Melasma is one of the most common skin concerns I am asked about. It is a chronic, relapsing form of facial hyperpigmentation that disproportionately affects women and significantly impacts quality of life. Although often referred to as a cosmetic condition, research clearly shows that melasma is a complex, biologically active disorder involving genetics, hormones, light exposure, oxidative stress, vascular changes, and inflammation. Importantly, melasma does not have a true “cure.” Instead, management focuses on control, lightening of pigmentation, trigger avoidance, and long-term relapse prevention.
Understanding the underlying causes and evidence-based treatments is essential for setting realistic expectations and designing effective, individualized management plans.
What Causes Melasma?
Melasma develops when genetically predisposed skin is repeatedly exposed to internal and external triggers that overstimulate melanocytes.
Genetic Susceptibility
A strong genetic component underpins melasma. Studies show that approximately 40 to 60 percent of affected individuals report a family history, suggesting inherited susceptibility rather than a single causative gene. Melasma-prone skin demonstrates stable structural differences, including alterations in the epidermis, basement membrane, and dermis, which favor persistent pigmentation and recurrence even after treatment.
This explains why melasma often behaves as a lifelong condition rather than a transient pigment issue.
Light, Heat, and Oxidative Stress
Ultraviolet and visible light exposure are the strongest external triggers for melasma. Lesions occur exclusively on photo-exposed skin and show increased solar elastosis, vascularity, and mast cell activity compared with surrounding skin.
Heat exposure, such as cooking or occupational heat, further worsens melasma by increasing oxidative stress pathways. Pollution, particularly fine particulate matter, activates the aryl hydrocarbon receptor, which upregulates melanogenesis and acts synergistically with ultraviolet radiation.
At a biochemical level, melasma skin exhibits increased markers of oxidative stress and impaired antioxidant defense systems. This pro-oxidative environment sustains melanocyte overactivity and contributes to relapse.
Hormonal Influences and Pregnancy
Hormonal factors play a central role, particularly female sex hormones. Pregnancy-associated melasma, often called the mask of pregnancy, affects between 14.5 percent and 56 percent of pregnant women, with even higher rates reported in some clinical cohorts.
During pregnancy, estrogen, progesterone, luteinizing hormone, follicle-stimulating hormone, and melanocyte-stimulating hormone all increase. Estrogen, in particular, enhances melanogenesis by upregulating tyrosinase and related enzymes. Studies show that higher estradiol levels correlate with greater melasma severity.
Melasma usually appears during the second or third trimester and often fades within a year postpartum, but persistence is common. Importantly, a history of pregnancy-related melasma strongly predicts melasma triggered later by oral contraceptives or hormone therapy.
Inflammation, Vascular Changes, and Skin Barrier Dysfunction
Melasma lesions demonstrate increased dermal blood vessels, mast cells, nitric oxide signaling, senescent fibroblasts, and basement membrane damage. These features create a pro-pigmentary microenvironment that continuously stimulates melanocytes.
Prior skin inflammation, from cosmetic products, contact dermatitis, or aesthetic procedures, can localize melasma, highlighting the importance of barrier protection and gentle skin care.
Emerging research also suggests roles for microbiome alterations and lifestyle factors. Alcohol consumption has been identified as a novel systemic risk factor, likely via oxidative and hormonal pathways.
Core Principles of Melasma Management
Because melasma is chronic and relapsing, treatment aims to control pigmentation rather than permanently eliminate it.
Strict Photoprotection
Daily, rigorous photoprotection is the foundation of all melasma management. This includes broad-spectrum high-SPF sunscreens covering ultraviolet B, ultraviolet A1, and visible light, preferably tinted formulations to block visible light, and physical protection such as hats and shade.
Without consistent photoprotection, even the most advanced treatments will fail or relapse rapidly.
Trigger Identification and Expectation Management
Hormonal medications, photosensitizing drugs, heat exposure, harsh cosmetics, and inflammatory skin care practices should be reviewed. Patients must be counseled that recurrence is common and that long-term maintenance is required.
Evidence-Based Treatment Options
Topical Therapies
Hydroquinone remains the most studied depigmenting agent. The triple combination cream, which includes hydroquinone, tretinoin, and a corticosteroid, is consistently shown to be the most effective topical therapy. While irritation is more common, it is considered the gold standard for first-line treatment.
Azelaic acid, non-hydroquinone lighteners, thiamidol, topical tranexamic acid, antioxidants, and vitamin C are useful alternatives or adjuncts, particularly when hydroquinone is not tolerated or long-term safety is a concern.
Chemical Peels
Superficial chemical peels, particularly glycolic acid, can improve melasma when used as adjuncts to topical therapy. However, they carry risks of irritation and post-inflammatory hyperpigmentation, especially in darker skin types, and should be used cautiously.
Energy-Based Devices
Low-fluence Q-switched Nd:YAG lasers, non-ablative fractional lasers, ablative fractional lasers, and intense pulsed light can produce significant short-term improvement. Network meta-analyses rank these among the most potent interventions.
However, recurrence rates are high, and adverse pigmentary changes are a concern. These modalities are best reserved for resistant cases and are almost always combined with topical maintenance therapy.
Oral Therapies
Oral tranexamic acid has emerged as a promising option for moderate to severe or refractory melasma. Studies show meaningful reductions in severity and lower relapse rates when tranexamic acid is combined with topical therapy or lasers.
However, tranexamic acid carries potential risks, including thromboembolic events and menstrual disturbances, and should only be prescribed with careful patient selection and medical oversight.
Other oral agents, such as Polypodium leucotomos and antioxidants, may offer modest supportive benefits but should not replace core therapies.
Why Combination Therapy Works Best
Across systematic reviews and randomized trials, combination therapy consistently outperforms monotherapy. A stepwise, multimodal approach is now considered best practice.
This approach begins with strict photoprotection, followed by topical depigmenting combinations, particularly triple combination cream. Adjunctive peels or microneedling may be added where appropriate, with energy-based devices and or oral tranexamic acid reserved for resistant cases.
By targeting multiple pathogenic pathways at once, including melanocytes, inflammation, vascular factors, and oxidative stress, combination therapy improves both efficacy and durability.
Take-Home Message
Melasma is a biologically complex, chronic condition driven by genetic susceptibility interacting with light exposure, hormones, oxidative stress, and inflammation. There is no cure, but strong evidence supports effective control through rigorous photoprotection and well-designed combination therapies.
Hydroquinone-based triple combination creams remain the most reliable first-line treatment, while oral tranexamic acid and energy-based devices can enhance outcomes in carefully selected patients. Success in melasma management depends on realistic expectations, long-term maintenance, and individualized, evidence-based care.
As always, a visit to your dermatologist is recommended to get the best advice for your skin.
Follow me on Instagram for more skin tips (sarahcurranfitpro)
The bodybuilding aesthetician 
Leave a comment