affected skin.
Your baseline skin tone matters too. People with Fitzpatrick skin types III and IV (olive to medium-brown complexions) who live in sunny climates are most prone. Prevalence rates vary widely by population: about 9% among Latina women in the southern U.S., 13 to 16% among Arab American women in Michigan, and as high as 40% in some Southeast Asian populations. Family history also plays a role, though the exact genetic contribution isn’t fully mapped.
Epidermal vs. Dermal Melasma
Not all melasma sits at the same depth, and this matters for treatment. A dermatologist can use a special UV light called a Wood’s lamp to help classify what type you have. Epidermal melasma, where excess pigment is concentrated in the skin’s outermost layers, appears well-defined under the lamp with clearly accentuated borders. This type tends to respond better to topical treatments.
Dermal melasma, where pigment has migrated into deeper tissue, looks more diffuse and poorly defined under the lamp, often with a bluish tint visible even in normal light. Mixed melasma has features of both. In people with very dark skin, the lamp may not provide useful contrast at all. Knowing which type you have helps set realistic expectations: epidermal melasma can often be significantly lightened, while dermal melasma is more stubborn and tends to respond slowly and incompletely.
First-Line Treatment
The standard starting treatment is a prescription cream that combines three active ingredients: a pigment-reducing agent, a retinoid that speeds skin cell turnover, and a mild anti-inflammatory steroid. This triple combination is applied once daily, and improvement can begin as early as four weeks, with an initial treatment course typically lasting eight to twelve weeks.
For people who can’t use that combination or prefer alternatives, several other options exist. Cysteamine cream, applied once daily, has shown results comparable to prescription lightening agents in 16-week trials. Tranexamic acid, which works by interrupting the signaling between skin cells and pigment cells, can be taken orally or applied topically. In one study, 50% of people taking it orally for 12 weeks saw meaningful improvement, compared to about 6% on placebo. Combining it with a topical lightening agent appears to work better than using either alone.
Chemical Peels and Lasers
When topical treatments aren’t enough, in-office procedures can help. Chemical peels work by removing the outer layers of skin, taking some of the excess pigment with them. They’re slower to show results than laser treatments but carry a lower risk of side effects, making them a safer choice for people with darker skin.
Laser treatments are more effective on average at reducing melasma severity, but they come with a significant catch: up to 25% of people treated with certain lasers develop post-inflammatory hyperpigmentation, meaning the skin gets darker in the treated area as part of the healing response. This risk is highest in darker skin tones, which are exactly the people most likely to have melasma in the first place. For this reason, lasers are generally reserved for cases that haven’t responded to other approaches, and the choice of laser type and settings requires careful consideration.
Sunscreen Is Not Optional
Every melasma treatment plan depends on rigorous sun protection, and standard sunscreen may not be enough. Visible light, the kind you can see with your eyes, makes up nearly half the sunlight spectrum and can worsen hyperpigmentation on its own, particularly in darker skin tones. Regular UV-blocking sunscreens don’t filter visible light.
Sunscreens containing iron oxides do block visible light, and the difference is measurable. In a 12-week study of women with Fitzpatrick skin types III through VI, those using SPF 50 sunscreen with iron oxides saw meaningful improvements in skin tone, texture, and overall appearance. Among the melasma patients in that group, 36% experienced superior gains in skin radiance compared to zero in the group using SPF-only sunscreen without iron oxides. Look for tinted sunscreens, which get their color from iron oxides, and apply them daily regardless of weather.
Recurrence and Long-Term Management
Melasma is a chronic condition, not a one-time problem. Even after successful treatment, the underlying tendency to overproduce pigment remains. In one study, patients who cleared their melasma after 12 weeks of daily treatment were moved to a twice-weekly maintenance schedule. About half of them relapsed during that maintenance phase and needed to return to daily treatment. This pattern of clearing, maintaining, and occasionally retreating is typical.
The practical takeaway is that managing melasma is more like managing a tendency than curing a disease. Consistent sun protection, periodic use of topical treatments, and realistic expectations about the timeline are all part of living with it. Many people find a routine that keeps their melasma well-controlled, even if it never disappears entirely.