Melasma: Why It's Tricky and What Can Help

Melasma is a long-term pigment condition that can be improved and kept under control, but it is rarely cured. It is tricky because the same things that treat other brown spots, especially strong heat, can make melasma darker. The approach that tends to work is gentle, patient and centred on daily sun protection and topical care, with in-clinic treatment playing a supporting role.

What melasma looks like

Melasma usually appears as symmetrical, blotchy brown or greyish-brown patches. The most common areas are the cheeks, forehead, bridge of the nose, upper lip and chin. It can also appear on the forearms. The edges are often irregular, and the patches tend to look more obvious after time in the sun.

It is much more common in women, especially during the reproductive years, and in people with medium to darker skin tones, although anyone can develop it. It is not dangerous and is not a sign of skin cancer, but it can affect how people feel about their appearance. Because other conditions can look similar, it is worth having a clinician confirm the diagnosis before starting treatment.

The triggers: hormones, sun and heat

Melasma is thought to result from pigment cells that have become overactive and easily stimulated. Several factors are known to set it off or make it worse:

• Hormones: pregnancy (where it is sometimes called the "mask of pregnancy"), hormonal contraceptives and hormone therapy
• Ultraviolet light: even small amounts of sun on unprotected skin
• Visible light: some research suggests visible light, not just UV, can deepen melasma, particularly in darker skin
• Heat: hot kitchens, saunas, hot yoga and heat-generating treatments
• Genetics: it often runs in families
• Skin irritation: harsh products and inflammation can stimulate pigment

If you take hormonal medication and think it may be contributing, talk to your family doctor. Do not stop a prescribed medication on your own.

Why aggressive heat can backfire

With ordinary sun spots, a strong laser pulse can break up pigment and the spot often fades. With melasma, the pigment cells are already overreactive. Heat and inflammation can stimulate them further, causing rebound darkening that may end up worse than where you started. This is a well-recognised problem with aggressive laser and intense pulsed light in melasma.

That is why melasma treatment is usually conservative. Many clinicians avoid high-energy or heavily ablative settings altogether in melasma, or reserve them for carefully selected cases. If your brown patches turn out to be ordinary sun spots instead, the options are different; see Laser Treatment for Sun Spots and Pigmentation.

The foundation: sun protection every day

No treatment for melasma works for long without consistent protection. This is the single most important part of any plan.

• A broad-spectrum sunscreen of SPF 30 or higher, applied every morning, year-round
• A tinted sunscreen containing iron oxides, which helps block visible light as well as UV
• Reapplication every two hours when outdoors
• A wide-brimmed hat and shade in summer

Cloudy Cape Breton days still carry UV, so sun protection matters in every season. Our article on year-round sunscreen in Nova Scotia covers this in more detail.

Topical treatment and maintenance

Topical products are usually the first line of active treatment and the main way to maintain improvement. Depending on your situation, a physician may suggest one or more of the following:

• Hydroquinone, a pigment-lightening agent, usually used in courses rather than continuously
• Retinoids, which speed up skin turnover
• Azelaic acid, which can lighten pigment and is often well tolerated
• Tranexamic acid, used topically or, in selected cases, by mouth under medical supervision
• Other brightening ingredients, such as niacinamide, vitamin C and kojic acid

Some of these are prescription products and some are not suitable in pregnancy. Oral tranexamic acid in particular is not appropriate for people with a history of blood clots or certain other conditions, which is why medical assessment matters. Improvement with topicals typically takes two to three months to become noticeable.

Gentle in-clinic options

When topical care alone is not enough, gentle in-clinic treatments may help. These might include very superficial chemical peels or low-energy laser approaches designed to reduce pigment without significant heat build-up. With a Fotona laser, this can mean low-fluence Nd:YAG (1064 nm) passes delivered in a way that limits heating of the skin, usually as a series of sessions.

The evidence for laser in melasma is mixed. Some people improve, some see little change and some relapse after treatment stops. Laser is more accurately thought of as an add-on to topical care and sun protection, not a replacement. A test area is often a sensible first step.

Who should not have in-clinic treatment, or should wait

• People who are pregnant or breastfeeding, since many topicals and procedures are avoided during this time and melasma sometimes fades on its own after pregnancy
• Anyone with a current tan or recent heavy sun exposure
• People who cannot commit to daily sunscreen afterward
• Anyone with active skin irritation, eczema or infection in the area
• People who have recently taken isotretinoin

Risks and side effects

The main risk with melasma treatment is worsening of pigment, either from inflammation or from sun exposure during healing. Other possible effects include redness, dryness, irritation from topicals, and light patches if pigment is removed unevenly. Hydroquinone used for too long, or at high concentrations, can cause a rare bluish-grey discolouration, which is one reason it is usually prescribed in courses with breaks.

Frequently asked questions

Will my melasma go away for good?

Melasma often improves, but it tends to recur, particularly in summer or with hormonal changes. Most people need ongoing maintenance with sunscreen and topical care to keep it under control.

Does melasma fade after pregnancy?

It sometimes fades on its own in the months after pregnancy, though not always completely. It is reasonable to wait and protect your skin before considering active treatment.

Is makeup a problem?

No. Makeup can help even out the look of melasma, and tinted mineral products may add some protection from visible light. Choose non-irritating products and remove them gently.

A realistic plan

Melasma rewards patience and consistency more than intensity. A good plan starts with an accurate diagnosis, daily protection and well-chosen topicals, with gentle procedures added only where they make sense. If you would like to talk through your options, HealthPark Medical Aesthetics offers medical consultations where your skin is assessed and the benefits, limits, risks and fees of each approach are explained before any treatment.