Melasma: Causes, Types and How We Treat It

Of all the pigmentation concerns I see in clinic, melasma is the one I spend the most time talking patients through before we talk about treatment. That’s deliberate. Melasma has a reputation for being difficult, and that reputation is earned. Not because it can’t be improved, but because the treatments most patients arrive expecting, bright lights, laser, aggressive peels, are frequently the wrong answer and sometimes make things significantly worse.

If you’ve read the Lumecca IPL guide and found the note saying we often don’t use IPL for melasma, this is the article that explains why, and what we do instead.

What Melasma Actually Is

Melasma is a chronic, often relapsing condition of excess melanin production in the skin. The word comes from the Greek for “black spot”, which undersells the complexity of what’s happening. Melanocytes, the cells that produce melanin, become hyperactive in certain areas, typically the face, and begin producing significantly more pigment than the surrounding skin. The result is a patchy, often symmetrical darkening, usually across the cheeks, upper lip, forehead and chin.

What distinguishes melasma from other forms of hyperpigmentation is that it’s not primarily caused by damage. It’s driven by hormonal triggers, UV exposure and heat, individually and in combination. You can remove every visible brown patch and have it return within weeks if the triggers aren’t controlled. This is why photoprotection isn’t an afterthought in melasma management. It’s the foundation everything else sits on.

For the broader differential diagnosis of brown spots, the hyperpigmentation guide sets out the full range of pigmentation types.

The Three Types of Melasma

Melasma is classified by the depth at which the excess pigment sits. This matters because depth determines which treatments can reach it and which can’t.

Epidermal melasma sits in the outer layers of the skin. It typically looks light to medium brown and is the most responsive to topical treatment and carefully chosen superficial procedures. Under the cross-polarised light of our Observ 520, it appears clearly defined.

Dermal melasma involves melanin that has been deposited in the dermis, deeper in the skin structure. It appears blue-grey rather than brown, and it responds poorly to most topical treatments because the actives can’t reach the depth of the problem. Laser and IPL also struggle with dermal melasma and risk worsening it. This type is the most challenging to manage.

Mixed melasma is the most common pattern. Both epidermal and dermal components are present, often in overlapping areas. Treatment needs to target both layers, which requires a staged and careful approach.

What Causes Melasma

The underlying mechanism is an increase in melanocyte activity, driven by several triggers that often act together:

Hormonal fluctuations are the most common driver. Pregnancy-related melasma (historically called chloasma) affects a significant proportion of pregnant women and usually fades after delivery, though not always completely. Combined oral contraceptives, progesterone-only contraceptives, and hormone replacement therapy can all trigger or worsen melasma. Some patients find that changing or stopping hormonal medication significantly reduces the pattern.

UV exposure is the other major driver. Ultraviolet light directly stimulates melanocyte activity. Even brief, repeated UV exposure maintains melasma and reverses the progress of treatment. Visible light also plays a role, which is why patients with darker skin types sometimes find that even light through glass, without direct UV, triggers their melasma. This is the reason broad-spectrum, visible-light-protecting formulations matter specifically in melasma.

Heat stimulates melanocytes independently of UV. This includes sunburn, but also things patients don’t connect to skin: very hot showers, saunas, steam facials, vigorous exercise in heat, and certain light-based and laser treatments. One of the reasons Lumecca IPL is usually the wrong device for melasma is the heat it generates at the skin surface.

Thyroid disease, particularly hypothyroidism, is associated with melasma in some patients. We’ll ask about thyroid function at consultation.

Genetic predisposition is well established. Melasma runs in families, particularly in populations with Fitzpatrick skin types III to V. If your mother or sisters have it, your risk is higher.

How We Assess Melasma at LRC

The Observ 520 skin analysis system is at the centre of our melasma assessment. Different light modes reveal where pigment sits, how dense it is, and how much sun damage underlies it. UV fluorescence reveals sun damage that hasn’t yet emerged as visible pigment. Cross-polarised light distinguishes epidermal from dermal patterns. This isn’t decoration; it changes the treatment plan in a meaningful way.

Beyond the Observ, we take a thorough history at consultation: contraceptive use, pregnancy history, thyroid status, medications, previous treatments and their outcomes. Patients who’ve already tried laser or IPL elsewhere and seen their melasma worsen are among those where the consultation is most important. They’ve often been through exactly the treatment pathway that wasn’t right for their type.

The Non-Negotiable Foundation: Photoprotection

No treatment for melasma works without photoprotection. This isn’t a caveat; it’s a clinical fact. If you’re treating melasma and not using a broad-spectrum SPF 50 every morning, the treatment is fighting a losing battle.

For melasma specifically, the formulation matters. Some patients need protection beyond standard UV filters, particularly coverage into visible light and infrared, where tinted mineral sunscreens (iron oxides) are more effective than clear chemical-only formulas. We discuss this at consultation and recommend specific formulations based on your skin type and pattern.

Sun avoidance, hats, and where possible staying out of direct sunlight between 10am and 3pm, is the other half of this. No amount of SPF fully compensates for prolonged direct UV exposure.

Medical-Grade Topical Treatment

Topical treatment is usually the first clinical step alongside strict photoprotection, and for many patients it’s the intervention that delivers the most sustained improvement.

The most effective topical agents for melasma work by interrupting melanin synthesis at different points in the pathway. At LRC, our medical-grade skincare includes ranges from Obagi Medical and ZO Skin Health, both of which have specific formulations developed for pigmentation management. My training under Dr Zein Obagi in Los Angeles is where I developed the understanding that the skincare beneath and between clinic treatments is as important as the clinic treatments themselves.

The specific actives we use, and whether they require prescribing through our medical team, depend on your assessment. Some treatments are applied at medical-grade concentrations that require a prescribing consultation. Others, including azelaic acid, niacinamide, tranexamic acid and vitamin C, can be used without prescription and are woven into ongoing homecare programmes. We build the regimen at consultation, not in advance.

Consistency over months, not weeks, is what delivers results with topical treatment for melasma. Patients who see the most improvement are those who commit to the protocol before, during and after any clinic treatment.

Aesthetic Treatments for Melasma

Aesthetic treatments play a supporting role in melasma management, not the leading role. The topical regimen and photoprotection do the sustained work. Aesthetic treatments can accelerate progress, particularly on the epidermal component, when they’re the right type for the right patient.

Chemical peels, carefully selected, are often our first clinic treatment for epidermal melasma. Superficial peels using glycolic acid, lactic acid or mandelic acid can enhance topical penetration, reduce surface pigment density, and contribute to the overall improvement. We choose depths conservatively and space sessions carefully. Medium and deep peels carry a significant risk of worsening melasma in susceptible patients, particularly in those with Fitzpatrick types III and above. The patient guide to chemical peels sets out the peel types in full.

Fractora, our fractional RF microneedling platform, is a consideration for dermal melasma in carefully selected patients. RF energy doesn’t trigger melanocytes in the way that light and heat do, which means it can be used in some melasma cases where laser and IPL would be contraindicated. The evidence base is evolving rather than settled, and we’re honest about that at consultation. Where we do recommend Fractora for melasma, we do so as part of a comprehensive protocol, not as a standalone intervention. More on how Fractora works is in the patient guide to Fractora.

Microneedling can support topical delivery of pigment-modulating actives into the skin. We use SkinPen microneedling in combination with appropriate topicals for selected patients, particularly where improving skin texture and tone alongside pigmentation is the goal.

What we don’t use for melasma. IPL, including Lumecca, is usually not the right choice. The broadband light and the heat generated can trigger a melanocyte response and produce significant rebound pigmentation. We’ll say so at consultation even if Lumecca is what a patient arrives asking for. Similarly, aggressive laser treatments and anything that generates significant superficial heat are generally avoided.

What to Expect: Honest About the Long Term

Melasma is a chronic condition, not an acute one. The melanocytes that produce excess pigment don’t disappear. They’re managed. For most patients, the realistic goal is significant visible improvement with a maintenance programme that keeps the condition under control.

The patients who do best are those who accept two things: that SPF is non-negotiable and permanent, not something to use during treatment and stop afterwards; and that if the hormonal triggers remain, the melasma will be harder to control. Some patients find that discussing contraceptive options with their GP, or adjusting their approach to HRT, changes their melasma management substantially.

Some patients achieve clearance that’s so complete they don’t need active clinic treatment any more. Others find a manageable equilibrium with low-maintenance topical use and an annual clinic review. Neither outcome is a failure. Managing a chronic condition well is a success.

When to Refer

We refer to a dermatologist when:

• The pattern doesn’t fit typical melasma and warrants further investigation
• There’s any lesion with features that concern us using the ABCDE rule (asymmetry, border irregularity, colour variation, diameter, evolution)
• The melasma is severe, highly resistant, or involves significant quality-of-life impact that may benefit from dermatological-level prescribing options
• Underlying thyroid or hormonal disease is suspected and hasn’t been investigated

We’d rather refer a patient for the right level of care than continue treating something outside our scope.

Frequently Asked Questions

Is melasma the same as sun damage?

Not exactly. Both involve excess melanin, but the mechanism differs. Sun damage produces melanin in response to UV at the site of exposure. Melasma involves a systemic sensitisation of melanocytes, usually driven by hormonal triggers, that makes them hyperactive in certain areas. You can get sun damage without melasma and melasma without obvious sun damage. The treatments overlap somewhat, but melasma-specific management involves controlling the hormonal and heat triggers rather than just treating the surface pigment.

Can Lumecca or laser treat my melasma?

Often not safely, particularly for dermal or mixed melasma. Light and heat stimulate the melanocytes involved in melasma, and treatment can produce a rebound flare that leaves the skin significantly darker than before. Superficial chemical peels and selected RF treatments are generally safer options, alongside medical-grade topical regimens. We’ll assess your type at consultation and be clear about which treatments are appropriate and which we’d advise against.

Will my melasma go away on its own?

Pregnancy-related melasma often fades after delivery, though sometimes incompletely. Melasma linked to hormonal contraceptives often improves if the medication is stopped. Melasma unrelated to a clear hormonal trigger tends to be more persistent. For all types, UV exposure and heat maintain and worsen the pattern. Strict photoprotection gives the skin the best chance of improving without clinic treatment.

Do I need to stop the Pill to treat my melasma?

It depends. Oestrogen-containing contraceptives are a common trigger, and some patients see substantial improvement if they switch to a non-hormonal or progesterone-only method. But the decision to change contraception is a medical and personal one that belongs with your GP. We discuss it at consultation, and it’s worth raising with your doctor alongside your skin concerns.

How long will treatment take to work?

Topical treatment for melasma typically shows meaningful improvement over three to six months of consistent use. Clinic treatments such as peels accelerate this but don’t shortcut the timeline. Melasma that’s been present for years, particularly dermal melasma, takes longer to improve and may not clear completely. We set realistic expectations at consultation and track progress at each review.

What SPF should I be using for melasma?

A broad-spectrum SPF 50 or higher, applied every morning regardless of weather. For melasma specifically, the formulation matters. Tinted mineral sunscreens containing iron oxides offer protection into visible light wavelengths that standard chemical SPFs miss, and visible light is enough to stimulate melanocytes in some patients. We recommend specific formulations at consultation based on your skin type. Reapplication during sun exposure is as important as morning application.

Is melasma the same in men as in women?

Melasma does occur in men, though it’s less common. The distribution and triggers are similar, though the hormonal component is less often the primary driver. UV exposure is usually the dominant trigger in men. Assessment and treatment principles are the same: establish the type and depth, control the triggers, manage with topicals and, where appropriate, carefully selected clinic treatments.

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Related reading

• Hyperpigmentation: types and treatment
• Patient guide: Lumecca IPL
• Patient guide: chemical peels
• Patient guide: Fractora
• Patient guide: microneedling
• Sun damage prevention and SPF guide
• What to expect at an aesthetic consultation
• Homecare between treatments