What Is Melasma?

Melasma is a benign skin condition characterized by symmetrical brown, tan, or gray-brown patches on sun-exposed areas of the skin. It is sometimes called chloasma or the “mask of pregnancy” when it develops during pregnancy.

Dermatology classifies melasma into three types based on the depth of pigment:

• Epidermal melasma – affects the outer layer of skin and responds best to treatment

• Dermal melasma – involves deeper pigment and is more difficult to treat

• Mixed melasma – involves both epidermal and dermal layers

Melasma develops due to overactive melanocytes, the pigment-producing cells of the skin. These cells become overstimulated by internal and external triggers. Current medical evidence shows that estrogen and progesterone play a major role, which explains why melasma is far more common in women.

Known contributing factors include:

• Family history of melasma

• Pregnancy

• Oral contraceptives

• Hormone replacement therapy (HRT)

• Sun exposure (UV, visible light, infrared light)

• Tanning beds

• Hypothyroidism

• Certain medications

• Skincare or cosmetic products that irritate or photosensitize the skin

• Folate deficiency

• Sensitive or reactive skin

• Hormonal fluctuations

• Darker skin types

• Elevated copper levels

• Some cosmetic or laser procedures

Melasma presents as flat patches or macules that are:

• Light brown, dark brown, or bluish-gray

• Non-scaly and usually non-inflamed

Common distribution patterns include:

• Centrofacial (forehead, nose, cheeks, upper lip)

• Malar (cheeks and nose)

• Mandibular (jawline)

• Lateral cheek pattern

• Neck, particularly in adults over 50

• Upper arms and shoulders (less common)

Sun exposure is the most significant modifiable trigger for melasma. Daily sun protection is considered first-line prevention and treatment.

Current dermatology recommendations include:

• Broad-spectrum mineral sunscreen SPF 30 or higher

• Ingredients such as zinc oxide and iron oxides to block UV and visible light

• Tinted sunscreens to reduce pigment stimulation

• Apply sunscreen 15 minutes before sun exposure

• Reapply every 2 hours when outdoors

If sunscreen is not tolerated:

• Wear wide-brimmed hats

• Use UPF-rated clothing

• Limit sun exposure during peak hours

Vitamin D levels can be assessed with blood testing if deficiency is a concern.

Melasma may worsen with:

• High UV exposure, especially in summer or near the equator

• Heat, which increases blood vessel dilation and melanocyte activity

Cold, dry weather can also exacerbate melasma by:

• Causing skin irritation

• Compromising the skin barrier

Maintaining hydration and consistent moisturization helps reduce flare-ups.

Topical Treatments

• Hydroquinone – gold-standard skin-lightening agent

• Retinoids (retinol, tretinoin) – increase skin cell turnover

• Azelaic acid – reduces pigment and inflammation

• Combination creams (e.g., hydroquinone + retinoid + mild steroid)

Procedural Treatments

• Chemical peels

• Microdermabrasion

• Laser or light-based therapies (used cautiously; not first-line)

Procedures should be guided by a dermatology-trained provider, as improper treatment can worsen melasma.

Lifestyle modification plays a supportive role:

• Stress reduction (exercise, meditation, yoga)

• Anti-inflammatory, antioxidant-rich diet

• Adequate folate intake

Copper intake should remain within recommended limits:

• 900 mcg/day for non-pregnant adults

• 1000 mcg/day during pregnancy

• 1300 mcg/day while breastfeeding

If copper levels are elevated, iron and vitamin C intake may help rebalance levels.