> ## Documentation Index > Fetch the complete documentation index at: https://docs.hi-doctor.ai/llms.txt > Use this file to discover all available pages before exploring further. # Melasma — why the pigment returns > Melasma is a chronic pigmentary condition driven by light, hormones and heat. How a doctor assesses it online, what topical treatment achieves, and its limits. Melasma is a chronic acquired pigmentary disorder that produces symmetrical brown to grey-brown patches, almost always on the face. It is common, it is harmless to health, and it is stubborn. Treatment lightens it; nothing reliably cures it, and relapse on sun exposure is the rule rather than the exception. A registered doctor reviews the questionnaire and photographs and decides whether a topical treatment is appropriate. ## What melasma is Melanocytes in affected skin are larger, more dendritic and more active than in surrounding skin, and they deliver more melanin to the keratinocytes above them. The affected areas are also biologically distinct in ways that explain why the condition persists: increased vascularity, changes to the basement membrane, and features of photoageing in the surrounding dermis. The condition is best understood as skin that has been chronically stimulated, not simply as a patch of extra pigment sitting on the surface. Three distributions are described. Centrofacial — forehead, nose, upper lip, chin — is the most common. Malar affects the cheeks. Mandibular follows the jawline. There is also a version on the forearms. ## Why it happens Ultraviolet radiation drives melanogenesis, and — importantly for melasma specifically — so does high-energy visible light, which ordinary UV-only sunscreen does not block. This is why tinted, iron-oxide-containing sun protection is recommended for melasma where plain chemical filters are not enough. Pregnancy, the combined oral contraceptive pill and hormone therapy are all common triggers. The pregnancy-associated form is called chloasma and often fades after delivery, though not always and not completely. Melasma responds to heat independently of light. Cooking over a stove, saunas, hot yoga and even hot flushes have all been implicated in flares, which is why a person who avoids the sun diligently can still find it worsening. Family history is present in a large proportion of cases, and melasma is far more common in Fitzpatrick skin phototypes III to V. That combination — susceptible pigment cells and sun exposure — is the setting the condition needs. ## How a doctor assesses it The melasma questionnaire is thirteen steps and **a photograph is mandatory** — the case cannot be submitted without one. It also has twelve individual blocking answers, and a dedicated hydroquinone-history step, which exists for a specific safety reason covered below. The doctor is establishing the pattern and symmetry, the Fitzpatrick phototype (because the risk of post-inflammatory hyperpigmentation from any irritant treatment rises with it), how long the pigment has been present, what is driving it, and — critically — whether the patch is actually melasma. Symmetrical, gradual, light-related and hormone-related points towards melasma. Asymmetry, a single lesion, recent change in an existing mark, irregular borders, multiple colours within one lesion, bleeding or itching point somewhere else entirely, and none of those belongs in an asynchronous topical consultation. Any pigmented lesion that is new, changing, asymmetric, irregularly bordered, multicoloured, larger than about six millimetres, bleeding, crusting or itchy needs an **in-person examination with dermoscopy**. A photograph submitted for melasma is not a skin cancer screen, and it should never be treated as one. Epidermal pigment — melanin sitting in the upper layers — lightens far more readily than dermal pigment sitting deeper. That distinction is normally made with a Wood's lamp during an in-person examination, and it cannot be made reliably from a photograph. It is one honest limitation of assessing melasma remotely, and it is part of why response varies so much between people who look similar in a picture. ## What a doctor may prescribe The long-standing reference topical for melasma. It inhibits tyrosinase, the rate-limiting enzyme in melanin synthesis, and is used in defined courses rather than indefinitely. The same active in a lighter vehicle, which some people tolerate better on oily or humid-climate skin. A compounded 30 g preparation combining hydroquinone 4%, tretinoin 0.025%, kojic acid 2% and niacinamide 4% — several points in the pigment pathway addressed together. Read more about the individual actives: [hydroquinone](/library/medicines/hydroquinone), [tretinoin](/library/medicines/tretinoin) and [niacinamide](/library/medicines/niacinamide). **Pregnancy and breastfeeding.** The combination formula contains tretinoin, a topical retinoid, and topical retinoids are not used in pregnancy. Hydroquinone is likewise avoided. Pregnancy-associated melasma is generally left until after delivery and breastfeeding, with photoprotection in the meantime. The pregnancy step in the questionnaire is there so the doctor knows before deciding. ## Photoprotection is most of the treatment This is the part people skip and it is the part that determines the outcome. Melasma that is being treated with a lightening agent and simultaneously exposed to sun will not improve, because the stimulus is being reapplied faster than the treatment removes the result. What that means in practice: broad-spectrum protection at a high sun protection factor applied every morning and reapplied through the day, tinted formulations containing iron oxides for visible-light coverage, a wide-brimmed hat, and shade. It applies on cloudy days, through windows, and in winter. If only one element of a melasma routine survives, it should be this one. ## Realistic timelines Nothing visible yet, and possibly some irritation as the skin adjusts. Irritation matters here more than in other conditions, because inflammation itself produces pigment in susceptible skin — the treatment can darken the area if it is pushed too hard. The earliest point at which lightening is usually noticeable, and generally subtle. A photograph taken at the start in consistent lighting is far more reliable than memory. The usual point of assessment. Hydroquinone is used in defined courses and then paused; the doctor decides the length, and unlimited continuous use is specifically what should not happen. Maintenance moves to non-hydroquinone agents and relentless photoprotection. Relapse in summer, on holiday, or in pregnancy is common, and it is a feature of the condition rather than a failure of the treatment. ## What does not work * **Lightening without photoprotection.** The single most common reason a course fails. * **Aggressive scrubs, high-strength peels at home and lasers chosen badly.** Melasma is famously easy to worsen. Any procedure that inflames the skin can trigger a rebound darker than the starting point, and in darker phototypes that rebound can be long-lasting. * **Unregulated skin-lightening products.** Creams bought outside a pharmacy have repeatedly been found to contain mercury salts or potent corticosteroids. Both cause real harm — mercury toxicity in the first case, skin atrophy and steroid-induced pigmentation in the second. * **Expecting a permanent result.** Melasma is chronic. The realistic goal is a lighter, better-controlled patch, maintained. ## When to see someone in person An in-person appointment is the right route for any pigmented lesion with the features listed in the warning above, for pigment that is asymmetric or confined to one spot, for pigment that appeared abruptly after starting a medicine, for melasma that has not responded to a full topical course, or if you are considering a laser or chemical peel — those need an assessment of your phototype and pigment depth first. ## Common questions Very often, yes, particularly after sun exposure, in pregnancy, or on starting hormonal contraception. Treatment is best framed as control with maintenance, not as a cure. Because prolonged uninterrupted hydroquinone use is associated with exogenous ochronosis, a paradoxical blue-black discolouration that is difficult to treat. Knowing your prior exposure is how the doctor decides on course length, or decides against it. The usual answer is no. Retinoids are excluded in pregnancy and hydroquinone is avoided. Rigorous photoprotection is the approach until after delivery and breastfeeding, and pregnancy-associated melasma frequently fades on its own once hormones settle. No. Solar lentigines are discrete, usually well-defined spots on chronically exposed skin. Freckles are small, light-dependent and often childhood-onset. Melasma is a larger, symmetrical, patchy discolouration with an indistinct border, and it behaves differently under treatment. Combined hormonal contraception is a recognised trigger in susceptible people. Whether to change contraception is a conversation with the prescriber who manages it, not something to decide unilaterally, and it is not part of this consultation. Sometimes, in the right hands, on the right pigment depth, in the right phototype — and it can also make it markedly worse. Laser for melasma is an in-person decision made after a proper assessment, and it is not something to arrange from a photograph. ## Related reading * [Hydroquinone](/library/medicines/hydroquinone) · [tretinoin](/library/medicines/tretinoin) · [niacinamide](/library/medicines/niacinamide) · [azelaic acid](/library/medicines/azelaic-acid) * [Side effects of dermatology topicals](/library/guides/side-effects-dermatology) * [How to apply a prescription topical](/library/guides/how-to-apply-topicals) * [Taking your dermatology photos](/library/guides/dermatology-photos) * [Skin ageing](/library/conditions/skin-ageing) — the photoageing that usually accompanies melasma * [Safety and eligibility](/essentials/safety) · [how a consultation works](/essentials/how-it-works) ## Start a consultation Answer the melasma questionnaire and upload the required photograph. A registered doctor reviews it and decides whether a topical treatment is appropriate — declining is a normal outcome. See [what it costs](/essentials/pricing) and [how the review works](/essentials/how-it-works). This page is reference information, not medical advice and not a prescription. Whether a medicine is appropriate for you is decided by a registered doctor after reviewing your consultation.