Everything you need to know about melasma

There’s pigmentation – the surface discolouration that forms when melanin molecules cluster together under the skin – and then there’s melasma.  It happens for a few different reasons, but it’s usually a result of sun damage or acne scarring. 

The more common types of pigmentation are most often the result of  sun damage or acne scarring.  There are many effective options for treating these, and usually, the pigmentation can be pretty well cleared with appropriate treatment. But what if your pigmentation is melasma? And how do you even know?

Melasma is a type of pigmentation usually caused by hormonal fluctuations – hence why it’s nicknamed ‘pregnancy mask’ – that forms a veil of darker colour over the face with patches of clustered pigmentation. Because of its hormonal nature, melasma is much more common in women, and you’re also more likely to develop melasma if you have dark skin.

‘Typically, the pattern of pigmentation is diffuse and looks almost like the skin is mottled,’ says Dr Maryam Zamani, aesthetic doctor and oculoplastic surgeon who has a clinic in London. ‘It is different from sunspots, which generally have a smaller diameter with distinct borders. Pigmentation from melasma also worsens with UV exposure and thus patients usually say that their pigment worsens in the summer and improves in the winter.’

Why is melasma so hard to treat?

Melasma has a reputation for being more challenging to treat than other types of pigmentation, which isn’t great news for people who have it, especially as it can be very noticeable on the face. It’s a skin condition that can’t ever be made to completely go away, so you need to find a way to live with it. ‘The best way to appreciate why melasma is so tricky to tackle is by likening the pigment cells to hyperactive little children,’ says Dr Zoya Awan, founder and medical director of Secret Aesthetics in Birmingham.

‘There are multiple factors that can trigger their hyperactivity, including hormonal changes, sun exposure and certain drugs. Because they are already hyperactive and primed, it doesn’t take much to get them to overproduce melanin as a response.’  It’s a case of managing these hyperactive cells rather than being able to eliminate them. ‘It also doesn’t help that this type of hyperpigmentation is usually found in stubborn, deep pockets within the skin, so it is not as easy to get to and lift off,’ adds Dr Zoya.

Her first step in melasma treatment is to have patients start using topical tyrosinase inhibitors as part of their medical-grade skincare routine. These ingredients essentially work by disrupting the melanin-forming process in the skin, and they need to be used long-term to keep those cells dormant and stop further pigmented areas from developing. Tyrosinase inhibitors include things like azelaic, l-ascorbic (vitamin C) and kojic acids – all ingredients commonly found in anti-pigmentation skincare.

‘Over-the-counter skincare should include skin brighteners like vitamin C, arbutin, liquorice extracts, azelaic acid, retinols and a host of other ingredients that can help lighten pigmentation,’ agrees Dr Maryam. She considers hydroquinone (a skin-lightening agent only available via prescription) the ‘topical gold standard’ for treating melasma, and often combines it with retinoids and a light topical steroid to start tackling it on the surface. ‘Topical skincare takes time to work and is not a quick fix,’ she says, which is why it has to be combined with targeted in-clinic treatments to really start to get a handle on melasma.

The best melasma treatments

Chemical peels, microneedling and fractional lasers are generally considered the most effective tweakments for melasma, but it’s vital you find a practitioner experienced in treating the condition, because it’s much more nuanced than other types of hyperpigmentation. ‘Chemical peels and microneedling can help lift off this kind of pigment, as well as retinoids, by increasing cell turnover, bringing the pigment to the surface much faster to shed away,’ says Dr Zoya.

Medium-strength chemical peels (meaning that they remove the skin cells from the epidermis and from some of the upper part of the middle layer of the dermis) including glycolic, salicylic, or trichloroacetic acid (known as a TCA peel) can be effective, providing the solution is at the right strength and the peel is applied correctly – a good practitioner will tailor the right peel for you following consultation.

A word of warning on lasers – ‘Although lasers can shatter the pre-existing pigment, lasers can be another trigger for these hyperactive cells, hence why lasers can often cause rebound hyperpigmentation in melasma,’ advises Dr Zoya. ‘If laser and light-based devices are being used in melasma, they need to be done so cautiously and always alongside medical-grade skincare.’ Dr Maryam agrees – ‘Light and laser therapy can be effective but must be particularly used with caution in patients with melasma.’

This is why she has created her own combination treatment for hyperpigmentation and melasma called Complexion Balance. It involves gentle, fractional, non-ablative Moxi laser layered with intradermal injections of tranexamic acid alongside prescription topical skincare. ‘Moxi can be used on all skin tones to promote new cell growth and reduce unwanted pigmentation with less downtime than more aggressive laser treatments. It is safe on all skin types because there is no deep heat creation triggering melanocyte activity,’ she explains. ‘Tranexamic acid works to interrupt pathways in the skin that create melanin and therefore pigment in the skin.’ Tranexamic acid is typically prescribed orally or topically, and these are options for Dr Maryam’s patients if they would rather not have intradermal injections.

Managing melasma

The bottom line with melasma is that it can’t ever be completely eliminated, but it can be very effectively managed and mostly kept at bay with appropriate treatment. This also means committing to minimising exposure to the things that you know trigger your melasma – causing it to produce more pigment – like direct heat from saunas, very sweaty exercise, etc., and certain medications such as the oral contraceptive pill (of course, talk to your doctor before stopping or changing any medication).

The biggest trigger by far though is the sun. ‘Good sun protection habits are paramount, says Dr Zoya, ‘Namely, twice-hourly application of broad-spectrum SPF 30-50 during daylight hours, sunglasses and a wide-brim hat. Avoiding direct sun exposure completely during the day is best, but not always possible. Dr Zamani emphasises the importance of keeping up with a practitioner-prescribed medical-grade skincare routine on an on-going basis as key to getting – and keeping – a handle on melasma: ‘Consistent topical skincare is imperative to help keep melasma at bay. There can be long-term improvement but often pigmentation from melasma does rebound.’