Therapy guide · medical education
Melasma: the full therapy pathway
From the sunscreen that is genuinely the therapy to the prescriptions, peels and lasers dermatologists use — and an honest account of why this one comes back.
Before anything else
Not everyone should start at the bottom of this pathway. These presentations are reasons to
see a clinician without waiting out an over-the-counter trial first.
- A pigmented patch that is changing, growing, or asymmetrical See a dermatologist soon
Melasma is symmetrical and stable in outline. Pigment that is enlarging, changing shape, has an irregular border or looks different from everything around it is a question for a clinician promptly — not because it is likely to be sinister, but because that is not a question a page can answer.
- Pigment that got darker after a laser or peel See a dermatologist soon
Rebound hyperpigmentation after aggressive treatment is a recognised and genuinely common outcome in melasma, particularly in richer skin tones. It needs someone experienced with melasma rather than more of the same treatment — repeating what caused it is the usual mistake.
- Blue-black or slate-grey pigment after long-term skin-lightening use See a dermatologist soon
Exogenous ochronosis is an uncommon but disfiguring consequence of prolonged high-strength hydroquinone, and it is very difficult to reverse. Stop and get it looked at rather than escalating.
- You bought a skin-lightening cream without an ingredient list Worth a clinician visit
Unregulated lightening products are a genuine public-health problem and have been repeatedly found to contain mercury or undeclared potent steroids. If you cannot read what is in it, that is reason enough to stop.
Which part of this pathway is yours?
Four branches are mapped here, and one of them withdraws most of the ladder. Six questions, about a minute — including two that decide whether this is melasma at all, because several things that look like it are treated completely differently.
Answers stay in this browser. Nothing is sent anywhere, and one button clears them.
One thing to be clear about. This places you on a map rather than diagnosing you, and melasma has more convincing lookalikes than most conditions — post-inflammatory marks, sun spots, drug-induced pigment and, importantly, changing lesions that need assessing on their own terms. If the description here does not match what you see, that mismatch matters more than the result.
What this looks like
Melasma used to be staged by depth — epidermal, dermal, mixed — usually with a Wood's lamp. That framework is falling out of use: the most recent international consensus no longer relies on Wood's light to choose treatment, because in practice almost all melasma turns out to be mixed and the label rarely changed what was done. What matters more is how long you've had it, how much of your face it covers, and whether it recurs the moment treatment stops.
Recent and limited
Appeared within the last year or so — often after a pregnancy, a new pill, or a strong summer — and confined to a patch or two.
What it looks like: Light-to-mid brown, reasonably defined, symmetrical, over cheekbones or the upper lip. This is melasma at its most treatable, and the window when relentless photoprotection does the most good.
Established
Present for years, through multiple summers and probably several treatment attempts.
What it looks like: Broader patches, sometimes greyer or more diffuse, often with a history of clearing partly and returning each summer. Realistic goal here is control and maintenance rather than clearance.
Refractory or rebounding
Melasma that has not responded to proper topical treatment, or that has been made worse by treatment.
What it looks like: Persistent despite a genuine attempt — or darker after a laser or an aggressive peel, which is a real and well-documented outcome rather than bad luck. This is the presentation that most needs a clinician who treats melasma often.
Three things that change the plan regardless of severity
Pregnant, nursing, or planning to be
This changes the plan more than anything else on the page. Most of the effective ladder — hydroquinone, tretinoin, oral tranexamic acid — is off the table, and melasma that arrives in pregnancy often fades on its own in the months after. The right move is frequently photoprotection and patience rather than treatment.
On a hormonal contraceptive or HRT
Oestrogen is a driver. Melasma that started with a pill and is treated aggressively while the pill continues is being fought with the tap running — worth raising, though it is a genuine trade-off rather than an obvious answer.
Richer skin tones
Melasma is commonest in mid-to-deep skin tones, and those are also the tones most likely to be worsened by aggressive treatment — post-inflammatory hyperpigmentation from a peel or laser can be worse and longer-lasting than the melasma. The cost of an over-enthusiastic practitioner is higher here, and choosing one who treats melasma in your skin tone often is not fussiness.
Heat exposure
Not just light — heat provokes melasma too. Cooking over a stove, hot yoga, saunas, long commutes with the sun on one side of your face. People who cannot work out why theirs flares in winter are often finding heat, not UV.
What else it could be
- Post-inflammatory hyperpigmentation — Marks that sit exactly where spots, a reaction or a scratch used to be — they follow the injury, not a symmetrical pattern, and they fade on their own given time and sun protection.
- Solar lentigines — Discrete, well-edged 'sun spots' on the most-exposed areas rather than diffuse symmetrical patches. They respond to treatments melasma doesn't, and vice versa.
- Drug-induced pigmentation — Some medicines — certain antibiotics, antimalarials, amiodarone among them — produce facial pigment that can look like melasma and won't budge until the drug is addressed.
- Ochronosis — Paradoxical blue-black pigmentation from prolonged high-strength hydroquinone use, often on unregulated products. Rare, disfiguring, and the reason hydroquinone is a supervised treatment rather than something to buy indefinitely online.
One distinction is worth carrying to the appointment: melasma and post-inflammatory pigment look similar and are treated differently, and people spend years and considerable money treating one as the other. Symmetry across both cheeks points to melasma; a mark that maps onto an old spot points the other way.
Why it happens
Melasma is the pigment factory running hot, not pigment sitting where it shouldn't. Melanocytes in affected skin are larger, busier and more easily provoked than their neighbours, and what provokes them is light — ultraviolet, but also visible light, which ordinary sunscreen barely touches — plus heat and hormones. Underneath the pigment there is usually a damaged upper dermis and a leaky, over-vascularised environment keeping those cells stimulated. That is why melasma behaves less like a stain to be removed and more like a condition to be kept quiet: the cells that made it are still there, still primed, and still watching for light.
Anyone with symmetrical brown or grey-brown patches across the cheeks, forehead, upper lip or jaw who has worked through the brightening aisle and wants to know what's actually available — and anyone who has been told melasma is untreatable and would like a more accurate picture. It is treatable. It is not curable, and those are different sentences.
Orientation, not diagnosis. This page helps you orient — it is not a diagnosis. Several things produce facial pigment: post-inflammatory marks left by acne or a reaction, sun-induced lentigines, drug-induced pigmentation, and — less commonly — conditions that need a clinician to recognise. Melasma's tell is symmetry and a hormonal or light-related trigger. A patch that is one-sided, changing, or growing is a different conversation and belongs with a clinician.
All of this is available without a prescription The over-the-counter pathway
Melasma is the one condition on this site where the most important product is a sunscreen — and where nearly everyone's routine is built the wrong way round. People buy the brightening serum and treat the sunscreen as housekeeping. It is the reverse: photoprotection is the treatment, and the international consensus calls broad-spectrum SPF 50 with a visible-light filter the irreplaceable cornerstone of melasma management. Everything else on this page, prescriptions included, is working against the tap if that part isn't right.
Appropriate for: Melasma of any severity — because this tier isn't a rung you pass through, it's the floor the whole ladder stands on. Photoprotection continues under every prescription and every procedure above, and it is the only part that never stops.
One route, and it is unusual in one respect: the first step is not a preparation for treatment, it is the most effective treatment available over a counter. Everything after it is an addition to photoprotection rather than a replacement for it, and every rung above works less well — or stops working entirely — without it.
The rule that reverses everything you know about actives
Irritation makes melasma darker. Not temporarily, and not only in some people — inflammation drives the pigment cells that cause the problem, so a routine that leaves skin pink and stinging is actively feeding the condition it is meant to treat. That single fact reverses the usual instinct. Here, the strongest plan you can tolerate is the wrong plan; the right one is the gentlest thing that works, applied for far longer than feels reasonable.
Four rules, and the first is the whole pathway
- Photoprotection is not optional and it is not seasonal. Without it, everything else on this page is being undone daily.
- It has to be tinted. Visible light drives melasma and ordinary UV filters do not block it — the iron oxides that give a tinted sunscreen its colour are what does.
- One pigment active at a time. Stacking three does not work three times faster; it irritates, and irritation darkens.
- Anything that stings, burns or leaves the skin pink comes straight back out of the routine, however well reviewed it is.
Answer as you go and the chart tracks where you are. Nothing is sent anywhere.
- From today, permanentlyYou are here
Photoprotection, done properly
Stop adding to the pigment faster than anything can remove it.
What this step involves
Morning
- Tinted mineral sunscreen, SPF 30+ The tint is the active part here. Iron oxides block visible light, which ordinary sunscreen filters let straight through — and visible light is a genuine driver of melasma, not a technicality. Browse all sunscreens →
- Enough of it, reapplied A generous layer in the morning and again in the early afternoon on any day you are outdoors. A single thin morning application is most of a sunscreen's advertised protection thrown away.
- Shade and a brim A wide-brimmed hat does more for the cheeks and upper lip than any product, and costs nothing after the first purchase.
Evening
- Nothing yet Deliberately. The evening slot is where actives go later, and starting them in the same week as the sunscreen makes it impossible to tell which one did anything.
Why this step: Photoprotection is described in the current consensus as the irreplaceable cornerstone of melasma treatment, and it is the one intervention that both fades existing pigment over time and prevents new pigment. It is also the step most often done at half strength, which is why nothing else works.
What's normal: Heat matters too, separately from light. Cooking over a hot stove, saunas and long hot commutes can all provoke it, and none of that is helped by sunscreen.
Ready for the next step?
Are you wearing a tinted sunscreen every day, including indoors near windows and in winter?
Yes, every day: Then the foundation is in place and worth giving a run on its own. Go to step 1 ↓
Not consistently: Fix this before adding anything. An active layered over inconsistent photoprotection is money spent undoing itself.
- Weeks 1–6You are here
Give photoprotection alone a proper run
Find out how much of the problem is ongoing exposure before treating it as something else.
What this step involves
Morning
- Unchanged Tinted sunscreen, generously, reapplied. Nothing added. Browse all sunscreens →
Evening
- A plain moisturiser Nothing active. Skin that is comfortable and intact tolerates what comes next; skin that is already irritated does not. Browse all moisturizers →
Why this step: A surprising amount of melasma lightens on photoprotection alone, and starting an active at the same time means never knowing that. It also means any irritation that appears cannot be attributed to anything in particular.
Six weeks feels like a long time to do nothing. It is the difference between knowing what is working and guessing for a year.
Ready for the next step?
Has six weeks of relentless photoprotection lightened it at all?
Yes, a little: Encouraging, and a reason to keep going rather than to stop. Adding one active from here builds on something that is already moving. Go to step 2 ↓
No change: Also useful. Photoprotection stays regardless — it is now preventing rather than fading — and an active is the reasonable addition.
- Week 6 onwardsYou are here
Add one pigment active — one
A single addition, given long enough to be judged.
What this step involves
Morning
- Unchanged Photoprotection is not replaced by an active and never becomes optional.
Evening
- Pick one and stay with it Azelaic acid is the most tolerable and the only one available in pregnancy. Topical tranexamic acid is well tolerated and has grown a real evidence base. Niacinamide is the gentlest. Vitamin C is the most likely to sting and the least stable. Any of them is a reasonable choice; using all four is not. Browse all azelaic acid products →
- Moisturise over the top Comfort is a treatment goal here rather than a nicety — it is what keeps the routine irritation-free for the months this takes. Browse all moisturizers →
Why this step: Every one of these actives interrupts pigment production by a different route, and none of them works quickly. Choosing one and giving it twelve weeks produces an answer; rotating through four produces twelve months and no information.
Ready for the next step?
Have you settled on one active, applied most nights, with no stinging?
Yes: Then the twelve-week clock starts now, and the job until then is not changing anything. Go to step 3 ↓
Not yet: If the one you picked stings, swap it for a gentler one rather than pushing through — pushing through is how melasma gets darker.
- OngoingYou are here
Protect the result from your own routine
Remove the things quietly undoing it.
What this step involves
Morning
- Audit what else is on your face Scrubs, strong acid exfoliants, retinoid strengths chosen for acne, at-home devices and anything advertised as resurfacing all carry an irritation cost that melasma charges back in pigment.
Evening
- Gentle everything else A plain cleanser and a plain moisturiser around the one active. This is the routine where dullness is a feature. Browse all cleansers →
Why this step: Melasma is the one condition on this site where a more aggressive routine reliably produces a worse outcome. Most of what people add in frustration — stronger acids, more exfoliation, a device — makes the pigment darker over the following months.
Ready for the next step?
Is everything else you use on your face genuinely bland?
Yes: Then nothing in the routine is working against the one thing that is. Go to the checkpoint ↓
There's a scrub or an acid in there: Take it out for the duration. It is almost certainly costing more than it contributes.
Twelve weeks on photoprotection plus one active
Twelve weeks from settling on the active — not from the first tinted sunscreen, and not from the first tube of anything.
How to judge it: Photographs, in the same light, without makeup, roughly monthly. Melasma changes too slowly to see in a mirror and too much with the light to judge from memory — this is the condition where photographs are least optional.
Compared with three months ago, is the pigment lighter or less extensive?
It is working, and the plan does not change.
Melasma fades slowly and returns quickly, so the useful instruction here is patience rather than escalation. Keep the same active and the same photoprotection through at least another few months, and expect the photographs rather than the mirror to show it. What you must not do is stop the sunscreen because the pigment improved — that is the most reliable way to lose the ground gained.
Normal for this condition, and not yet a reason to change anything.
Twelve weeks is a short window for melasma, and ambiguous progress at this point is closer to expected than to disappointing. If the photographs suggest movement, continuing is more likely to help than switching. If they suggest nothing at all after a further few months, that is when it becomes a conversation.
This is the handover point.
Twelve weeks of genuine photoprotection plus one active, with nothing to show for it, is the result this checkpoint exists to produce. It does not mean the products were wrong or that you were careless. It means the pigment sitting deeper, or a driver that is still running, is beyond what the aisle reaches — and the prescription tier begins with combinations that are considerably more effective and need supervising for exactly that reason.
Stop the active and look at what irritated it.
Melasma that darkens during treatment is usually responding to irritation rather than to the pigment active itself — from that active, from something else in the routine, or from light and heat exposure that outpaced the sunscreen. Take the active out, keep the photoprotection, let the skin settle for a few weeks, and treat that darkening as information rather than as a reason to try something stronger.
These are not melasma, and this pathway is the wrong one for them
A pigmented patch that is changing shape, growing, or is noticeably asymmetrical needs assessing on its own terms rather than treating as melasma. So does pigment that turned blue-black or slate-grey during long-term use of a skin-lightening cream, and any pigment that got markedly darker after a laser or a peel. None of those improve by continuing down this page.
Melasma is managed rather than cured, and it recurs — with sun, with pregnancy, with hormonal changes. A plan that worked once is worth restarting early rather than waiting for the pigment to re-establish, and treatment that has run for months without visible progress is worth reassessing rather than continuing on faith.
Where the over-the-counter pathway ends
Everything above is available without seeing anyone, and photoprotection continues unchanged through every rung above it — it is the one part of the plan that never stops. Beyond this point the treatments are prescription-only, and the reason is not simply potency: the standard next step combines three agents and is used in courses with a defined stopping point, because using it indefinitely causes its own problems. That is a decision needing supervision rather than a stronger tube.
See the prescription pathway →Melasma: the full therapy pathway · dermapproved.com/treatments/melasma/ · not a diagnosis — confirm anything you act on with a clinician
What to expect
Melasma asks for something no other condition on this site does: accepting that the goal is control rather than cure, and then doing the boring part anyway, forever. The pigment cells that made it are still there when it fades, still primed, still waiting for light. That is not a defeatist framing — melasma responds well to treatment, and people get genuinely good results. But those results are held rather than won, and almost every story of it 'coming back worse' is a story about what stopped after it cleared.
- Photoprotection is the treatment. Everything else is negotiable; that is not.
- One active at a time, and nothing that stings. Irritation makes this darker — the opposite of what every other skincare instinct tells you.
- Judge at 8 to 12 weeks, in daylight, against a photo. Not in the bathroom mirror at week three.
- Expect summer to test it, and plan for that rather than being surprised each year.
- Say no to the aggressive option. In melasma, restraint outperforms enthusiasm more reliably than in anything else we cover.
This is where the site stays useful during clinical care rather than only before it: the photoprotection half of the plan is a product problem the catalog genuinely helps with, and it is the half you will be doing for years. Finding a tinted SPF 50 you will actually wear every day is a more consequential piece of shopping than any serum on the page — and the photo tracker is what turns 'I think it's a bit better' into something a clinician can act on.
What would bring you back sooner
Whatever step you are on, these do not wait for the end of a trial period. They are the same
presentations listed at the top of this page — repeated here because that is where they
matter, rather than where they were easiest to put.
- A pigmented patch that is changing, growing, or asymmetrical See a dermatologist soon
- Pigment that got darker after a laser or peel See a dermatologist soon
- Blue-black or slate-grey pigment after long-term skin-lightening use See a dermatologist soon
- You bought a skin-lightening cream without an ingredient list Worth a clinician visit
Prescription only — from here on, this is a clinician's decision The prescription pathway
Why this tier exists. What the aisle cannot do: shift established or dermal pigment quickly, do anything about a hormonal driver that is still running, or make melasma go away permanently — nothing does that. Expect slow. Twelve weeks of proper use, for partial improvement, on a condition that will test whether you keep going. Anything promising faster is selling something.
Melasma is the odd one here: everyone starts in the same place, and the routes differ only in how far past it they go. Read the screen upward — what each route adds, and what has to be true before it is added.
The same pathway in full below — each step names what it involves, why it sits where it does, and what tells you it's time to move up. Tap any therapy to jump to its detail.
Melasma in pregnancy or while nursing
Melasma has been called the mask of pregnancy for a reason — this is when a great deal of it arrives. It is also when almost the entire ladder above is withdrawn.
This branch does not continue past the over-the-counter tier. Everything available for it is in the over-the-counter pathway →
Melasma — where everyone starts
Symmetrical brown patches, any severity, any duration. There is no version of melasma that skips this branch: photoprotection and topicals are the floor under every treatment that follows.
You reach this column when: Little change after a fair trial, or it's extensive enough that this was never going to be sufficient.
- Prescription topical
Prescription topicals
Why this step sits here: Triple combination carries the strongest recommendation in current consensus and is the gold standard — hydroquinone with a retinoid to drive it in and a steroid to make it tolerable. It is prescribed as a course with a stop date, then stepped down to maintenance, because the components that make it work are the ones that make indefinite use unsafe.
Three starting points, all well evidenced, none of them a rank above the others. What decides between them is skin tone, how much irritation the skin will accept, and whether a defined course with a stop date is realistic.
- Triple combination cream — hydroquinone with a retinoid and a low-potency steroid backed by large randomized trials
Reached for when melasma is established and a defined course can be seen through to its stop date. The three agents cover pigment production, turnover, and the irritation that would otherwise undo both.
- Hydroquinone on its own backed by large randomized trials
Suits skin that has reacted badly to retinoids, or a situation where a topical steroid is unwelcome — fewer moving parts, and the same discipline about stopping on schedule.
- A topical retinoid alone — tretinoin or adapalene backed by large randomized trials
Fits where hydroquinone is being avoided or rested and there is patience for a slower curve; the trial behind tretinoin ran forty weeks, and adapalene is the better tolerated of the two.
Which formulation, at what strength, for how many weeks, and what you step down to afterwards — those are the questions, and they depend on your skin tone, how long you've had this, and what has already been tried. That is the appointment.
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Moderate-to-severe or not responding
Extensive melasma, or melasma that has sat through a proper topical course without shifting. The ladder continues — but every rung above assumes photoprotection and topicals are already in place and staying there.
You reach this column when: It's extensive, long-standing, or has already failed a proper topical course.
- Prescription topical
Prescription topicals
Why this step sits here: Same gold standard as the first-line branch, and it remains the backbone here — the additions below are adjuncts to it, not replacements for it.
When to move up
- A fair trial
- A course of triple combination as prescribed, typically weeks to a few months, with the stop date observed.
- Improvement looks like
- Meaningful lightening, and pigment that holds through the step-down to maintenance rather than rebounding the moment the course ends.
- Move up if
- Limited response despite proper use, or it returns immediately every time the course stops.
→ The next step up this pathway.
Where are you with this step?
- Prescription oral
Oral tranexamic acid
Why this step sits here: Consensus recommends oral tranexamic acid as an adjuvant for moderate-to-severe melasma. It reaches a driver creams cannot, and the trade is a systemic drug plus a clotting-risk screen — which is exactly why it is a prescription and why the screen is not a formality.
When to move up
- A fair trial
- A low dose over a few months, alongside topicals and photoprotection rather than instead of them.
- Improvement looks like
- Lightening beyond what topicals achieved, and fewer rebounds between courses.
- Move up if
- Insufficient, not tolerated, or ruled out by clotting risk — in which case procedures are the remaining conversation.
→ The next step up this pathway.
Where are you with this step?
- In-office procedure
Procedures — cautiously, and last
Why this step sits here: Procedures sit last here for a reason that inverts the usual logic: not because they are the most powerful, but because melasma responds to energy and injury by making more pigment. Superficial peels and microneedling are reasonable adjuncts on top of a working plan. Laser is the treatment people most want and the one most likely to make this worse — current consensus is cautious, low-fluence, experienced hands, never first.
Procedures are where melasma most often gets worse rather than better, so the real choice here is how much energy the skin is asked to absorb — and who is holding the device.
- Superficial chemical peels, usually glycolic acid backed by large randomized trials
Offered as an adjunct once topicals have done what they can, on skin already primed with them. The depth is deliberately shallow, and glycolic acid carries the longest safety record of the agents that have been compared head to head.
- Microneedling limited evidence
Sometimes used to help topicals penetrate rather than as a treatment in its own right; the evidence is thin enough that it belongs in a conversation about expectations rather than a plan built around it.
- Lasers and energy-based devices backed by smaller studies
Considered late, in experienced hands, where pigment has not moved on anything else. Trials show improvement during follow-up alongside a real rate of relapse and post-inflammatory darkening — and that risk climbs with skin tone.
If you take one thing from this page to a consultation, take this: for melasma, the aggressiveness of the treatment is not the measure of its quality. Ask what happens if it rebounds, ask how often they treat melasma in your skin tone, and be wary of anyone who answers the question 'how fast?' rather than 'how safely?'
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Keeping it away
This is the part that decides how you actually live with melasma, and the part most plans skip. The melanocytes that made it are still there and still primed; clearance is a state you hold, not a finish line. Almost every story of melasma 'coming back worse' is a story about what happened after it cleared.
Just finished a triple-combination course
Step down, don't stop. The course has a stop date for good reason, and what follows it — a retinoid or azelaic acid, plus the sunscreen — is what holds the result. Stopping everything at once is the single most reliable way to be back where you started by autumn.
Clear or nearly clear, going into summer
Summer is the test. Reapplication, hats, shade, and the tinted sunscreen you were already using — plus a gentle active running underneath. Most relapse happens in the months nobody is thinking about it.
It came back anyway
Recurrence is the expected behaviour of this condition, not a failure of yours or your clinician's. The plan is usually another course and a firmer maintenance phase — not a more aggressive intervention, and specifically not a laser.
Melasma: the full therapy pathway · dermapproved.com/treatments/melasma/ · not a diagnosis — confirm anything you act on with a clinician
When the rules change
Melasma rarely arrives alone. A hormonal driver may still be running, the skin tone that makes it more likely also changes what is safe to do about it, and some of it turns up nowhere near a face. These are the situations where the ladders above need adjusting rather than following.
When a hormonal driver is still running
Combined oral contraceptives and hormone therapy are among the most consistently reported precipitants, and melasma treated while one is still running is being treated against a current. Whether anything changes is a conversation with whoever prescribes it. There are good reasons to stay on contraception that works, and stopping is not automatically the right trade — but it is worth knowing that the driver is there, because it explains a course that fades slowly and returns fast.
What can be used
- Every treatment on this page — a hormonal driver withdraws nothing
- A conversation with the prescriber about alternatives, if the melasma matters enough and other options are acceptable
- Adjusted expectations while it continues: a slower fade, and a higher chance of relapse once a course ends
- Thyroid symptoms
- Thyroid disease has been reported alongside melasma in some studies. It is not a cause to assume, but symptoms — fatigue, weight or temperature changes, hair shedding — are worth mentioning at the appointment rather than saving for a different one.
Melasma that began in pregnancy behaves differently again: some of it settles over the months after delivery without treatment, which is why the pregnancy branch waits instead of escalating.
Melasma in deeper skin tones
Melasma is more common from Fitzpatrick type III upward, and the same treatments carry a different risk profile there. The interventions most likely to produce a fast result are also the ones most likely to leave post-inflammatory darkening — which is the thing being treated. This is the group for whom the restraint principle at the top of this page matters most, and it is also the group most often sold the opposite.
What can be used
- Tinted photoprotection with a visible-light filter, which is doing more work here than anywhere else on the page
- The full topical first line, given time — the slow route is the one that holds
- Superficial glycolic peels, primed with topicals first and in hands that treat this skin tone often
- Oral tranexamic acid as an adjunct where a clinician judges it appropriate
What comes off the table
- Aggressive resurfacing, and high-energy device settings reached for early
- Any plan whose selling point is speed
- Stacking actives to the point of visible irritation — pink, stinging skin is the mechanism that darkens melasma
A fair question to ask any practitioner offering a device: how often do you treat melasma in this skin tone, and what happens if it rebounds?
Melasma below the face
The forearms, neck and upper chest are affected less often, and most often after menopause. The evidence is thinner there, the response is generally slower, and the page above is written face-first — which is worth naming rather than papering over.
What can be used
- The same photoprotection logic, with clothing doing more of the work than sunscreen realistically can over large areas
- The same topicals, applied the same way, with a longer horizon before judging them
- A clinician's read on whether this is melasma at all — other pigment patterns are more common at these sites
Extrafacial melasma responds less reliably than facial melasma. That is a reason to set expectations early, not a reason to escalate faster.
How an appointment actually happens, what to take to it, and how to keep your skin liveable while a prescription or procedure does its work.
What seeing a dermatologist actually looks like
A GP can start you on topicals and is the referral route in most systems. For melasma there is a real argument for seeing someone who treats it often — this is a condition where the wrong procedure makes things durably worse, and experience with your skin tone specifically is not a luxury. If you are considering laser, that argument becomes the whole ballgame.
What to bring
- Everything you've tried, for how long, and — the question you'll actually be asked — what sunscreen you used alongside it.
- Photos in consistent daylight over months. Melasma changes too slowly to describe from memory, and the mirror lies.
- When it started and what was happening then: a pregnancy, a new pill, a move somewhere sunnier, a course of a medication.
- Whether you're pregnant, might be, or are nursing — it removes most of the ladder.
- Any history of clotting, in you or your family, if oral tranexamic acid might come up.
Questions worth asking
- Is this melasma, or post-inflammatory pigment? They look similar and they're treated differently.
- How long is this course, and what do I step down to when it ends?
- What's the plan if it comes back — because it probably will?
- How often do you treat melasma in skin like mine?
- If we ever discussed laser: what happens if it rebounds?
Cost and access. Topicals and compounded creams are generally affordable; oral tranexamic acid is cheap and generic. Procedures are out-of-pocket almost everywhere and are the part where costs escalate fastest and results are least assured — which is worth knowing before, not after, a package of six sessions.
Melasma is routinely dismissed as cosmetic, including by people who have it, and that is exactly why it gets treated badly for years — by the aisle, by unregulated products, and occasionally by clinics selling the wrong procedure. It is a real condition with a real evidence base and a genuinely effective first-line treatment. It deserves a proper consultation rather than a decade of serums.
Skincare alongside therapy
For melasma the supporting routine and the treatment overlap almost completely — photoprotection is not the thing you do alongside treatment, it is the treatment, and it runs under every prescription and every procedure. What changes as you move up the ladder is mostly what you must stop doing.
One rule governs all of it: inflammation makes melasma darker. That inverts the instinct every other condition teaches. There is no pushing through, no 'it has to sting to work', no exfoliating harder because progress stalled. The gentlest version of a plan is usually the most effective version of it.
While you're on a triple combination or hydroquinone
This is a course with an end date, and the end date is the part people ignore. The steroid that makes it tolerable is also why it cannot run indefinitely, and the hydroquinone that makes it work is why prolonged unsupervised use produces the one outcome nobody wants.
Do
- Use it for exactly as long as you were told, then step down to what your clinician gives you next.
- Keep the tinted sunscreen going every single day — the cream is fighting pigment production while light is switching it back on.
- Expect irritation early. Tell your clinician if it doesn't settle rather than pushing on: irritation darkens melasma.
- Ask what maintenance looks like before the course ends, not after.
Avoid
- Staying on it indefinitely because it's working. That is precisely how ochronosis happens.
- Buying more online when the prescription ends. The supervision is the safety feature.
- Any exfoliant, scrub or acid on top. You are already using a retinoid.
What that looks like on a shelf: a tinted sunscreen (visible light), a gentle cleanser, a barrier moisturizer.
While you're on oral tranexamic acid
A systemic drug for a cosmetic condition is a real trade, and the screening beforehand is what makes it a reasonable one. Nothing about your topical routine changes — the tablet is an addition, never a replacement.
Do
- Keep photoprotection and topicals exactly as they were. This is an adjunct.
- Tell any clinician you're taking it, particularly before surgery or a long flight.
- Report calf pain, swelling, breathlessness or chest pain immediately rather than waiting for your next appointment.
Avoid
- Treating it as a substitute for the sunscreen. It is not, and it will not out-run daily light exposure.
- Sourcing it without the clotting-risk screen. The screen is the entire reason this is safe to do.
What that looks like on a shelf: a tinted sunscreen (visible light), a gentle cleanser.
After a peel, laser or microneedling
Your provider's aftercare overrides this page. But melasma has a specific post-procedure problem that other conditions don't: the treated skin is now inflamed, and inflammation is what drives melasma. The window right after a procedure is when this gets undone.
Do
- Absolute sun avoidance, not just sunscreen. Shade, hats, and staying in for a few days if that's what it takes.
- Bland everything until you are cleared — gentle cleanser and a plain moisturiser.
- Resume the tinted sunscreen the moment the skin tolerates it.
- Tell your provider promptly if the pigment darkens rather than waiting for the next session.
Avoid
- Assuming a bit of darkening is normal healing. In melasma it can be rebound, and repeating the procedure is the wrong response.
- Booking a course of sessions with no plan for what happens if it rebounds.
- Sun in the fortnight after. This is the single highest-risk period on the whole page.
What that looks like on a shelf: a gentle cleanser, a barrier moisturizer, a tinted sunscreen (visible light).
The supporting shelf
A tinted sunscreen (visible light)
A gentle cleanser
A barrier moisturizer
These are supporting products, and for melasma the phrase is misleading in the other direction: the tinted sunscreen in these lists is the most effective thing on this page. Products here are ranked on gentleness first — fragrance-free, low irritation — because on melasma, irritation is not a neutral cost. It is the thing that makes the pigment darker.
Every therapy named above, in full. Look things up here; it is not meant to be read end to end.
Every therapy, explained
Reference, not reading — every therapy named anywhere above, described the way a clinician would describe it. Nobody reads this section end to end; open the one you were sent here for. Which one is right for you is the appointment's job, not this page's.
Over the counter
Available without a prescription. Each one opens with what to look for on a label, which is the part that stays true regardless of which brand is on the shelf that month.
Over-the-counter Tinted sunscreen (iron oxides)
Visible-light photoprotection
Generally compatible
Tinted sunscreen (iron oxides)
Visible-light photoprotection
A broad-spectrum SPF 50 that is tinted — and the tint is not cosmetic. It is the treatment.
Browse all iron oxides products in our catalog →
How it works
UV filters stop UV. They do very little about visible light, which independently drives melasma and passes straight through window glass and cloud. Iron oxides — the pigments that make a sunscreen tinted — absorb visible light, which is why a tinted SPF 50 outperforms an untinted SPF 50 here despite the identical number on the bottle.
What the evidence says well established
International consensus describes broad-spectrum SPF 50 with a visible-light filter (iron oxide or coloured titanium dioxide), applied daily and reapplied every two hours, as the irreplaceable cornerstone of melasma treatment — not an adjunct to it.
Typical course
Every morning, all year, indoors near windows included. Reapplied every two hours on a day out. Forever — this is the part that does not stop when the pigment fades.
Commonly discussed side effects
- The tint has to match your skin, which is the real barrier to using it
- Reapplication over makeup is genuinely awkward
Worth knowing
- An untinted sunscreen, however high the SPF, is not melasma photoprotection
- Heat is a trigger too — sunscreen does nothing about a stove or a sauna
Pregnancy: Sunscreen is not only compatible with pregnancy — during pregnancy it is very often the entire treatment, because most of the rest of this page is unavailable. Mineral filters are the usual choice.
Why it sits where it does: It sits at the base and under every rung above it. Melasma treated without visible-light protection is melasma treated with the tap running, and it is the commonest reason an otherwise sensible plan fails.
Over-the-counter Tranexamic acid (topical)
Over-the-counter pigment modulator
Individualized — ask a clinician
Tranexamic acid (topical)
Over-the-counter pigment modulator
The most interesting non-prescription active in melasma, and one of the few with a mechanism that matches what melasma actually is.
Browse all tranexamic acid products in our catalog →
How it works
Interrupts the plasmin pathway, which quiets both the signalling from skin cells that keeps melanocytes busy and the vascular component underneath. That is upstream of the classic brighteners, which mostly just inhibit the pigment enzyme.
What the evidence says promising
Topical tranexamic acid has accumulated meaningful trial evidence in melasma over recent years and features in current expert consensus. The studies are mostly small and comparisons with hydroquinone are mixed but not embarrassing.
Typical course
Once or twice daily; judge at 12 weeks, not before.
Commonly discussed side effects
- Mild irritation
- Occasional dryness
Worth knowing
- Topical is not the same as oral — the oral drug is a different conversation with different risks
Pregnancy: Topical tranexamic acid has limited pregnancy data. Given melasma frequently arrives during pregnancy and often fades afterwards, deferring treatment is a reasonable option worth discussing rather than pushing on.
Why it sits where it does: It leads the pigment actives because its mechanism addresses the signalling and vascular side of melasma rather than only the enzyme — which is the part the older brighteners never touched.
Over-the-counter Azelaic acid
Selective tyrosinase inhibitor
Generally compatible
Azelaic acid
Selective tyrosinase inhibitor
A naturally-derived acid available over the counter around 10% and by prescription at 15–20%. Quietly the most useful active on this page for a specific reason.
Browse all azelaic acid products in our catalog →
How it works
Inhibits tyrosinase, but selectively — it acts on hyperactive melanocytes and largely leaves normal ones alone. Melasma is precisely a disease of hyperactive melanocytes among normal ones, so the selectivity is the point rather than a footnote.
What the evidence says strong
Azelaic acid is an established melasma treatment and appears in current consensus guidance; its selectivity and its pregnancy compatibility give it a role nothing else quite fills.
Typical course
Twice daily. Slow — 12 weeks minimum before judging, and it rewards patience more than most.
Commonly discussed side effects
- Tingling in the first weeks
- Mild dryness
Worth knowing
- Not a fast active. People abandon it at week six and conclude it doesn't work.
Pregnancy: Azelaic acid is generally regarded as compatible with pregnancy, which on this page makes it disproportionately important: for someone whose melasma arrived with pregnancy, it and photoprotection are often the whole available plan. Confirm with a clinician.
Why it sits where it does: It sits on the first rung and stays available on every rung above, including the one where everything else is withdrawn — pregnancy. That combination of selectivity and availability is why it outranks better-marketed actives here.
Over-the-counter Niacinamide
Pigment-transfer blocker
Generally compatible
Niacinamide
Pigment-transfer blocker
The most widely available active here, and the one whose mechanism is most often misdescribed.
Browse all niacinamide products in our catalog →
How it works
It doesn't stop pigment being made — it blocks the handover of finished pigment from the melanocyte to the surrounding skin cells. A different link in the chain, which is why it combines sensibly with actives that work on production.
What the evidence says strong
Niacinamide has reasonable evidence in melasma and hyperpigmentation, with an unusually good tolerability profile that matters for a condition needing years of treatment rather than weeks.
Typical course
Once or twice daily, indefinitely. Its strength is that you can keep using it.
Commonly discussed side effects
- Rarely flushing at high concentrations
Worth knowing
- Modest on its own; it is a team player rather than a headline act
Pregnancy: Topical niacinamide is generally considered compatible with pregnancy.
Why it sits where it does: It sits on the first rung as a tolerable long-term partner rather than a driver — for a relapsing condition, an active you can use for years beats a stronger one you can't.
Over-the-counter Vitamin C
Antioxidant with mild pigment activity
Generally compatible
Vitamin C
Antioxidant with mild pigment activity
The most-hyped active in the brightening aisle and, for melasma specifically, a supporting player rather than a lead.
Browse all vitamin c products in our catalog →
How it works
Mops up the free radicals light generates and mildly inhibits tyrosinase. The antioxidant half is the more useful half here — it supports photoprotection against the damage that keeps melanocytes provoked.
What the evidence says promising
Vitamin C has modest evidence in melasma as an adjunct. It is not a match for the prescription tier and does not claim to be.
Typical course
Mornings, under sunscreen. Judge over months.
Commonly discussed side effects
- Irritation at higher concentrations
- Oxidises; a brown serum has expired
Worth knowing
- A vitamin C serum is not a melasma treatment on its own, whatever the marketing implies
Pregnancy: Topical vitamin C is generally considered compatible with pregnancy.
Why it sits where it does: It sits on the first rung as photoprotection's partner rather than a pigment treatment in its own right — which is a demotion from how it is usually sold, and an accurate one.
Over-the-counter Kojic acid
Over-the-counter tyrosinase inhibitor
Individualized — ask a clinician
Kojic acid
Over-the-counter tyrosinase inhibitor
A fungus-derived brightener that appears in a great many melasma serums, almost always with company.
Browse all kojic acid products in our catalog →
How it works
Binds the copper that tyrosinase depends on, so pigment production slows at the enzyme itself. That is the same link in the chain hydroquinone works on, which is why the two are studied together far more often than apart.
What the evidence says promising
Graded as a third-line therapy in current treatment references. The trial base is real but narrow: a randomised comparison found kojic acid improved melasma on its own and improved it more in combination with hydroquinone, and it is a standing ingredient in the multi-active serums that have been evaluated as a group.
Typical course
Once daily, most often inside a combination serum rather than alone. Judged at twelve weeks, like everything else on this page.
Commonly discussed side effects
- Stinging on application
- Contact sensitisation, which becomes more likely the longer it is used
Worth knowing
- A recognised sensitiser, and that carries a specific penalty here: a contact reaction on melasma-prone skin darkens the patch it was meant to lighten
- Rarely tested alone — the evidence supporting it is largely combination evidence
Pregnancy: Pregnancy data for topical kojic acid is limited. Given melasma that begins in pregnancy often settles on its own afterwards, waiting is a reasonable choice to put to a clinician rather than a compromise.
Why it sits where it does: It belongs on this rung as a combination partner rather than a lead. The evidence is strongest where it sits alongside hydroquinone, and its sensitising potential is the reason to introduce it by itself rather than buried in a stack of actives.
Over-the-counter Cysteamine 5%
Over-the-counter pigment inhibitor
Individualized — ask a clinician
Cysteamine 5%
Over-the-counter pigment inhibitor
A breakdown product of the amino acid cysteine, sold as the non-prescription route to the same target hydroquinone aims at — and known almost as widely for how it smells.
How it works
Inhibits tyrosinase and peroxidase, slowing pigment at the point of production. Unlike most brighteners it already occurs inside skin cells, which is the argument usually made for its tolerability.
What the evidence says promising
Graded as a third-line therapy in current treatment references. A meta-analysis pooling six randomised trials found 5% cysteamine effective with few adverse effects — genuine randomised evidence, on a base of roughly 120 patients across short study periods.
Typical course
Applied to dry skin once daily and washed off after a short contact time — the formulation is built around that, not around being left on. Judged at twelve weeks.
Commonly discussed side effects
- A strong sulfur odour, which is the most common reason people abandon it
- Transient stinging or redness after application
Worth knowing
- Contact time is part of the instruction, not a detail — it is a short-contact product rather than a leave-on serum
- The supporting trials are small and short; this is a reasonable option rather than a settled one
Pregnancy: Pregnancy data is limited. The same reasoning applies as elsewhere on this page: melasma arriving in pregnancy frequently fades on its own, so deferring is a legitimate option to raise rather than an admission of defeat.
Why it sits where it does: It reaches the same link in the chain as hydroquinone without a prescription, which is what makes it worth knowing about for anyone who cannot use one or would rather not. It sits below the actives above it because the evidence base, while randomised, is small.
Browse the whole catalog for this condition:
What changed recently: The interesting movement in melasma is not a new drug but new cosmetic actives: cysteamine, thiamidol and topical tranexamic acid have all accumulated real trial evidence in the last few years, and a couple compare respectably to hydroquinone over 12 weeks in small studies. Worth knowing, and worth keeping in proportion — these are small trials, not registration programmes, and 'better than hydroquinone' has been claimed for a great many things.
Prescriptions and procedures
About the brand names below. Brand names are what the pharmacy label says; the generic name underneath is what matters. Melasma is unusual on this site in how much of its treatment is compounded rather than branded — a cream mixed for you by a pharmacy often has no brand name at all, which is normal. It is also the condition where the gap between what is legal and what is sold is widest: unregulated skin-lightening products are a genuine public-health problem. Where a region is missing below, that reflects what we could verify rather than proof of absence.
The links below go to national medicines sources rather than to any one brand. Melasma treatments are regulated very differently from market to market — hydroquinone is prescription-only in some countries and restricted in others, and the strengths studied above are not sold over the counter in most of them. What the label says where you live is the authority, not what a page like this one says.
Prescription topical Triple combination cream
Hydroquinone + tretinoin + corticosteroid
Avoid in pregnancy
Triple combination cream
Hydroquinone + tretinoin + corticosteroid
The gold standard of melasma treatment, and a drug with a firm stop date rather than an indefinite prescription.
- Fluocinolone + hydroquinone + tretinoin — The classic and best-evidenced formulation; the only FDA-approved hydroquinone-containing drug in the US.
What it's called at the pharmacy
Generic name Fluocinolone + hydroquinone + tretinoin
Sold as
- Tri-Luma — fluocinolone + hydroquinone + tretinoin; the only FDA-approved drug containing hydroquinone
- Compounded triple-combination creams are prescribed in many countries; the exact formulation and strengths vary by pharmacy
Because so much of this is compounded rather than branded, what you are handed may have no brand name at all. That is normal here and not a sign of anything irregular — but do ask what strengths are in it.
How it works
Three mechanisms at once: hydroquinone blocks pigment production, tretinoin speeds turnover and helps the other two penetrate, and the corticosteroid calms the irritation the first two would otherwise cause. The combination outperforms any of them alone, which is why it exists.
What the evidence says well established
Hydroquinone-based triple combination carries the strongest recommendation in current international consensus as the gold standard for melasma, with Grade A evidence and clear superiority over monotherapy.
Typical course
A defined short course — measured in weeks to a few months, not open-ended — usually followed by a maintenance plan built from gentler actives.
Commonly discussed side effects
- Irritation, redness and peeling early on
- Steroid-related thinning if used far beyond the intended course
- Exogenous ochronosis with prolonged high-strength hydroquinone use
Monitoring
A clinician sets the stop date and the step-down. The stop date is the part that gets ignored, and it is the part that matters.
Worth knowing
- Not a cream to stay on indefinitely, and not one to buy from an unregulated source
- The steroid in it is why it must be supervised — it is also why it is tolerable
Pregnancy: Contains tretinoin and is avoided in pregnancy; hydroquinone is also avoided. Given melasma frequently arises in pregnancy and often fades afterwards, deferral rather than substitution is usually the right answer — a conversation worth having explicitly.
Why it sits where it does: It is the first prescription rung because it is the most effective topical there is for melasma and the one every guideline names — and it sits under a stop date because its own components are what make indefinite use unsafe.
Prescription topical Hydroquinone alone
Prescription depigmenting agent
Avoid in pregnancy
Hydroquinone alone
Prescription depigmenting agent
The single most effective depigmenting molecule available, and the one whose availability has changed most dramatically — in opposite directions depending on where you live.
What it's called at the pharmacy
Generic name Hydroquinone alone
Sold as
- Prescription or compounded only. Over-the-counter hydroquinone was removed from sale in September 2020 under the CARES Act, when it lost its generally-recognised-as-safe-and-effective status
- Banned in cosmetic products under EU Cosmetics Regulation 1223/2009; available as a prescription medicine in some countries
If you can buy hydroquinone over the counter in the US, or in a cosmetic in the EU, it is not a legitimate product. That matters more than it sounds: unregulated skin-lightening creams are repeatedly found to contain mercury or undeclared potent steroids.
How it works
Inhibits tyrosinase and is toxic to melanocytes at higher concentrations, which is both the source of its effectiveness and the reason it is time-limited.
What the evidence says well established
Hydroquinone remains the reference standard against which melasma treatments are compared, most often as part of a triple combination rather than alone.
Typical course
Cycled — a course, then a break, then reassessment. Continuous long-term use is what produces the problems.
Commonly discussed side effects
- Irritation
- Exogenous ochronosis with prolonged high-strength use — uncommon, disfiguring, hard to reverse
Monitoring
Supervised, with a stop date. The whole regulatory history of this drug is about people using it without either.
Worth knowing
- Buying hydroquinone from an unregulated source defeats every safeguard that makes it a reasonable treatment
- It is a course, not a routine
Pregnancy: Hydroquinone is avoided in pregnancy and while nursing.
Why it sits where it does: It shares the prescription-topical rung with the triple combination — usually as a component of it rather than an alternative to it, because the combination works better and irritates less.
Prescription topical Other prescription topicals
Retinoids and higher-strength azelaic
Avoid in pregnancy
Other prescription topicals
Retinoids and higher-strength azelaic
The rest of the prescription topical shelf — usually where you land after a triple-combination course ends, rather than instead of one.
- Tretinoin — Speeds turnover and disperses pigment; slow, and the mainstay of maintenance for many.
- Azelaic acid 15–20% — The prescription strength of the same active available at 10% over the counter.
How it works
Retinoids accelerate epidermal turnover and improve penetration of everything else; higher-strength azelaic does what the over-the-counter version does, harder.
What the evidence says strong
Topical retinoids and azelaic acid are established components of melasma management, particularly in maintenance after an intensive course.
Typical course
Long-term, at night, usually as the maintenance half of the plan.
Commonly discussed side effects
- Irritation and peeling — and in melasma, irritation itself can darken the pigment
Worth knowing
- Irritation is not harmless here the way it is in acne: inflammation provokes the melanocytes you are trying to quiet, so 'pushing through' is counterproductive
Pregnancy: Tretinoin is avoided in pregnancy. Azelaic acid is the member of this group that remains available.
Why it sits where it does: It sits alongside the triple combination as the thing that continues after it stops — melasma's ladder loops back to maintenance rather than ending at the strongest rung.
Prescription oral Oral tranexamic acid
Systemic adjunct for stubborn melasma
Avoid in pregnancy
Oral tranexamic acid
Systemic adjunct for stubborn melasma
A drug licensed for heavy menstrual bleeding, used off-label for melasma — and the most significant addition to melasma treatment in years.
What it's called at the pharmacy
Generic name Oral tranexamic acid
Sold as
- Prescribed off-label for melasma almost everywhere, and dispensed generically. It is licensed for heavy menstrual bleeding, not for melasma
Off-label prescribing is routine and lawful, and it is how most melasma is treated systemically. It is not a warning sign — but it does mean the manufacturer's leaflet will not mention your skin.
How it works
The same plasmin pathway as the topical version, reached systemically: less signalling to melanocytes and less of the vascular stimulation that keeps melasma going.
What the evidence says strong
Oral tranexamic acid is recommended in current consensus as an adjuvant for moderate-to-severe melasma. On the safety question that dominates the conversation, a 2025 systematic review of randomised controlled trials found no thromboembolic events — reassuring, though trials exclude the people most at risk, which is exactly why screening happens.
Typical course
A low dose over a few months, alongside topicals and photoprotection rather than instead of them.
Commonly discussed side effects
- Nausea
- Menstrual changes
- Headache
Monitoring
A clinician screens for clotting risk before prescribing — personal and family history of thrombosis, smoking, hormonal contraception, immobility, recent surgery.
Worth knowing
- Contraindicated where there is a clotting risk, and that screen is the whole reason this is a prescription rather than a supplement
- Off-label for melasma nearly everywhere — normal practice, not a red flag
Pregnancy: Oral tranexamic acid is avoided for melasma in pregnancy. Pregnancy is already a thrombotic risk state, and melasma arising in pregnancy frequently fades afterwards on its own.
Why it sits where it does: It sits above the topicals because it accepts a systemic drug — and a clotting-risk screen — in exchange for reaching a driver creams cannot. It is added to the plan, never a replacement for photoprotection.
Procedure Chemical peels
Superficial in-office peels
Individualized — ask a clinician
Chemical peels
Superficial in-office peels
Controlled superficial exfoliation, done in a clinic, to speed removal of pigmented cells — and one of the two procedures where enthusiasm is the enemy.
How it works
Removes pigment-laden epidermis and improves penetration of what you put on afterwards. The depth is deliberately shallow — deeper is not better here, it is worse.
What the evidence says promising
Superficial chemical peels are an established adjunct in melasma when used cautiously alongside topical treatment and photoprotection; they are not a substitute for either.
Typical course
A series of light peels spaced weeks apart, always on top of a topical regimen rather than instead of it.
Commonly discussed side effects
- Redness and flaking for days
- Post-inflammatory hyperpigmentation — the outcome you were trying to avoid
Worth knowing
- Aggressive peeling makes melasma worse, reliably and often durably
- In richer skin tones the margin for error is smaller and the consequences last longer
Pregnancy: Elective procedures are generally deferred in pregnancy; timing is a conversation with the provider.
Why it sits where it does: It sits above topicals as an adjunct rather than an escalation — it accelerates a working plan and undoes a fragile one, which is why it comes after control rather than instead of it.
Procedure Lasers and energy devices
Low-fluence laser and light
Individualized — ask a clinician
Lasers and energy devices
Low-fluence laser and light
The treatment people most want for melasma and the one that most often makes it worse. Included here so that the risk is stated plainly rather than discovered.
- Low-fluence Q-switched Nd:YAG — The most-studied approach; deliberately gentle, repeated.
- Picosecond and non-ablative fractional devices — Used cautiously and by practitioners who treat melasma often.
How it works
Breaks up pigment with light energy. The problem is that melasma's melanocytes respond to energy by making more pigment — so the same device that clears a sun spot can provoke the thing you're treating.
What the evidence says limited
Laser and light treatment for melasma has mixed evidence and a well-documented tendency to rebound. Current consensus is cautious: low-fluence approaches by experienced practitioners, as an adjunct to topical treatment and photoprotection, never as a first move.
Typical course
A series of low-energy sessions, on top of an established topical plan, with realistic expectations.
Commonly discussed side effects
- Rebound hyperpigmentation — common enough to be an expected risk, not a rare complication
- Paradoxical worsening
- Post-inflammatory pigmentation, worse in richer skin tones
Worth knowing
- This is the step where choosing the practitioner matters more than choosing the device
- A clinic that offers laser as the first answer for melasma is telling you something about the clinic
- Melasma treated by laser without photoprotection and topicals in place reliably returns, often darker
Pregnancy: Elective laser is generally deferred in pregnancy; timing is a provider conversation.
Why it sits where it does: It sits last, and it is the only entry on this site whose position reflects risk rather than potency: not because it is the strongest, but because everything else should be in place before energy is aimed at skin that responds to energy by making pigment.
Procedure Microneedling
Collagen-induction and delivery
Individualized — ask a clinician
Microneedling
Collagen-induction and delivery
Fine needles creating controlled micro-channels, used in melasma mainly to help actives penetrate rather than for the injury itself.
How it works
Improves delivery of topical agents — tranexamic acid most often — and remodels the damaged upper dermis that helps keep melasma stimulated.
What the evidence says promising
Microneedling, generally combined with topical tranexamic acid, has encouraging but limited evidence in melasma and is used as an adjunct rather than a primary treatment.
Typical course
A series of sessions weeks apart, alongside topicals.
Commonly discussed side effects
- Redness for a day or two
- Post-inflammatory pigmentation if done too aggressively
Worth knowing
- Same rule as every procedure here: gentler is better, and inflammation is the enemy of melasma
Pregnancy: Deferred during pregnancy like any elective procedure — and with less to weigh than usual, since melasma that arrives in pregnancy often settles considerably on its own afterwards. Waiting frequently costs nothing here.
Why it sits where it does: It sits with the procedures as a delivery mechanism rather than a treatment in itself — its value is what you put on the skin with it.
On the horizon
Pipeline information current as of 2026-07-16
Only treatments in phase 3 or later. For melasma, applying that rule honestly produces an unusual result — see below.
This changes nothing about what to do now. None of this changes what to do now, and for melasma that sentence carries more weight than usual: there is no drug arriving that will make the sunscreen unnecessary.
Recently arrived
No new approved drug (2026). Melasma has had no significant new approved drug in years. The most consequential recent change is regulatory rather than pharmaceutical: over-the-counter hydroquinone was removed from sale in the United States in September 2020, which took the most effective self-treatment away from a lot of people and pushed some of them toward unregulated sources.
In late-stage development
Applying the phase-3 rule to melasma leaves this section empty, and that emptiness is the honest finding — so it is stated rather than padded. There is real activity, but it is a different kind: cysteamine, thiamidol, topical tranexamic acid, topical metformin and 2-MNG have accumulated genuine evidence, and a couple compare respectably to hydroquinone in small trials. None of them is a registration programme; most reach you as cosmetics or compounded preparations rather than as approved drugs. That distinction matters here more than anywhere else on this site, because melasma is a condition where people are desperate, results are slow, and 'clinically proven, better than hydroquinone' is a claim you will meet often and should read carefully. Re-reviewed on its own faster schedule than the rest of the page.
Things people arrive already asking about
Two of the actives that used to sit here — kojic acid and cysteamine — are treated as third-line therapies in current references and are covered as options above. What is left is the one that keeps being sold as a shortcut and is not.
- Oral antioxidants, Polypodium leucotomos in particular limited evidence
Studied as something added to photoprotection rather than as a treatment in itself. The plausible reading is that it supports sun protection at the margins. Nothing here substitutes for the sunscreen, and a supplement that quietly licenses less careful shade habits is a net loss for melasma.
Common questions
Why does my melasma get worse in summer even though I wear sunscreen every day?
Most likely because your sunscreen handles UV and melasma is also driven by visible light, which ordinary filters barely touch. The fix is a tinted sunscreen — the iron oxides that create the tint are what block visible light, which is why a tinted SPF 50 beats an untinted SPF 50 here despite the identical number. Heat is a second answer worth knowing about: cooking, saunas and hot cars provoke melasma independently of light.
Will melasma ever go away completely?
Honestly: it can fade a great deal, and in some cases — particularly melasma that arrived with a pregnancy — it fades substantially on its own afterwards. But the melanocytes that produced it remain, and they remain primed, so recurrence is the expected behaviour rather than a treatment failure. The realistic aim is control you maintain, not clearance you finish. Anyone promising permanent clearance is describing a product they want to sell.
Why can't I buy hydroquinone over the counter any more?
In the United States, over-the-counter hydroquinone was removed from sale in September 2020 under the CARES Act, when it lost its generally-recognised-as-safe-and-effective status. It remains available on prescription or compounded. In the EU it has long been banned in cosmetic products. The practical consequence matters: if you find hydroquinone being sold over the counter in the US or in an EU cosmetic, that is not a legitimate product — and unregulated skin-lightening creams have repeatedly been found to contain mercury or undeclared potent steroids.
Should I get laser for my melasma?
Not as a first move, and only from someone who treats melasma often. Melasma's melanocytes respond to energy by producing more pigment, so the same laser that clears a sun spot can provoke the condition you're treating — rebound is common enough to count as an expected risk rather than a rare complication, and worse in richer skin tones. Current consensus is cautious: low-fluence approaches, by experienced hands, on top of photoprotection and topicals that are already working. A clinic that offers laser as the answer before asking what sunscreen you use is telling you something.
Is oral tranexamic acid safe? It's a clotting drug.
It's licensed for heavy menstrual bleeding and used off-label for melasma, which is routine practice rather than a warning sign. The clotting question is the right one to ask: a 2025 systematic review of randomised trials found no thromboembolic events, which is reassuring — with the honest caveat that trials exclude the people most at risk, which is exactly why a clinician screens your personal and family history before prescribing. That screen is the reason this is a prescription and not a supplement.
I'm pregnant and my melasma appeared out of nowhere. What can I do?
Photoprotection and azelaic acid, essentially — and that is genuinely worth doing rather than a consolation prize, since photoprotection is the most effective part of the plan anyway. Hydroquinone, tretinoin, the triple combination and oral tranexamic acid are all avoided in pregnancy. The more useful thing to know is that melasma arriving in pregnancy often fades considerably in the months after, so the right move is frequently protection and patience rather than hunting for something stronger — and specifically not buying hydroquinone from an unregulated source because the legitimate route is closed to you.
The other 128 questions
Everything that doesn’t fit on a therapy ladder — side effects, timelines, pregnancy, cost, the things people get told that aren’t true. Here are the ones asked most.
- Is this melasma or just sun damage? Melasma is symmetrical, blotchy and map-like across the cheeks, forehead and upper lip. Sun spots are discrete, scattered and asymmetric.
- Is ordinary daylight enough to worsen melasma? Yes. Visible light drives melasma independently of UV, so a clear sunscreen protecting only against ultraviolet leaves a major trigger untouched.
- What actually causes melasma? Genetically susceptible pigment cells over-responding to three drivers: ultraviolet and visible light, hormones, and inflammation — with light the most modifiable.
- Why does irritation make melasma darker? Because inflammation itself stimulates pigment production — so any product that leaves skin pink and stinging is feeding the condition it is meant to treat.
- Isn't laser the quickest way to clear it? No. Melasma is the pigment condition where lasers most often backfire, with rebound hyperpigmentation and patchy loss of pigment both well documented.
- What's the risk with unlabelled skin-lightening creams? Mercury, undeclared potent steroids and high-strength hydroquinone are all repeatedly found in them — causing kidney damage, skin thinning and permanent discolouration.
- What should I stop using? Scrubs, cleansing brushes, at-home peels, high-strength acids, fragrance and anything that stings — subtraction often produces visible improvement on its own.
- Which brightening actives actually work? Azelaic acid, niacinamide, vitamin C, tranexamic acid, cysteamine and thiamidol all have trial support — used one or two at a time, not stacked.
- Which sunscreen should I use for melasma? Tinted, SPF 50, broad-spectrum, containing iron oxides — the tint is not cosmetic, it is what blocks the visible light that drives melasma.
- How long before I see any improvement? Twelve weeks for partial improvement, and often longer. Anything promising visible clearance in weeks is either irritating your skin or misleading you.
- For how long is hydroquinone safe? In defined courses of about three to six months with review and breaks — not continuously, because prolonged use risks exogenous ochronosis.
- Is oral tranexamic acid safe to take for melasma? At the low doses used, the thromboembolic risk appears very low — but it needs screening for clotting risk factors first and is not for casual use.
- What can I use for melasma while pregnant? Tinted sunscreen, azelaic acid and niacinamide are the usual safe core. Hydroquinone and retinoids are avoided, and much of it fades after delivery anyway.
- Why is melasma so common in deeper skin? More active melanocytes respond more readily to light, hormones and inflammation — so the same trigger produces more pigment and it lasts longer.
- When is a pigmented patch not melasma? When it is solitary, asymmetric, growing, changing colour or shape, or has an irregular border — that needs examining before any pigment treatment.
Sources and further reading
The staging, escalation points, and therapy descriptions on this page are anchored to published clinical guidelines rather than editorial judgment.
What this page is built on
- Global consensus on the management of melanin hyperpigmentation disorders
- No thromboembolic events observed in randomized controlled trials of oral tranexamic acid: A systematic review
The studies behind this pathway
Melasma attracts more confident claims than almost any condition on this site, so it is worth showing the work. These are the papers the page above actually rests on, with what each one is doing here. Every link was resolved against the PubMed record while this page was written — title, journal and year checked against the entry it points to, not assembled from an identifier.
- Role of broad-spectrum sunscreen alone in the improvement of Melasma Area Severity Index (MASI) and Melasma Quality of Life Index in melasma The claim that photoprotection is treatment rather than housekeeping: sunscreen alone, no lightening agent, moved MASI over twelve weeks.
- Near-visible light and UV photoprotection in the treatment of melasma: a double-blind randomized trial Why this page insists on a tinted filter rather than any high-SPF sunscreen — the arm with visible-light protection did better on identical hydroquinone.
- Prevention of melasma relapses with sunscreen combining protection against UV and short wavelengths of visible light The maintenance branch's central argument: visible-light protection changed the relapse rate over six months, not just the initial fade.
- Melasma: the need for tailored photoprotection to improve clinical outcomes The review behind the tinted-sunscreen role, including its double duty as camouflage.
- Melasma Treatment: An Evidence-Based Review The ordering of the prescription rungs, and the honest reading of peels and lasers as mixed in result and higher in complication rate.
- Best practices in the treatment of melasma with a focus on patients with skin of color The skin-of-colour section, and the reason triple combination sits where it does among the first-line options.
- A histological examination for skin atrophy after 6 months of treatment with fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05% cream The steroid-atrophy question that triple combination always raises: no clinical or histological atrophy after twenty-four weeks of daily use.
- Topical tretinoin (retinoic acid) improves melasma. A vehicle-controlled, clinical trial The retinoid-alone option, and its slow curve — the trial ran forty weeks.
- Adapalene in the treatment of melasma: a preliminary report Why adapalene appears alongside tretinoin as the gentler retinoid choice.
- Azelaic Acid Versus Hydroquinone for Managing Patients With Melasma: Systematic Review and Meta-Analysis of Randomized Controlled Trials Azelaic acid's standing on the over-the-counter rung — pooled across six trials it did not separate significantly from hydroquinone.
- Chemical Peels for Melasma: A Systematic Review The procedure rung's ordering, and the reason glycolic acid is named specifically among peeling agents.
- Comparative Evaluation of Efficacy and Tolerability of Glycolic Acid, Salicylic Mandelic Acid, and Phytic Acid Combination Peels in Melasma That peels are an adjunct to primed skin rather than a treatment in themselves — every arm ran on hydroquinone and tretinoin underneath.
- Comparative study of trichloroacetic acid versus glycolic acid chemical peels in the treatment of melasma The side-effect trade between peeling agents at comparable efficacy.
- A Double-Blind, Randomized Clinical Trial of Niacinamide 4% versus Hydroquinone 4% in the Treatment of Melasma Niacinamide's place on the over-the-counter rung, tested head-to-head in Fitzpatrick IV–V skin.
- Efficacy and safety of tranexamic acid 5% cream vs hydroquinone 4% cream in treating melasma: a split-face comparative clinical, histopathological, and antera 3D camera study Topical tranexamic acid on the over-the-counter rung, split-face against the prescription comparator.
- Randomized, placebo-controlled, double-blind study of oral tranexamic acid in the treatment of moderate-to-severe melasma The oral tranexamic acid rung, including the part the page is careful about: the gain narrowed three months after stopping.
- Tranexamic acid as a therapeutic option for melasma management: meta-analysis and systematic review of randomized controlled trials The breadth behind tranexamic acid across routes, and the side-effect profile the clotting-risk screen exists for.
- Effect of a Tranexamic Acid, Kojic Acid, and Niacinamide Containing Serum on Facial Dyschromia: A Clinical Evaluation Why these three actives turn up together in so many over-the-counter serums.
- Is cysteamine use effective in the treatment of melasma? A systematic review and meta-analysis Cysteamine's placement further down the page: pooled from six small trials, effective with few adverse effects.
- Kojic acid vis-a-vis its combinations with hydroquinone and betamethasone valerate in melasma: a randomized, single blind, comparative study of efficacy and safety Kojic acid as a combination partner rather than a standalone, which is how it is almost always studied.
- Laser and laser compound therapy for melasma: a meta-analysis The laser option's evidence and its ceiling — improvement across nine trials, measured during follow-up.
- Pulsed dye laser versus intense pulsed light in melasma: a split-face comparative study That melasma has a vascular component both device types act on, which is part of why results are inconsistent.
Take the charts with you
Print exactly the piece you need. Each chart is one landscape page — no prose, no controls, sized to pin up or hand to someone — and the full document is the whole pathway as it reads on screen. Every printout carries the date, the source, and a line making clear it is not a diagnosis.
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