Understanding Melasma — Triggers, Treatments, and Management

Last updated: 5 March 2026

What Is Melasma? A Clinical Perspective

Melasma is a chronic, acquired hyperpigmentation disorder characterised by symmetrical, irregularly bordered brown or greyish-brown patches on sun-exposed areas of the face. Affecting an estimated 1.5–33% of the global population, melasma disproportionately impacts women of reproductive age and those with Fitzpatrick skin types III–V. Despite its prevalence, melasma remains one of the most challenging pigmentation conditions to treat.

At Axiom Aesthetics, our dermatology-trained practitioners specialise in evidence-based melasma management protocols tailored to each patient’s unique skin profile and lifestyle factors.

Understanding the Pathophysiology

Current research, including findings in the Journal of the American Academy of Dermatology (2023), identifies melasma as a disorder involving multiple cutaneous cell types:

• Melanocytes — increased melanogenesis and dendritic activity
• Keratinocytes — altered signalling pathways stimulating pigment production
• Dermal fibroblasts — secretion of stem cell factor and melanogenic mediators
• Mast cells — increased numbers contributing to inflammation
• Vascular endothelial cells — increased vascularity in melasma lesions

The Three Types of Melasma

1. Epidermal melasma — brown patches with well-defined borders; most responsive to treatment
2. Dermal melasma — blue-grey patches with less defined borders; more resistant to treatment
3. Mixed melasma — the most common presentation, combining both components

Common Triggers and Exacerbating Factors

Ultraviolet and Visible Light Exposure

UV radiation remains the most significant trigger. Research demonstrates that visible light (particularly high-energy visible/blue light) and infrared radiation also stimulate melanogenesis. A study by Castanedo-Cazares et al. showed that visible light alone could induce persistent pigmentation in darker skin types.

Hormonal Influences

• Pregnancy (chloasma or “mask of pregnancy”) — affects 15–50% of pregnant women
• Combined oral contraceptive pills
• Hormone replacement therapy (HRT)
• Thyroid disorders — both hypo- and hyperthyroidism linked to melasma

Heat Exposure

Thermal energy, independent of UV exposure, can worsen melasma, including environmental heat, cooking over hot stoves, saunas, and heated yoga environments.

Other Contributing Factors

• Genetic predisposition — family history present in 40–60% of cases
• Certain medications — phototoxic drugs, anti-epileptics
• Stress — elevated cortisol may influence melanocyte activity
• Skin inflammation — any inflammatory process can trigger post-inflammatory hyperpigmentation

Evidence-Based Treatment Approaches

First-Line: Topical Therapies

• Triple combination therapy — hydroquinone (2–4%), tretinoin (0.05%), and fluocinolone acetonide (0.01%)
• Tranexamic acid (topical) — action on the plasminogen pathway; well-tolerated
• Azelaic acid (15–20%) — safe in pregnancy, anti-tyrosinase and anti-inflammatory
• Cysteamine cream (5%) — naturally occurring antioxidant with promising efficacy
• Vitamin C (L-ascorbic acid) — mild depigmenting effects, best as adjunctive therapy

Procedural Treatments

• Chemical peels — superficial peels (glycolic 30–50%, mandelic, lactic acid) enhance topical penetration
• Laser and light therapies — low-fluence Q-switched Nd:YAG shows benefit in some studies
• Microneedling — tranexamic acid delivery via microneedling shows promising results
• Intense pulsed light (IPL) — addresses the vascular component but requires caution in darker skin

Oral Treatments

Oral tranexamic acid (250mg twice daily) has emerged as a significant treatment option. A randomised controlled trial in the JAAD (2020) demonstrated significant MASI score improvement versus placebo, though careful patient selection is required due to potential thrombotic risk.

The Critical Role of Sun Protection

• Broad-spectrum SPF 50+ applied daily, regardless of weather
• Iron oxide-containing sunscreens for visible light protection
• Reapplication every 2 hours during outdoor exposure
• Physical barriers — wide-brimmed hats, UV-protective clothing

Living with Melasma: The Psychological Impact

Studies using the Melasma Quality of Life Scale (MELASQOL) consistently demonstrate significant impacts on self-esteem, social interactions, and emotional well-being. A holistic approach should address psychological aspects alongside clinical treatment.

Frequently Asked Questions

Can melasma be permanently cured?

Melasma is a chronic condition that can be effectively managed but is rarely permanently cured. Maintenance therapy and strict photoprotection are typically lifelong commitments.

Is melasma treatment safe during pregnancy?

Hydroquinone and retinoids are contraindicated during pregnancy. However, azelaic acid, vitamin C, and rigorous sun protection can be safely used. Always inform your practitioner if you are pregnant.

How long does treatment take to show results?

Visible improvement typically begins at 6–8 weeks with topical treatment, though optimal results may take 3–6 months.

Does melasma get worse with age?

Melasma can fluctuate throughout life, often improving after menopause. However, cumulative sun damage may perpetuate the condition. Early intervention offers the best long-term outcomes.

This article is for informational purposes only and does not constitute medical advice. Always consult a qualified practitioner for personalised melasma assessment. Individual results may vary.