Melasma#

Melasma shows up as darkened patches of skin, usually brown or greyish, on the face. The patches are often symmetrical - meaning they appear in mirror-image positions on both sides of the face. Common locations are the cheeks, forehead, upper lip, bridge of the nose, and chin.

Melasma is grouped by how deep the extra pigment is in the skin:

• Epidermal - pigment is in the top layer of skin; tends to respond better to topical treatment
• Dermal - pigment is deeper in the skin; harder to treat with creams alone
• Mixed - the most common type; pigment is in both layers

Most commonly on sun-exposed parts of the face:

• Cheeks
• Forehead
• Bridge of the nose
• Upper lip
• Chin

It can sometimes appear on the neck, forearms, or upper chest, but facial melasma is far more common.

• Women, particularly during their reproductive years
• People with deeper skin tones (often Hispanic/Latin American, South Asian, East and Southeast Asian, Middle Eastern, or African background)
• People with a family history of melasma
• People with hormonal triggers - pregnancy, combined hormonal birth control, hormone therapy

• Epidermal melasma - the extra pigment is in the top layer (epidermis) and is generally easier to fade with topical treatment.
• Dermal melasma - the pigment is deeper in the skin (dermis) and is harder to reach with creams; it tends to take longer and respond less completely.

In practice, most melasma is a mix of the two.

A dermatologist can use a Wood's lamp (a UV light) to look at the skin: epidermal pigment looks brighter under the lamp, dermal pigment does not change much. This is an in-person assessment and is not always required to plan treatment.

Melasma is caused by melanocytes (the cells that make pigment) overproducing melanin. The most common drivers are:

• Sun exposure (UV light)
• Hormones (estrogen, progesterone)
• Genetics (family history)
• Visible light (including some indoor light and blue light from screens, smaller effect)
• Certain medications that increase sun sensitivity

UV light triggers melanocytes to make more pigment as a protective response. In melasma-prone skin, even short, daily sun exposure stacks up. This is why daily broad-spectrum sunscreen is the single most important habit for melasma management - without it, treatment results plateau or reverse.

Estrogen and progesterone can directly stimulate melanocytes. This is why melasma often appears or worsens with:

• Pregnancy (sometimes called the "mask of pregnancy" or chloasma)
• Combined hormonal birth control (especially estrogen-containing)
• Hormone therapy

Yes - melasma has a genetic component. If a parent or sibling has melasma, your risk is higher, particularly when combined with sun or hormonal triggers.

Yes - melasma during pregnancy is common, especially in the second and third trimesters. It may improve after delivery but can persist or recur.

Combined hormonal birth control can trigger or worsen melasma in susceptible people. Switching to a progestin-only method or a non-hormonal method may help - improvement is not guaranteed because progestins can still be hormonally active - and this is a decision to discuss with the clinician who manages your contraception.

Yes - visible light (including high-energy blue light) can stimulate melanocytes in melasma-prone skin. This is why tinted mineral sunscreens with iron oxide are useful for melasma: they block visible light, not just UV.

Stress can indirectly contribute by altering cortisol and other hormones, which can in turn affect estrogen and progesterone balance. Stress on its own is rarely the main driver.

Some medications increase sun sensitivity (certain antibiotics, anti-inflammatories, diuretics). In melasma-prone skin, this can indirectly worsen pigmentation if it leads to more UV-related inflammation or tanning. Hormonal medications (combined birth control, hormone therapy) can also trigger melasma directly.

Yes. Melasma is most common in Fitzpatrick skin types III to VI but can occur in all skin types. Deeper skin tones have more active melanocytes, so they respond more strongly to sun and inflammation.

In most cases, melasma is diagnosed by how it looks and by the patient's history. Symmetrical, gradually-appearing dark patches on sun-exposed facial skin in a person with typical triggers is usually enough.

A Wood's lamp uses UV light to help a clinician assess how deep the pigment is. Epidermal melasma appears brighter under the lamp; dermal pigment does not change as much. This is done in person and is helpful but not required.

Usually not. Biopsies are reserved for uncertain cases or to rule out other conditions. Most melasma is diagnosed clinically.

Dermoscopy is a hand-held magnifying tool with a light. It helps clinicians look at pigmentation patterns more closely and tell melasma apart from other pigmentation problems. It is an in-person tool.

• Prescription brightening creams - reduce melanin production. Used in short courses with breaks (typically up to 12 weeks at a time). See Prescription brightening creams.
• Anti-inflammatory brightening creams - calm inflammation, fade dark marks, and reduce small bumps. Gentler and can be used long-term. See Anti-inflammatory brightening creams.
• Prescription retinoids - speed up skin-cell turnover so pigmented cells are replaced faster. Not safe in pregnancy.
• Antioxidants - topical vitamin C is the most common; supports brightness and adds sun-damage protection.
• Triple therapy compounded creams - combine a prescription retinoid, a prescription brightening agent, and a mild prescription steroid in one product. Faster than single agents but used for time-limited courses. See Triple therapy for pigmentation.
• AHA and BHA exfoliating products - alpha-hydroxy acids and beta-hydroxy acids can support fading of surface pigment as part of a routine.

Daily sunscreen is part of every regimen. Without daily sunscreen, the gains from any of these plateau or reverse.

A compounded cream that combines three components in one product: a prescription retinoid, a prescription brightening agent, and a mild prescription steroid. The combination tends to fade pigment faster than any single agent. Because of the steroid component, it is usually used for time-limited courses (typically 8 to 12 weeks), then transitioned to a gentler maintenance regimen. See Triple therapy for pigmentation for the full details.

Most show meaningful improvement at 8 to 12 weeks of consistent daily use. Some patients see initial change at 4 to 6 weeks; deeper or more stubborn pigment can take longer.

For sensitive skin, gentler categories - an anti-inflammatory brightening cream, topical vitamin C, or a vitamin A product started at a lower strength - are typically chosen first. The clinician can also slow the schedule (every other night instead of nightly) and use a richer base.

Some yes, most no:

• An anti-inflammatory brightening cream - generally considered low-risk in pregnancy
• Topical vitamin C - generally considered low-risk
• Niacinamide - safe in pregnancy and breastfeeding
• Prescription brightening creams - usually avoided in pregnancy
• Prescription retinoids - avoided during pregnancy and while trying to conceive. During breastfeeding, only use if a clinician specifically recommends them, and avoid the breast/nipple area and large body areas.
• Triple-therapy creams - usually avoided in pregnancy

Tell your clinician if you are pregnant, breastfeeding, or planning to become pregnant.

• Mild to medium-depth chemical peels (using alpha-hydroxy acids or beta-hydroxy acids)
• Non-ablative fractional lasers - the safer laser category in skin of colour
• Q-switched lasers - for specific pigment patterns
• Microneedling - sometimes combined with topical treatments

Deeper ablative lasers (CO2, erbium) carry a higher risk of post-inflammatory hyperpigmentation, scarring, and lighter patches in deeper skin tones, and are used with caution.

TeleTest does not perform any of these procedures. The clinician can give you a written, unbiased overview of which category is reasonable for your skin type and what to ask about when you book in person.

• Mild dryness, peeling, redness, or stinging, especially in the first 2 to 4 weeks
• Temporary increased sensitivity to sunlight (daily sunscreen is required)
• In sensitive skin, occasional irritation that may need a dose reduction or schedule change

If irritation is severe, stop and contact your clinician for an adjustment.

Triple-therapy combination creams contain a mild prescription steroid. On the face, prolonged daily use can cause:

• Skin thinning (the skin becomes thinner and more fragile)
• Visible small blood vessels
• Stretch marks (rare on the face, more common in groin/armpits)
• Steroid dependency - the skin can become reliant on the steroid and flare when stopped

For this reason, triple-therapy creams are used for time-limited courses (often 8 to 12 weeks) with breaks afterwards and a transition to a gentler maintenance regimen. Your clinician will plan this with you.

Signs include:

• Visible small blood vessels on the cheeks or treated area
• Easy bruising or skin that tears with minor injury
• Shiny or translucent-looking skin
• Stretch marks in areas where skin stretches (uncommon on the face)
• Persistent dryness, peeling, or fragility

If you notice any of these, stop the cream and contact your clinician. Early detection matters - severe, long-term thinning may not fully reverse.

Mild thinning often improves over weeks to months after stopping the steroid component, as the skin regenerates collagen. Severe or long-standing thinning with stretch marks or persistent visible blood vessels is typically not fully reversible. Catching it early is key.

If a prescription steroid cream has been used daily on the face for a long time, stopping it can produce a flare:

1. About 1 week after stopping, redness and peeling in the previously treated area, often lasting around 2 weeks
2. A second flare roughly 2 weeks later with similar symptoms
3. Cyclic flares that gradually shorten over weeks to months

The total length depends on how long the steroid was used. Tapering rather than stopping abruptly, and using gentle moisturizers and barrier-supportive products, can reduce the severity. This should be managed with your clinician.

Several approaches can improve mild thinning, especially when started early:

• Prescription retinoids reintroduced carefully - support collagen production and skin thickness
• Topical vitamin C - antioxidant and collagen-supportive
• Platelet-rich plasma (PRP) treatments (in-person procedure)
• Hyaluronic acid fillers (in-person procedure) - restore volume temporarily
• Collagen-stimulating laser treatments (in-person procedure)

TeleTest does not perform the in-person procedures listed; the clinician can give general guidance.

Yes, when matched correctly. The clinician typically starts at a lower strength, uses a richer base, and titrates up to reduce post-inflammatory hyperpigmentation. Daily sunscreen with visible-light protection (tinted formulas with iron oxide) is part of every plan.

It may, partially. Hormonal melasma often improves after the hormonal trigger ends, but it does not always disappear completely - especially if sun exposure continues. Daily sunscreen and gentle skincare during and after the trigger helps. If the patches do not fade on their own within 6 to 12 months, a TeleTest consultation can help with a topical plan.

Melasma can last months to years if left untreated, and can be lifelong with periodic flares triggered by sun or hormones. With consistent sunscreen and treatment, most people see meaningful improvement, but full and permanent clearance is uncommon. Maintenance is part of the long-term plan.

Sunscreen will not actively fade existing melasma, but it is essential for preventing it from getting worse and for allowing any treatment to work. Daily broad-spectrum SPF 30+ with iron oxide for visible-light protection is the foundation of every melasma plan.

A daily broad-spectrum mineral sunscreen with iron oxide (which gives it a tinted appearance) is the most effective for melasma. Iron oxide blocks visible light in addition to UV, which is relevant for melasma. Re-apply every 2 hours when outdoors.

Mild melasma sometimes responds to consistent OTC treatment (daily sunscreen, vitamin C, niacinamide, gentle exfoliation). Moderate-to-severe melasma usually needs prescription-strength brightening and a structured plan. A consultation can help decide whether OTC is enough or whether prescription treatment will save you time and money.

If you have any new, changing, asymmetrical, or atypical dark spots, have them checked in person before treating with a cream. Cosmetic-dermatology consultations are for diagnosed cosmetic pigmentation, not for evaluating skin lesions.

Laser does not cure melasma. It can fade pigment but does not stop the underlying drivers (sun, hormones, inflammation), and in darker skin tones it can sometimes make pigmentation worse. Topical regimens with daily sunscreen are first-line for most patients. Laser is an option after topical treatment plateaus, and only with an experienced provider in skin of colour.

Yes. Many people use a tinted mineral sunscreen as both sun protection and light coverage, then add a regular foundation if they want more coverage. Choose makeup that is non-comedogenic and labelled for sensitive skin.

Diet has a minor role at most. Some plant-based oral supplements have been studied for extra sun protection alongside sunscreen, but they do not replace sunscreen and are not a primary treatment. The biggest dietary thing is staying well hydrated and following a generally healthy diet.

Track progress with photos every 4 weeks in consistent lighting. Compare side by side. Most people see initial change at 4 to 6 weeks and stronger results at 8 to 12 weeks. If you see no change at 12 weeks with consistent sunscreen and treatment, talk to your TeleTest clinician about adjusting the plan.

Common. Submit a follow-up request. The clinician can prescribe a second short course of prescription brightening or triple therapy, and reinforce the maintenance plan (sunscreen + a gentler daily brightening cream).

For most cases of typical melasma, a TeleTest consultation is enough. See an in-person dermatology or cosmetic clinic (which you would arrange yourself - TeleTest does not arrange referrals) if you are considering laser or other procedures, if the diagnosis is uncertain, or if a topical regimen has not worked after several months of consistent use.

Yes. Apply the cream at night, let it absorb fully, then apply your usual moisturizer. In the morning, apply sunscreen and then makeup as usual.

Cosmetic dermatology consultations and most prescription cosmetic creams (especially compounded ones) are not covered under provincial health plans - they are self-pay. Some private drug plans cover compounded prescriptions in whole or in part.

Ask two or three compounding pharmacies for a quote on the prescription before filling. Costs can differ significantly. If you live in Ontario, TeleTest's home-delivery partner pharmacy (Pace Pharmacy) ships at pharmacy prices with no markup - they are worth comparing.

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