Melasma

In short: Melasma is a chronic, relapsing pigmentation disorder with symmetric brown-grey patches, mainly on the cheeks, forehead, bridge of the nose and upper lip. Sunlight (ultraviolet and visible light), hormonal factors and genetic predisposition act together. The foundation of management is light protection maintained every day, all year round; the strongest evidence supports prescription topical treatment used under medical supervision. Results from peels and lasers are variable, and they can worsen pigmentation in darker skin. A permanent cure vary.

What is melasma?

Melasma (chloasma, often called the "mask of pregnancy") is an acquired hyperpigmentation of sun-exposed facial skin, with symmetric, irregularly bordered patches ranging from light brown to grey-brown. Centrofacial, malar (cheek) and mandibular (jawline) patterns are described; it can also appear on the neck and forearms.

It is more common in women and in medium-to-dark skin types (Fitzpatrick III–V). It is medically harmless, but because it is visible and tends to return it can affect quality of life. Epidermal, dermal and mixed types are distinguished by pigment depth; in practice most patients have a mixed picture.

Causes and mechanism

Melasma develops when several factors combine in predisposed people. Recent reviews describe melasma not simply as a "hormonal mark" but as a disorder linked to chronic sun exposure that shares features with photoaging (Passeron & Picardo, 2018).

• Ultraviolet and visible light: UVB and UVA stimulate melanin production. Visible light can cause lasting pigmentation, particularly in darker skin, so products that protect only against UV may be insufficient in melasma.
• Hormonal factors: Pregnancy, oestrogen-containing contraception and hormone therapy are associated with onset or worsening. It also occurs in men, however.
• Genetic predisposition: A substantial proportion of patients have a family history of melasma.
• Heat and irritation: Hot environments, irritating products and aggressive procedures can increase pigmentation through inflammation.

How is it assessed? Differential diagnosis and when to see a dermatologist

The diagnosis is usually made from the history and examination: time of onset, any link with pregnancy or hormone use, sun exposure, the products used, previous procedures and family history. Dermoscopy and a Wood's lamp can give an idea of pigment depth, although the Wood's lamp is less discriminating in darker skin. Standardised photographs and the MASI/mMASI scores are used for follow-up.

Conditions that can resemble melasma include:

• Post-inflammatory hyperpigmentation (darkening after acne, eczema or a procedure)
• Sun spots (solar lentigines) and freckles
• Dermal melanocytoses such as Hori's naevus
• Lichen planus pigmentosus, drug-induced pigmentation and discolouration after contact dermatitis
• Exogenous ochronosis (blue-grey darkening that can be associated with long-term hydroquinone use)

When should you see a dermatologist? A pigmented lesion that is on one side only, growing quickly, changing irregularly in colour or border, bleeding, crusting or looking different from the other patches should not be treated as melasma. It needs assessment by a dermatologist and, if necessary, a biopsy; the main reason is lentigo maligna (a melanoma precursor), which can look like a slowly enlarging facial patch. No pigmented lesion without a confirmed diagnosis should be treated with a laser or a peel. If irregular periods or marked excess hair growth are present, referral for hormonal assessment is arranged.

Management options by level of evidence

A Cochrane review examined 20 randomised trials (2,125 participants), stressed that study quality was generally poor and noted the lack of long-term outcome data (Rajaratnam et al., 2010). A more recent review including 113 controlled studies (6,897 participants) paints a similar picture (McKesey et al., 2020). The evidence levels below are an editorial summary of these sources.

1. Sun and visible-light protection — the foundation

Broad-spectrum, high-protection sunscreens that also protect against visible light (tinted products containing iron oxides), together with hats and shade, are the basis of every plan. In a double-blind randomised trial of 68 patients on the same hydroquinone treatment, those who also used an iron-oxide sunscreen improved about 15% more in MASI score at 8 weeks than those using a UV-only sunscreen (Castanedo-Cazares et al., 2014). The study was short and single-centre. Evidence: moderate. Limitation: the effect of protection on its own is hard to measure.

2. Prescription topical treatments

Hydroquinone, and "triple combination" cream combining hydroquinone, tretinoin and a corticosteroid, are the most studied and most effective options in melasma (McKesey et al., 2020). In the Cochrane review, triple combination produced significantly more lightening than hydroquinone alone or dual combinations (Rajaratnam et al., 2010). Azelaic acid was more effective than low-strength hydroquinone in some comparisons; studies of ingredients such as niacinamide, cysteamine and topical tranexamic acid are mostly small and short.

Evidence: strong-to-moderate for hydroquinone and triple combination; limited for other ingredients. Limitations: irritation, dryness and secondary darkening caused by them; skin thinning and visible small vessels with long-term use of steroid-containing products; rare but potentially permanent exogenous ochronosis with prolonged, unsupervised hydroquinone use. For these reasons the physician decides the ingredient, strength and duration. The appropriate topical in pregnancy and breastfeeding is assessed separately.

Regulatory note: In the European Union hydroquinone may not be used in cosmetic products applied to the skin, and Türkiye's cosmetics legislation is aligned with EU rules; hydroquinone is used only as a medicine under medical supervision. In the United States, one specific triple-combination cream containing hydroquinone, tretinoin and fluocinolone acetonide is FDA-approved for the short-term treatment of moderate-to-severe facial melasma; that approval applies only to that product and that indication.

3. Chemical peels

Superficial chemical peels have added some benefit to topical treatment in certain studies, but reviews find peels equal to or less effective than topical treatment, with a higher risk of side effects (McKesey et al., 2020). Evidence: limited-to-moderate. Limitation: risk of post-inflammatory hyperpigmentation, especially in darker skin; medium-depth and deep peels are generally not appropriate for melasma.

4. Laser and light treatments

Low-fluence Q-switched Nd:YAG ("laser toning"), non-ablative fractional lasers, picosecond lasers and IPL have been tried in melasma. One review reported that these methods can look effective in the short term but recurrence over time is high; that some techniques increase the risk of post-inflammatory hyper- or hypopigmentation; that ablative fractional lasers should be used with caution because of a very high pigment risk; and that vascular-only lasers do not appear effective (Trivedi et al., 2017). Evidence: limited-to-moderate; equal to or less effective than topicals (McKesey et al., 2020). Limitation: high recurrence, rebound and colour changes that may be permanent. Laser is not first-line; it is an adjunct considered cautiously in carefully selected patients who respond inadequately.

5. Tranexamic acid (oral, intradermal, with microneedling)

Tranexamic acid is a medicine that prevents blood clots from breaking down; in Türkiye, the EU and the US the approved indications of its oral forms relate to bleeding, and its use in melasma is off-label. In a double-blind, placebo-controlled trial of 44 patients, the mMASI score fell by 49% after 3 months of oral tranexamic acid versus 18% with placebo; 3 months after stopping, part of the gain was lost (26% versus 19% below baseline) (Del Rosario et al., 2018). The trial was single-centre. In a retrospective series of 561 patients, most improved, but the relapse rate was 27.2% and one patient developed deep vein thrombosis; she was later found to have an inherited clotting disorder (Lee et al., 2016). The authors recommend screening for personal and family thrombosis risk before starting.

Oral tranexamic acid is therefore a prescription decision and can be considered only after the physician's individual risk assessment. A history of or active deep vein thrombosis, pulmonary embolism, stroke or heart attack; a known inherited clotting tendency; oestrogen-containing contraception or hormone therapy; pregnancy; smoking; and kidney disease increase the risk or make its use inappropriate. Only the prescribing physician sets the dose and duration; this content is not a personal medication recommendation. In Türkiye, off-label use of medicines is subject to separate regulation.

Intradermal injection and microneedling delivery have also been studied. A meta-analysis pooling 17 randomised trials reported that these routes were associated with greater improvement in MASI score than other routes of administration (Chen et al., 2025). Evidence: moderate (small randomised trials and meta-analyses). Limitation: long-term relapse and safety data remain limited (McKesey et al., 2020).

Risks in darker skin types: PIH, rebound and lasting colour change

In Fitzpatrick IV–VI skin, melanocytes respond more strongly to inflammation. Irritating creams, frequent or aggressive peels, high-energy lasers and heat-generating procedures can therefore add post-inflammatory hyperpigmentation on top of melasma. After a short period of lightening following laser, patches have been reported to return, sometimes darker than before ("rebound"); reviews also highlight a risk of mottled lightening (hypopigmentation) with some techniques (Trivedi et al., 2017). "Pigment creams" of unknown composition are an additional risk because they may contain undeclared hydroquinone or potent steroids.

Key precautions: calming the barrier first, a small test area, no procedures on tanned skin, and strict light protection afterwards.

Realistic expectations and recurrence

Melasma is a chronic condition; the goal is not to "erase it permanently" but to lighten the patches clearly and keep that gain. With topical treatment, meaningful change is usually seen over weeks to months. Darkening again in summer, during pregnancy or while using hormones is common. As the tranexamic acid studies show, part of the gain can be lost when treatment stops (Del Rosario et al., 2018, Lee et al., 2016). Maintenance is therefore part of the plan: continuous light protection, a gentle care routine recommended by the physician, and early review when darkening starts. Melasma that begins in pregnancy may fade after delivery, but it does not always disappear completely.

When is a procedure not appropriate?

• When the diagnosis is unclear, or there is a suspicious, changing or one-sided pigmented lesion (dermatology assessment first).
• When the skin has active irritation, eczema, infection or an open wound.
• When the skin is tanned or has had recent intense sun exposure, or when sun protection after the procedure will not be possible (for example before a holiday).
• During pregnancy and breastfeeding: elective procedures and oral treatments are generally postponed and protection comes first.
• When a previous laser or peel caused marked darkening or rebound (the method should be reconsidered).
• When expectations are unrealistic (such as permanent clearance in one session).
• For oral tranexamic acid: when there is a history of thrombosis or a high thrombosis risk.

How this clinic approaches melasma

Dr. Hamza Gemici is a medical aesthetics physician, not a dermatologist, so the first priority is to establish whether the pigmentation is melasma and whether dermatology referral is needed. For patients with suspected melasma, the plan usually starts with daily light protection and barrier-friendly skincare; prescription topicals, peels or lasers are added only in cautious steps, after the skin type has been assessed and the benefits and risks discussed. Progress is followed with photographs under standard lighting; no promises are made about results, number of sessions or price. If the diagnosis is uncertain or oral medication may be needed, the clinic works with the relevant specialist.

Sources and references

This content is based on the peer-reviewed publications in this page's reference list; it is not a personal diagnosis or treatment instruction.

Status: Last physician review: 23 September 2026 · Medical editor: Dr. Hamza Gemici