Melasma: treatment, causes and what helps

BAD says there is no cure at present, but several treatment options may improve appearance, and they can be used together: avoiding known triggers, avoiding the sun and using sun-blocking creams, skin-lightening creams, tranexamic acid (a drug usually used to stop bleeding) as a tablet or cream, procedures such as chemical peels, microneedling and laser therapy, and skin camouflage. Even if treated, melasma often returns after stopping treatment.

Hydroquinone prevents pigment cells making melanin and is commonly used. BAD says it may cause skin irritation, should only be used for a few weeks at a time to prevent over-lightening, can only be prescribed by doctors and may occasionally make the skin darker. Retinoid creams can help but can cause irritation, and creams or serums containing azelaic acid, vitamin C, kojic acid, cysteamine and thiamidol are also helpful. Some combine two or three ingredients. BAD says lightening creams must only be used when prescribed and under medical supervision, and hydroquinone and retinoids should be avoided in pregnancy.

BAD says chemical peels, microneedling and laser are usually not available as NHS procedures and carry risks, so you should only seek them from reputable and qualified providers, and your NHS doctor should be able to advise.

BAD says melasma is a common skin condition of adults in which brown or greyish patches develop, usually on the face. It is more common in women, particularly during pregnancy (when up to 50% of women may be affected), and also in people of colour and those who tan very quickly, although it can occur in anyone. Men can be affected.

Changing Faces, a UK charity for people with visible differences, says onset is typically between the ages of 20 and 40, and that it may be more noticeable in summer and improve over winter. BAD says it usually becomes more noticeable in the summer and improves during the winter months.

The exact cause is not known. BAD says it is thought to be due to pigment-producing cells in the skin (melanocytes) producing too much pigment (melanin). Several factors can contribute, including pregnancy and hormonal drugs such as birth control pills and hormone replacement therapy. Rarely, other hormone problems such as thyroid problems, and some medications such as anti-epileptics, may cause it.

UV light from the sun and the use of sunbeds or phototherapy can trigger melasma or make it worse. High energy visible (blue) light may also contribute, although BAD says there is no evidence that blue light from personal electronic devices has an effect on the skin. Changing Faces also lists cosmetics, particularly those containing perfumes, and stress as possible triggers.

BAD says melasma is more common in people with a family history, but is not hereditary; Changing Faces says 40% report that family members are affected.

BAD says most people are upset by how it looks, but there are no physical symptoms. The affected skin is not itchy or painful. It appears darker than the surrounding skin and can affect the cheeks, forehead, upper lip, nose and chin, and also other sun-exposed areas such as the forearms and neck. Areas are flat, not raised.

Changing Faces describes three types: epidermal (well-defined border, dark brown, responds well to treatment), dermal (ill-defined border, pale brown to blue-grey, does not respond well) and mixed.

BAD says melasma is usually recognised by doctors from its appearance. Occasionally a dermatologist may suggest removing a small sample of skin (under local anaesthetic) for examination under the microscope (a biopsy) to exclude other conditions. Changing Faces similarly says a GP should easily diagnose it from its distinctive pigmentation and distribution, with a biopsy in some cases.

BAD says skin affected by melasma darkens more than the surrounding skin when exposed to light, so sun avoidance and protection are important. It recommends clothing, a hat that protects the face, neck and ears, UV protective sunglasses, shade between 11am and 3pm, and a high-factor sunscreen of at least SPF 30 with 5 UVA stars, applied 15 to 30 minutes before going out and reapplied every two hours, and straight after swimming and towel-drying. Sun cream containing iron oxides can provide added protection against visible light. Avoid sunbeds.

BAD notes that people avoiding the sun may be at risk of vitamin D deficiency and may want to consider vitamin D supplements; Changing Faces makes the same point and says supplements can be bought from most pharmacies.

BAD says melasma is more common in women, particularly during pregnancy when up to 50% may be affected, hence the name pregnancy mask. If it occurs during pregnancy it may go away a few months after delivery and treatment may not be necessary, although it may come back during another pregnancy.

BAD advises that hydroquinone and retinoid creams should be avoided in pregnancy as they could harm the baby in the womb.

See a GP if you are concerned about pigmentation, if the patches change, or if you have any mole or patch of skin that is changing; BAD recommends telling your doctor about any changes to a mole or patch of skin. A GP can confirm the diagnosis and discuss treatment or referral to a dermatologist.

Changing Faces notes that melasma can affect how people feel about their appearance and offers support for people with a visible difference.

GPs and NHS dermatologists can diagnose melasma and prescribe creams. BAD says chemical peels, microneedling and laser are usually not available as NHS procedures, and so people usually pay privately for them. It advises seeking such procedures only from reputable and qualified providers and checking risks first, since procedures can worsen pigmentation or cause scarring.

Skin camouflage services can be found with help from a healthcare professional, according to BAD.