Melasma: Symptoms, Types, Causes and Treatment

Melasma is more than just a skin concern—it’s a visible, emotional, and sometimes stubborn challenge that affects millions worldwide. This article provides an evidence-based, comprehensive overview of melasma, covering its symptoms, types, causes, and the full spectrum of treatment options. Whether you’re a patient, healthcare provider, or just curious, understanding melasma is the first step toward effective management.

Symptoms of Melasma

Melasma presents itself in ways that are often unmistakable, yet it can be confused with other forms of skin discoloration. Knowing the primary symptoms is essential for timely recognition and appropriate management.

Appearance	Location	Demographics	Source(s)
Brown/gray-brown patches	Face (cheeks, forehead, upper lip, chin, nose)	More common in women, especially of darker skin types	1, 3, 6
Symmetrical lesions	Sun-exposed areas	Onset often in 20s-40s	3, 6
Well-defined borders	Centrofacial, malar, mandibular patterns	May flare up with sun exposure or hormonal changes	1, 3, 6

Table 1: Key Symptoms

Common Skin Changes

Melasma typically manifests as flat, brown or gray-brown patches on the skin. These patches are usually symmetrical, appearing on both sides of the face and often with well-defined borders. While the face is the most affected area—especially the cheeks, forehead, upper lip, chin, and nose—melasma can occasionally occur on other sun-exposed skin regions 1, 3, 6.

Patterns of Distribution

Melasma is most commonly seen in three clinical patterns:

• Centrofacial: Involves the forehead, cheeks, nose, upper lip, and chin; this is the most prevalent pattern 1, 3.
• Malar: Affects the cheeks and nose.
• Mandibular: Involves the jawline.

Who Is Most Affected?

Women are disproportionately affected, with studies showing a female to male ratio as high as 4:1. The condition is more common in people with darker skin types (Fitzpatrick skin types III–V) and typically appears in adults aged 20–40 3, 6.

Flare Factors

Symptoms may worsen or flare up with:

• Sun exposure
• Pregnancy
• Use of oral contraceptives
• Hormonal fluctuations

These triggers often make melasma more noticeable or increase the affected area 3, 6.

Types of Melasma

Melasma is not a one-size-fits-all condition. Understanding its types is crucial for accurate diagnosis and effective treatment planning. The classification is based on both clinical presentation and the depth of pigmentation.

Clinical Pattern	Pigment Location	Diagnostic Method	Source(s)
Centrofacial, malar, mandibular	Epidermal, dermal, mixed, indeterminate	Visual exam, Wood’s lamp, reflectance confocal microscopy	1, 2, 3

Table 2: Melasma Types Overview

Clinical Patterns

• Centrofacial: Most common, affecting central facial regions 1, 3.
• Malar: Localized to the cheeks and nose.
• Mandibular: Along the jawline.

Pigment Depth Types

Melasma is also classified by the depth of pigment deposition, typically assessed using Wood’s lamp (a special ultraviolet light) or reflectance confocal microscopy 1, 2:

• Epidermal: Pigment is concentrated in the upper skin layers, appearing more prominent under Wood’s lamp 1, 2.
• Dermal: Pigment is deeper, within the dermis; less enhancement seen under Wood’s lamp 1, 3.
• Mixed: Features of both epidermal and dermal pigmentation.
• Indeterminate (Fourth Type): Seen in individuals with very dark skin, where contrast is insufficient for clear identification 1.

Diagnostic Tools

• Wood’s Lamp Examination: Helps distinguish between epidermal and dermal pigment by highlighting how much the discoloration intensifies under UV light.
• Reflectance Confocal Microscopy (RCM): A non-invasive imaging technique that provides precise information about pigment depth and distribution, aiding diagnosis and treatment monitoring 2.

Why Typing Matters

Knowing the type of melasma helps guide treatment. For instance, epidermal melasma typically responds better to topical therapies, while dermal or mixed types may be more challenging to treat and require more advanced interventions 2.

Causes of Melasma

Melasma does not have a single identifiable cause. Instead, it results from a complex interplay of genetic, hormonal, and environmental factors.

Factor	Description	Impact Level	Source(s)
Sun exposure	Ultraviolet (UV) and visible light trigger pigment production	Major trigger	1, 3, 4, 5, 6, 7
Hormonal changes	Pregnancy, oral contraceptives, hormone therapy	Strong association	3, 4, 6, 7
Genetics	Family history increases risk	Moderate to strong	3, 4, 6
Skin type	Darker skin, more melanosomes	Higher susceptibility	1, 3, 6
Endocrine factors	Thyroid disorders	Possible association	3, 7
Inflammation	Skin inflammation may contribute	Emerging factor	7

Table 3: Main Causes of Melasma

Sun Exposure: The Biggest Culprit

Ultraviolet (UV) radiation is the most significant environmental trigger for melasma. Both UVA and UVB rays stimulate melanocytes—the pigment-producing cells of the skin—to overproduce melanin. Recent studies also highlight a role for visible light in exacerbating melasma 1, 3, 4, 5, 6, 7.

• Sun exposure not only initiates melasma but often causes flare-ups and worsens existing lesions 3.
• Year-round photoprotection is vital for prevention and management.

Hormonal Influences

Hormonal factors play a central role:

• Pregnancy: Sometimes called the “mask of pregnancy,” melasma frequently occurs in pregnant women due to elevated estrogen and progesterone 3, 4, 6.
• Oral Contraceptives: Estrogen-containing birth control pills are a well-established risk factor 3, 4.
• Hormonal Therapy: Other hormone-altering medications may also contribute.

Genetics

A positive family history increases the risk of developing melasma, indicating a genetic predisposition 3, 4, 6.

Skin Type

People with darker skin types (Fitzpatrick III–V) have more active melanocytes and higher baseline melanin, making them more susceptible to melasma 1, 3, 6.

Endocrine and Other Factors

• Thyroid Disorders: Some studies show a higher prevalence of hypothyroidism in people with melasma, although the connection is not fully understood 3, 7.
• Inflammation and New Discoveries: Ongoing research suggests inflammatory processes and novel genetic factors may be involved 7.

Summary

Melasma is multifactorial, with sun exposure, hormonal influences, and genetic predisposition being the most significant contributors. Understanding these factors helps guide both prevention and treatment.

Treatment of Melasma

Treating melasma can be challenging. Success depends on accurately diagnosing the type, identifying and minimizing triggers, and choosing the most effective therapies for each patient’s unique skin and lifestyle.

Therapy Type	Main Examples	Effectiveness/Notes	Source(s)
Topical	Hydroquinone, tretinoin, corticosteroids, azelaic acid, triple combination cream	Most effective, especially triple combo	6, 8, 9, 10, 11
Oral	Tranexamic acid, Polypodium leucotomos, glutathione	Promising adjuncts, more research needed	6, 10
Procedures	Chemical peels, microneedling, radiofrequency, lasers	Mixed results, higher risk in dark skin	6, 8, 9, 10, 11
Photoprotection	Broad-spectrum sunscreen, physical blockers	Essential for all patients	6, 11

Table 4: Key Treatments for Melasma

Topical Therapies

First-line treatment includes topical agents that inhibit melanin production or accelerate skin turnover:

• Hydroquinone: The gold standard bleaching agent; available in various concentrations 6, 8, 9, 10.
• Triple Combination Cream: A fixed combination of hydroquinone, tretinoin, and a corticosteroid is the most effective topical regimen, outperforming monotherapies and dual combinations 9, 10.
• Azelaic Acid (20%): An alternative with fewer side effects, effective especially in mild to moderate cases 9, 10.
• Other Agents: Tretinoin, kojic acid, and natural compounds may help but are generally less potent 6, 9.

Side effects of topicals include mild irritation, dryness, and, rarely, paradoxical hyperpigmentation.

Oral Therapies

• Tranexamic Acid: An antifibrinolytic agent showing promise as an oral adjunct, especially for moderate to severe or recurrent cases. Its long-term safety is still under investigation 6, 10.
• Polypodium Leucotomos & Glutathione: Natural supplements with antioxidant and pigment-modulating properties are being studied as supportive therapies 6.

Procedural Treatments

• Chemical Peels: Superficial peels (e.g., glycolic acid) can aid exfoliation but must be used carefully, particularly in darker skin, due to risk of irritation and post-inflammatory hyperpigmentation 6, 8, 9, 10, 11.
• Microneedling & Radiofrequency: These modalities are emerging as adjuncts, potentially enhancing the penetration of topical agents 6.
• Laser and Light-Based Therapies: Generally reserved for refractory cases. Results are mixed, and there is a significant risk of worsening pigmentation, particularly in patients with dark skin 6, 8, 9, 10, 11.

Photoprotection

Consistent, year-round use of broad-spectrum sunscreen (covering UVA and UVB) is essential for both prevention and treatment. Physical blockers (e.g., zinc oxide, titanium dioxide) and sun-protective clothing are strongly advised 6, 11.

Combination Approaches

Using a combination of therapies—whether multiple topicals or integrating procedures with topical/oral agents—yields better results than monotherapies alone 6, 9, 10, 11.

Maintenance and Relapse Prevention

Melasma is often chronic and prone to relapse. Maintenance therapy with milder topical agents and strict sun protection is vital for sustaining results 8, 11.

Conclusion

Melasma is a complex, multifactorial skin disorder that affects millions, particularly women with darker skin types. Effective management requires understanding its symptoms, accurately diagnosing its type, addressing underlying causes, and personalizing treatment.

Key takeaways:

• Melasma presents as symmetrical, brown or gray-brown patches mainly on the face and sun-exposed areas.
• It is classified by both clinical pattern (centrofacial, malar, mandibular) and by pigment depth (epidermal, dermal, mixed, indeterminate).
• Major causes include sun exposure, hormonal changes, genetic predisposition, and, to a lesser extent, endocrine and inflammatory factors.
• First-line treatments are topical agents, especially triple combination creams, with strict photoprotection as an essential cornerstone.
• Oral and procedural therapies are available for more persistent or severe cases but must be carefully chosen based on skin type and risk factors.
• Combination therapies and maintenance regimens offer the best chance for long-term control and improved quality of life.

Understanding melasma empowers individuals and clinicians alike to take proactive, effective steps toward its management and, ultimately, a brighter outlook.