Key Takeaways
- Melasma is a common, acquired, symmetric darkening of sun-exposed facial skin, most often on the cheeks, forehead, upper lip, and chin.[7]
- It overwhelmingly affects women, especially ages 20 to 40 and people with medium to dark skin tones.[7][2]
- Ultraviolet light is the dominant trigger; hormones from pregnancy and birth control pills, genetics, thyroid disease, and some medications also contribute.[8]
- Daily broad-spectrum SPF 30+ sunscreen, tinted with iron oxide, is the non-negotiable foundation of every treatment plan.[7]
- The most effective topical is a triple combination cream of hydroquinone, tretinoin, and a corticosteroid; hydroquinone alone is the classic first line and is now prescription-only in the U.S.[1][6]
- Oral tranexamic acid helps stubborn cases, with meta-analytic support and no thromboembolic events observed across randomized trials.[4][5]
- Melasma is chronic and recurrent, not permanently curable; visible results take 3 to 12 months, and sun exposure brings it back.[7]
Melasma is one of the most common reasons a person with medium or dark skin sees a dermatologist, and also one of the most misunderstood. It is not dirt, it is not a sign of poor hygiene, and it is not something a harsher cleanser will fix. It is a chronic disorder of pigment, driven mainly by sunlight and hormones, and it responds predictably to the right combination of sun protection and medication while remaining stubborn in the wrong hands.
This guide explains what melasma is, why it appears, the difference between melasma and other brown spots, and the evidence behind each treatment, from hydroquinone to tranexamic acid. Every clinical claim is cited to a primary source.
What Is Melasma?
Melasma is an acquired skin condition that produces flat, irregular patches of darker color on sun-exposed skin, almost always the face. The classic locations are the cheeks, forehead, chin, and the area above the upper lip.[7] The patches are symmetric, meaning they appear on both sides of the face in a mirror pattern, and they range in color from tan to brown to grayish-brown.[7]
Under the microscope, the problem is overactive pigment-producing cells. Melanocytes, the cells that make melanin, are not more numerous but more active, producing excess pigment that settles in the skin.[8] The condition is harmless and cannot hurt you, but the appearance can significantly affect self-image.[7]
What Causes Melasma?
Melasma is triggered, not inherited as a simple on-off trait, though a genetic tendency plays a role. The main drivers are:
- Ultraviolet light. The single most important trigger. Sunlight causes the skin to make more pigment and both darkens existing melasma and creates new patches.[7] Tanning beds and sunlamps produce even stronger UV and do the same.[8]
- Hormones. Estrogen and progesterone, rising in pregnancy and present in birth control pills, are thought to activate melanocytes in susceptible people.[8]
- Genetics. Having a blood relative with melasma raises your risk. In one global study of 324 people with melasma, 48 percent reported a family member with the condition.[8]
- Other contributors. Thyroid disease, some anti-seizure medications, certain antibiotics, and a few blood pressure drugs can trigger or worsen melasma.[8]
Who Gets Melasma?
Melasma is far more common in women, most often striking between ages 20 and 40.[8] People with medium to dark skin tones, and people of Latin, Asian, Black, and Native American heritage, develop it more often than people with lighter skin.[8] Men get melasma too, but much less often.
That demographic pattern matters for treatment, because the same medications behave differently across skin tones. Treatments that irritate darker skin can paradoxically darken it further, so darker skin generally needs a slower, gentler approach and often takes longer to show results.[7]
Melasma During Pregnancy
Melasma is so common during pregnancy that it has been called the mask of pregnancy.[7] The rising estrogen and progesterone of pregnancy are thought to switch on the pigment cells in susceptible people.[8] Many women first notice melasma while pregnant or shortly after starting birth control pills.
Two practical points follow. First, melasma that begins in pregnancy often improves on its own after delivery or after stopping the contraceptive, though not always.[7] Second, the standard prescription treatments, hydroquinone, tretinoin, and oral tranexamic acid, are avoided during pregnancy. For a pregnant person, the right move is diligent sun protection and waiting; treatment is generally deferred until after delivery. This guide's treatment discussion is for adults who are not pregnant, and pregnancy-related skin changes should be managed with your obstetric team.
Melasma vs Other Brown Spots
Melasma is one of several conditions that darken the skin, and the distinction changes treatment. The broad umbrella term is hyperpigmentation, meaning excess pigment. Melasma is a specific pattern of it.
| Condition | What it looks like | Main trigger | Typical location |
|---|---|---|---|
| Melasma | Symmetric, blotchy patches | UV + hormones | Cheeks, forehead, upper lip, chin[7] |
| Post-inflammatory hyperpigmentation | Dark spots left after a pimple or injury heals | Skin inflammation | Wherever the skin was irritated |
| Sun spots (solar lentigines) | Small, flat, well-defined brown spots | Years of sun | Face, hands, chest |
| Freckles (ephelides) | Tiny light-brown spots | Sun + genetics | Face, arms, shoulders |
The practical difference is that melasma is a chronic, hormone-sensitive condition that flares with even brief sun exposure and tends to recur, whereas a sun spot or a post-acne mark is usually a one-time pigment deposit. A clinician can tell them apart on examination and sometimes with a Wood lamp.[2]
Sun Protection: The Foundation
Every effective melasma plan starts here, and skipping this step makes everything else fail. Sunlight both darkens existing melasma and creates new patches, so treatment only works if the skin is protected every single day, including cloudy days and days indoors near windows.[7]
For melasma specifically, dermatologists recommend a broad-spectrum sunscreen of SPF 30 or higher that contains zinc oxide or titanium dioxide, and, importantly, iron oxide.[7] Iron oxide blocks the visible light that ordinary sunscreens do not, and visible light also drives melasma. If a sunscreen leaves a white cast, a tinted sunscreen is the fix.[7] Add a wide-brimmed hat and shade when you can. This is not optional: sun protection is how you first fade melasma and then keep it from coming back.
Hydroquinone: The Gold Standard Topical
Hydroquinone is the classic first-line medicine for melasma. It works by reducing the skin's pigment production to even out skin tone.[7] For decades it was available over the counter at 2 percent, with 4 percent by prescription.
A recent regulatory change is worth knowing. Hydroquinone is no longer sold over the counter in the United States; it is now prescription-only.[7][6] This followed decades of safety review, centered on a rare but real side effect called ochronosis, a bluish-black darkening of the skin that can occur with prolonged or improper use, most often at high concentrations over years.[6]
Used correctly, at prescription strength and under supervision, hydroquinone is effective and generally well tolerated.[1] It is typically used for limited courses with breaks, rather than indefinitely, precisely to avoid ochronosis.
Triple Combination Cream and Other Topicals
The most effective topical treatment combines three medicines in one formulation: hydroquinone to lighten, tretinoin to speed skin turnover, and a mild corticosteroid to reduce irritation.[1][7] This triple combination consistently outperforms hydroquinone alone in trials, which is why it is the reference standard for moderate to severe melasma.[1][3]
Other options, often gentler and useful when triple combination is too irritating, include azelaic acid, kojic acid, vitamin C, and tretinoin used with a corticosteroid.[7] Azelaic acid is notable because it is generally considered safe in pregnancy, unlike hydroquinone and tretinoin.
| Medication | How it works | What to know |
|---|---|---|
| Hydroquinone | Reduces melanin production | Gold standard topical; prescription-only in the U.S.; use in limited, supervised courses[6] |
| Triple combination cream | Hydroquinone + tretinoin + corticosteroid | Most effective topical; reference standard for moderate to severe melasma[1] |
| Azelaic acid | Reduces pigment, gentler on skin | Generally considered safe in pregnancy[7] |
| Oral tranexamic acid | Interrupts the pigment-vascular pathway | Add-on for stubborn melasma; avoid with a clotting history[4] |
Oral Tranexamic Acid
For melasma that does not respond to topicals, oral tranexamic acid is the leading add-on. It is a medication that interferes with a pathway between the skin's blood vessels and pigment cells, and in studies it lightened melasma patches that had resisted other treatment.[7]
The evidence is genuinely supportive. A 2024 meta-analysis of randomized trials found oral tranexamic acid adds benefit when combined with triple combination topical treatment.[4] On safety, the main theoretical concern has been blood clots, because tranexamic acid stabilizes clots. A 2025 systematic review of randomized controlled trials found no thromboembolic events among participants.[5] It is still prescribed with caution and avoided in people with a personal or family history of blood clots, and it is not used in pregnancy.[7]
Procedures: Peels, Lasers, and Microneedling
When topicals are not enough, procedures can help, but they carry real risk in darker skin and should be done by a clinician experienced with melasma. Options include chemical peels, microneedling, and select laser or light treatments.[7]
The caution with lasers especially is that aggressive treatment can trigger rebound darkening or new pigment, particularly in medium and dark skin tones. For that reason procedures are usually an addition to, not a replacement for, daily sun protection and topical medication.[7]
Choosing a Treatment: The Ladder
| Step | Treatment | When it is used |
|---|---|---|
| 1 (always) | Daily SPF 30+ sunscreen with iron oxide, hat, shade | Every patient, every day[7] |
| 2 | Hydroquinone (prescription) | First-line topical for mild to moderate melasma[6] |
| 3 | Triple combination cream | Moderate to severe, or when hydroquinone alone is not enough[1] |
| 4 | Azelaic acid, kojic acid, vitamin C | Gentler alternatives, or pregnancy-safe (azelaic acid)[7] |
| 5 | Oral tranexamic acid | Stubborn or treatment-resistant melasma[4] |
| 6 | Procedures (peel, laser, microneedling) | Adjunct in experienced hands[7] |
Can Melasma Be Cured?
Honesty matters here. Melasma is a chronic condition, and treatments lighten it rather than permanently erase it. It can fade substantially with good care and stay controlled for long stretches, but it tends to return when sun protection lapses.[7] When a specific trigger is removable, like pregnancy or a medication, melasma may clear on its own.[7]
Set expectations accordingly. Visible improvement usually takes 3 to 12 months of consistent treatment, and results arrive more slowly the longer melasma has been present.[7] Those who do best treat sun protection as a lifelong habit, not a short course.
When to See a Doctor
Melasma itself is harmless, but some brown spots are not. A changing, asymmetric, or irregularly colored spot can be skin cancer, and the two should never be assumed to be the same thing.
A spot is new, changing, growing, bleeding, itchy, has ragged borders, or is much darker than surrounding skin. Also seek care if you have a personal or family history of blood clots and are considering oral tranexamic acid.[7]
Frequently Asked Questions
It is chronic, not permanently curable, but it can fade substantially with treatment and stay controlled with lifelong sun protection. It tends to return when sun protection lapses.[7]
Sometimes, when a removable trigger is behind it. Melasma triggered by pregnancy or a medication often improves after delivery or after stopping the drug.[7]
Hyperpigmentation is the umbrella term for any excess pigment. Melasma is a specific, hormone-sensitive pattern of symmetric patches on the face. Post-acne marks and sun spots are different forms of hyperpigmentation.[2]
Often, but not always. Melasma that starts in pregnancy, sometimes called the mask of pregnancy, frequently improves after delivery, but it can persist for months or years.[7]
Hydroquinone was removed from over-the-counter status in the U.S. after safety review, including a rare side effect called ochronosis, a bluish-black skin darkening from prolonged use. It is now prescription-only and used in supervised, limited courses.[6]
Visible improvement usually takes 3 to 12 months of consistent use, and longer for melasma that has been present for many years.[7]
The upper lip is one of melasma's classic locations, along with the cheeks, forehead, and chin. It is the same condition, driven by sun and hormones, and responds to the same treatment.[7]
Yes, recurrence is common, especially with sun exposure without protection. That is why daily sunscreen with iron oxide is a permanent part of the plan, not a temporary step.[7]
A broad-spectrum SPF 30 or higher sunscreen containing zinc oxide or titanium dioxide, and ideally iron oxide, which blocks the visible light that also worsens melasma. Tinted sunscreens avoid a white cast.[7]
See a clinician to confirm the diagnosis and get a plan matched to your skin tone. Seek care promptly for any spot that is new, changing, growing, bleeding, itchy, or irregular, since some brown spots are skin cancer, not melasma.[7]
References
- McKesey J, Tovar-Garza A, Pandya AG. Melasma Treatment: An Evidence-Based Review. American Journal of Clinical Dermatology. 2020;21(2):173-225. doi:10.1007/s40257-019-00488-w
- Rodrigues M, Pandya AG. Melasma: clinical diagnosis and management options. Australasian Journal of Dermatology. 2015;56(3):151-163. doi:10.1111/ajd.12290
- Leung JH, Leung HWC, Wang SY, Jang YC. Efficacy and Safety of Different Treatments for Melasma: Network Meta-Analysis of Updated Data. Diseases (Basel). 2025;13(10):316. doi:10.3390/diseases13100316
- Ribeiro Gonçalves O, de Souza MCF, Rocha AV, Alves GS, et al. Assessing the efficacy of oral tranexamic acid as an adjuvant to triple combination topical treatment in melasma: a meta-analysis of randomized controlled trials. Clinical and Experimental Dermatology. 2024;49(12):1518-1524. doi:10.1093/ced/llae226
- Kuceki G, Mendez D, Garza-Dueñas GG, Kruithoff C, et al. No thromboembolic events observed in randomized controlled trials of oral tranexamic acid: A systematic review and descriptive synthesis. Journal of the American Academy of Dermatology. 2025;93(4):1086-1088. doi:10.1016/j.jaad.2025.06.001
- Schwartz C, Daniels P, Patel P. Hydroquinone. StatPearls. Updated 2026. PubMed PMID 30969515
- American Academy of Dermatology. Melasma: Overview; Melasma: Diagnosis and Treatment. aad.org
- American Academy of Dermatology. Melasma: Causes. aad.org