What Causes Melasma? A Dermatologist Explains How to Tell It Apart from Freckles, Hori's Nevus and Dark Marks, the Types of Melasma, Why Some Lasers Make It Worse, and Evidence-Based Treatment
Facial melasma is a chronic condition in which the skin produces extra pigment, causing fairly symmetrical brown to grey-brown patches on the face. It is common on the cheekbones, forehead, nose, upper lip and chin. Melasma arises from pigment cells that are sensitive to light, hormones and genetics. It is not contagious and is not cancer. It can be lightened and controlled, but it can darken again if the triggers are still present.
Melasma is most common in women aged about 20–40, and men make up around 10% of patients. This article explains the types of melasma, how to tell it from freckles, Hori's nevus and dark marks, the drugs used to treat it with their timelines, and why melasma returns after treatment.
What does melasma look like, and how can you tell it is melasma?
Melasma does not itch or hurt. Most people notice it in the mirror or in photos. Five features together suggest melasma.
Patches, not dots: flat patches that cannot be felt as raised, with irregular, jagged edges.
Similar on both sides: if it is clearly on one side only, other conditions should be considered first.
Where the sun hits: cheekbones, forehead, bridge of the nose, upper lip, chin.
Color changes with season and sun: darker after a beach trip or outdoor work, lighter when you can consistently stay out of the sun.
Gradual onset: it appears little by little over months, not overnight.
These features raise suspicion but cannot confirm the diagnosis on your own, because several conditions can cause dark marks in the same places on the face, and some occur together with melasma.
What causes melasma?
Melasma has several contributing factors. The pigment cells (melanocytes) in affected areas are more reactive than normal, so when triggered they make too much melanin. Studies also show that skin with melasma has signs of sun damage, more small blood vessels, and cells in the dermis that send signals stimulating the pigment cells.
Sunlight and visible light: the main trigger, including UVA and UVB and visible light, which clearly stimulates pigment in Asian skin.
Hormones: pregnancy, birth control pills and hormone replacement therapy.
Genetics and skin tone: common in medium to dark skin (Fitzpatrick III–V), and many people have a close relative with melasma.
Heat and irritation: accumulated heat, scrubbing, peels and stinging creams trigger inflammation and more pigment.
Medicines and cosmetics: photosensitizing drugs, fragrances and creams with unknown ingredients.
Light from screens is far weaker than sunlight, so there is no clear evidence that it is a main cause of melasma. Evidence on stress and lack of sleep is limited. Do not overlook the sun and focus only on these.
How many types of melasma are there, and how do doctors classify them?
Doctors classify melasma in 3 main ways. The first is by pigment depth: superficial, deep and mixed. The second is by location: cheek, central face and jawline. The third is by trigger: hormonal and sun. One person can fit several types at once.
During an examination, the doctor looks at the color and edges of the melasma in good light and may use a Wood's lamp, which is long-wave ultraviolet light. Superficial melasma looks darker and clearer, deep melasma barely changes, and mixed melasma changes only in part. However, this method of telling the depth is not always accurate in darker skin, so the result must be read together with visual examination and history. Unclear cases may need dermoscopy or a skin biopsy.
Superficial melasma (epidermal melasma)
Appearance: light to dark brown patches with fairly clear edges.
Cause: pigment collects mainly in the epidermis, triggered by sun, hormones and irritation.
Severity/urgency: not dangerous and not urgent. This type responds to topical drugs better than the others, and changes are usually seen within 8–12 weeks.
When to see a doctor: when you are about to start a pigment-lightening drug, or when you have applied creams on your own for more than 8 weeks and the color has not moved.
Deep melasma (dermal melasma)
Appearance: grey-brown or blue-grey patches with edges that blend into normal skin.
Cause: pigment has dropped into the dermis and is held by pigment-eating cells, so topical drugs reach it only to a limited degree.
Severity/urgency: not dangerous, but it lightens slowly. Plan over months, and some parts may not lighten fully. This type can darken if too much laser energy is used.
When to see a doctor: before any laser, because it must first be distinguished from Hori's nevus. Read more at How is deep melasma different from superficial melasma?
Mixed melasma
Appearance: part brown and part grey within the same patch. This is the common type in Thai skin.
Cause: pigment is present in both the epidermis and dermis, often with accumulated sun damage and small blood vessels.
Severity/urgency: not dangerous. The superficial part lightens first and the deep part lightens slowly, so later on it can look as if the treatment has stopped working, when this is the natural course of the condition.
When to see a doctor: after using the drugs for the full 12 weeks with not enough improvement, or if it has darkened after a laser. See the next steps at Melasma not going away: what to do next
Cheek melasma (malar melasma)
Appearance: patches on the cheekbones and the ridges of both cheeks, which may spread to the temples.
Cause: the cheekbones receive the most direct sun on the face, so the effects of sun and face rubbing show clearly.
Severity/urgency: not urgent, but this area very often overlaps with Hori's nevus and sun spots, so it is where the diagnosis is easily confused.
When to see a doctor: when you see small grey dots mixed into the patch, or when part of the patch does not lighten at all with melasma treatment.
Central face melasma (centrofacial melasma)
Appearance: patches on the forehead, nose, inner cheeks, upper lip and chin. This is the pattern described most often in textbooks.
Cause: sun together with hormones. The area above the upper lip is often prominent in people on birth control pills or who are pregnant.
Severity/urgency: not dangerous, but easy to see. The skin around the mouth is thin and irritates easily, so drugs must be used with special care.
When to see a doctor: when a topical drug makes the area around the mouth red and stinging, or small bumps appear, which may be an effect of steroids.
Jawline melasma (mandibular melasma)
Appearance: patches along the jawline and lower chin, which may extend to the neck.
Cause: usually linked to accumulated sun exposure and more common around or after menopause.
Severity/urgency: not urgent. It is less common than the first two locations and must be told apart from darkening caused by an allergy to cosmetics or fragrance.
When to see a doctor: when there was itching and redness before the darkening, or when the darkening extends down the neck in a net-like pattern, which may not be melasma.
Hormonal melasma: pregnancy and birth control pills
Appearance: melasma that appears or darkens quickly during pregnancy (chloasma, or the mask of pregnancy) or within a few months of starting a hormonal drug.
Cause: estrogen and progesterone stimulate the pigment cells, and sun remains an important co-factor. Most data report melasma in about 15–50% of pregnant women.
Severity/urgency: not dangerous. Part of pregnancy melasma fades on its own within 6–12 months after delivery, but some cases persist. During pregnancy, mainly use tinted sunscreen. A doctor may consider azelaic acid and avoid hydroquinone, tretinoin and oral tranexamic acid.
When to see a doctor: before using any pigment-lightening drug during pregnancy or breastfeeding. If you suspect birth control pills are the trigger, talk to an obstetrician-gynecologist about other contraception. Do not stop the pill on your own without a replacement method.
Melasma from sun and visible light
Appearance: clearly darker after sun exposure, even in people who have never been pregnant or used hormones. Seen in men and in people who work outdoors or drive regularly.
Cause: UV and visible light stimulate pigment. Clear, untinted sunscreen blocks little visible light, so people who apply sunscreen regularly can still darken.
Severity/urgency: not urgent, but this is the type that comes back easily if the nature of the work cannot change.
When to see a doctor: when you apply sunscreen regularly and still darken every time you go out in the sun, or when a spot changes shape in the same area.
Sun spots (solar lentigines) are not melasma
Appearance: brown spots with clear edges, from a few millimeters to about 1–2 centimeters. They are separate spots, not symmetrical patches on both sides. Childhood freckles (ephelides) are smaller and fade with less sun.
Cause: sun exposure accumulated over many years, most common from middle age onward.
Severity/urgency: not dangerous. They respond to laser very differently from melasma. Using the same energy over the whole face may darken melasma next to them. Read more at How are sun spots different from melasma? For very small dark spots, see What causes freckles?
When to see a doctor: when a spot grows quickly, has uneven color or rough edges, or becomes an open sore, which needs examination to rule out skin cancer first.
Hori's nevus (ABNOM) is not deep melasma
Appearance: many small grey-brown to blue-grey dots on both cheekbones, and in some people on the temples, forehead or nose. It usually begins in adulthood.
Cause: pigment cells sit in the dermis. It is not the increased pigment production seen in melasma.
Severity/urgency: not dangerous, but often mistaken for deep melasma. Pigment-lightening drugs work poorly. The main treatment is pigment-breaking laser as assessed by a doctor, which works on a different principle from melasma treatment.
When to see a doctor: when the color is unchanged after 3–4 months of melasma drugs, or when you see small dots mixed into the patches on the cheekbones.
Post-inflammatory hyperpigmentation
Appearance: brown to dark marks where there was acne, a rash, a wound or a procedural burn. The shape follows the original mark and is not symmetrical like melasma.
Cause: inflammation prompts the skin to make more pigment. It occurs easily in darker skin.
Severity/urgency: not dangerous. It usually fades on its own over several weeks to 6–12 months if the cause is controlled and the skin is protected from the sun.
When to see a doctor: when new acne or rashes are still appearing, because the cause must be treated first. Details are at Post-inflammatory hyperpigmentation
Darkening from cosmetic allergy (Riehl's melanosis)
Appearance: grey-brown net-like skin on the forehead, temples, sides of the cheeks and neck.
Cause: chronic contact allergy to fragrances and cosmetic ingredients. Some people have almost no itching beforehand.
Severity/urgency: not an emergency, but it will not improve if the same substance is still used. Treatment starts with finding and stopping that substance, and some people need a patch test.
When to see a doctor: when skin darkens after changing cosmetics, or darkens in a net-like pattern. See more at Riehl's melanosis: dark marks from cosmetics
Darkening from skin-whitening creams (exogenous ochronosis)
Appearance: blue-grey to grey-black patches with tiny caviar-like dots on the cheekbones, cheeks and temples.
Cause: using hydroquinone continuously for too long without medical supervision. Unregulated creams may contain steroids or mercury, which thin the skin and darken it further.
Severity/urgency: not an emergency, but harder to correct than the original melasma, and stopping steroids suddenly can cause a rash flare, so a doctor should plan how to stop.
When to see a doctor: as soon as you feel a cream is making your face red, stinging or darker. Bring every cream you use for the doctor to see.
Sunscreen: the first step in treating melasma
Sunscreen is itself a treatment for melasma. If this part is missing, topical drugs and lasers usually cannot hold their results.
Type: SPF 30 is the minimum, but people with melasma are advised to use SPF 50 or higher, PA++++, and preferably a tinted sunscreen with iron oxide to block visible light.
Amount: about 2 finger-lengths for the face and neck, applied 15 minutes before going out in the sun.
Reapplication: every 2 hours when outdoors or sweating heavily.
Extras: a wide-brimmed hat, avoiding the sun between 10:00 and 16:00, and applying even when driving or sitting by a window.
Read how to choose at How to choose a suitable sunscreen
Treating melasma with topical drugs: names, strengths and timelines
Topical drugs are the main treatment for most melasma. This list helps you understand the treatment plan, but choosing and prescribing drugs is the doctor's job, based on the type of melasma, pregnancy and skin sensitivity. In Thailand, hydroquinone is prohibited in cosmetics, so you should not buy creams containing it to use on your own.
Triple combination: hydroquinone 4%, tretinoin 0.05% and fluocinolone acetonide 0.01%, applied only on the melasma at bedtime, for no more than about 8 weeks per course, after which the doctor reassesses and tapers. What decides the outcome is the depth of the pigment and the plan after 8 weeks, because using it too long risks steroid-related skin thinning.
Hydroquinone 2–4%: applied at bedtime, with clear results at 8–12 weeks, used continuously for no more than 3–4 months and then paused or switched. What decides the outcome is discipline with sunscreen and stopping on time. Using it too long risks permanent darkening (ochronosis).
Azelaic acid 15–20%: applied twice a day for 12–24 weeks, suitable for people who also have acne and an option during pregnancy. What decides the outcome is applying it consistently for the full period, because it works slowly and may sting or itch at first.
Tretinoin 0.025–0.05%: applied at bedtime, often needed for up to 24 weeks. Do not use when pregnant or planning pregnancy. What decides the outcome is avoiding irritation, because inflamed skin may develop more dark marks.
Cysteamine 5%: applied for 15 minutes and then washed off, once a day for 16 weeks, an option when hydroquinone should not be used. What decides the outcome is using it on schedule together with sunscreen.
Add-on drugs: kojic acid 1–4%, niacinamide 4–5% and topical tranexamic acid 2–5%, used as add-ons or for maintenance, with lighter evidence than the main group.
The benchmark is the color and area of the melasma compared with the start, at weeks 8–12. If nothing has moved, the doctor reviews the diagnosis and sunscreen use and changes the plan. Compare the main drugs at How hydroquinone, tranexamic acid and cysteamine differ
Oral tranexamic acid for melasma
Oral tranexamic acid is an option for moderate to severe melasma, or melasma resistant to topical drugs. It is an off-label use, so the doctor must ask about blood clot history before every prescription. Do not buy it and take it on your own.
Dose commonly used in studies: 250 mg twice a day for 8–12 weeks. In some plans the doctor extends it to 3–6 months with periodic monitoring. Results begin to show around weeks 4–8. Use it together with topical drugs and sunscreen.
Not allowed or needs caution: past blood clots, stroke or heart disease, severe kidney disease, current use of combined hormonal birth control, heavy smoking, pregnancy or breastfeeding.
Possible side effects: mild stomach pain, lighter periods, headache.
Stop the drug and see a doctor immediately: pain and swelling in one calf, chest pain, difficulty breathing or sudden blurred vision.
After stopping: melasma may return within a few months if topical drugs and sunscreen do not back it up.
Suitability is decided more by clot-risk history than by how dark the melasma is. People at high risk will not be given this drug even if the melasma is severe.
Lasers for melasma: how they work and realistic expectations
Lasers are an add-on, not the first-line treatment for melasma. A doctor considers them when topical drugs and sunscreen for 8–12 weeks are not enough, or in mixed and deep melasma resistant to drugs. No laser makes melasma disappear permanently in one session. Several sessions are generally needed, topical drugs must continue, results differ from person to person, and melasma may return if care stops.
Picosecond laser: delivers energy in a very short time to break pigment into small particles, with little heat build-up. For melasma, low-energy settings are used, about 2–4 weeks apart.
Fractional laser: creates tiny wounds in a dot pattern to speed up skin renewal. Skin injury may trigger dark marks and darker melasma in darker skin, so it is not an early option and is used only in suitable cases.
Radiofrequency microneedling (RF microneedling): delivers energy into the dermis through fine needles. There is early data in melasma that does not respond to other methods. Evidence is still limited.
Vascular laser: considered only in people with prominent small blood vessels or redness together with melasma. It manages the vascular component and is not a direct pigment reducer.
Why do some lasers make melasma darker?
The pigment cells in melasma areas are already easily triggered. Too much energy or heat, treating too often and sun exposure after treatment all trigger inflammation and extra pigment. This is called rebound melasma. It can appear within a few weeks of treatment and is harder to correct than before.
Another reason is an incomplete diagnosis. People who have melasma, sun spots and Hori's nevus on the same face need a different plan for each mark. Firing one setting over the whole face, set for sun spots, may worsen the neighboring melasma. This is why the conditions must be told apart before starting.
Who should postpone or avoid laser for melasma
Pregnant or breastfeeding: postpone.
Sunburned skin, or just back from strong sun.
Infection or inflamed rash in the area to be treated, such as an active cold sore.
Taking photosensitizing drugs or recently took isotretinoin: always tell the doctor first.
History of raised scars, keloids or severe post-inflammatory dark marks.
Melasma darkened after a previous laser: review the plan with your doctor before repeating.
Marks that have not yet been diagnosed, such as a spot that is growing fast or has uneven color.
Side effects and aftercare following laser
Common effects: redness, warmth and mild swelling, lasting a few hours to 1–2 days.
Risks to know about: rebound melasma, post-inflammatory dark marks, patchy white spots (guttate hypopigmentation) when treatment is too frequent or the energy is unsuitable, blisters or wounds (uncommon), and not getting the expected result.
Aftercare: wash the face gently, apply moisturizer, use sunscreen every day, avoid scrubs and exfoliating acids for about 3–5 days or as your doctor advises, and continue the topical drugs the doctor prescribed.
Return to the doctor if: there are blisters, pus, increasing pain, or the marks keep darkening 2–4 weeks after treatment.
Surgery is not a treatment for melasma. For a mark suspected to be skin cancer or one that is not clearly diagnosed, a biopsy is a more suitable answer than laser.
Why does melasma come back after treatment?
Melasma is a chronic condition. The pigment cells in the area remain sensitive to triggers even after the color has lightened. Recurrence is therefore common and does not mean the drugs did not work. Common causes are
Not enough sunscreen: applying too little, not reapplying or using an untinted type, especially when traveling and working outdoors.
Triggers still present: birth control pills, hormone replacement or a new pregnancy.
Stopping drugs as soon as the color fades: with no plan to taper and no maintenance drug.
Laser too often or too strong: inflammation followed by rebound darkening.
Continuous irritation: hard rubbing, scrubs or stinging creams.
Incomplete diagnosis: the part that does not lighten is Hori's nevus or darkening from creams, which is not melasma.
Once the color has lightened to the target, doctors usually step the main drug down to one that is safer for long-term use, such as azelaic acid, and schedule periodic reviews. The first phase of treatment usually takes about 3–6 months, while sunscreen must continue indefinitely.
Melasma myths that do not match the evidence
Melasma comes from a vitamin deficiency: melasma is not a vitamin deficiency. Taking vitamin C or E does not directly treat melasma.
You must avoid fried and sweet foods if you have melasma: diet is not the main cause. Eating well is good for health but does not lighten melasma.
Scrubbing or peeling hard will get rid of melasma: irritation actually triggers inflammation and makes it darker.
Any sunscreen will do: clear, untinted sunscreen blocks little visible light, so it may not be enough for melasma.
One laser session and it is over: laser is an add-on, and sunscreen and topical drugs must continue.
When should you see a dermatologist about melasma?
You are not sure whether a mark on your face is melasma, freckles, Hori's nevus or a dark mark.
You have applied creams on your own for more than 8 weeks without lightening, or it has darkened.
You used a cream with unknown ingredients and your face became red, stinging or darker.
You are pregnant, breastfeeding or planning a baby and want to treat melasma.
You are interested in oral drugs or laser, which need a doctor to assess contraindications first.
You have a spot that is growing fast, has uneven color or rough edges, or is an open sore. It should be examined promptly.
If you are looking for somewhere to be examined, there is a page on how to choose a melasma clinic in the Bangkok–Samut Prakan area, and details on examination, hours and directions are on the melasma clinic in Samut Prakan–Bangna page.
Quick summary
Melasma is a brown to grey patch on both sides of the face. It is not contagious, is not cancer, and is a chronic condition.
Melasma is divided into superficial, deep and mixed, and superficial melasma responds to topical drugs better.
Sun spots, Hori's nevus, post-inflammatory dark marks and darkening from creams are treated differently from melasma, so they must be told apart first.
The main treatment is tinted sunscreen SPF 50 or higher together with topical drugs prescribed by a doctor, with the result assessed at 8–12 weeks.
Oral tranexamic acid 250 mg twice a day and laser are add-ons that need a doctor's risk assessment.
Melasma can return, so sunscreen and control of triggers must continue.
Frequently asked questions about facial melasma
Why did I suddenly get melasma on my face?
Melasma usually does not appear out of nowhere. It arises when pigment cells that are already sensitive, by genetics, meet a trigger. Common triggers are sunlight and visible light, birth control pills, pregnancy, hormone replacement and irritation from creams or scrubbing. Try to review the 3–6 months before the melasma appeared: did you start a drug or change a cream, or were you out in the sun more? Bring this information and the creams you use to the doctor, which will help plan more targeted treatment.
Can melasma be cured completely, or do I have to apply drugs forever?
Melasma is a chronic condition, so it can be lightened and controlled, but no method can promise it will not come back. Melasma from pregnancy or birth control pills fades on its own in some people once the trigger is gone. Most people use a main drug for about 3–6 months at first and then step down to a drug that is safer for long-term use, so you do not need strong drugs for life. What truly must continue is tinted sunscreen every day, because light is the fastest trigger for it to darken again.
What should I apply for melasma, and can I buy a cream myself?
Commonly used drugs are the triple combination for about 8 weeks, hydroquinone 2–4% for no more than 3–4 months, azelaic acid 15–20% and cysteamine 5%. Choosing the drug is the doctor's job, because it depends on the type of melasma and on pregnancy. We do not recommend buying melasma creams on your own without knowing the ingredients, because unregulated creams may contain steroids, mercury or hydroquinone not listed on the label, which can thin the skin or darken it permanently. What you can start on your own right away is tinted sunscreen.
How do I tell melasma and freckles apart?
Melasma is a flat patch with jagged edges on both sides of the face and often darkens after sun exposure. Freckles are separate spots with clear edges. Sun spots are common from middle age onward, from a few millimeters to about 1–2 centimeters, while Hori's nevus is many small grey dots on the cheekbones that are often mistaken for deep melasma. Many people have more than one on the same face, so a doctor should examine you before you choose a drug or laser, because a plan suited to freckles may darken melasma.
What vitamin am I lacking if I have melasma, and what foods should I avoid?
Melasma is not caused by a vitamin deficiency, and no food has been proven to be the main cause or to make melasma go away when avoided. Taking vitamin C or E is therefore not a direct treatment for melasma. But if you take any drug or supplement, tell your doctor, because some make skin sensitive to light or contain hormones. Supplements that claim to whiten skin deserve extra caution. What truly affects melasma is sunscreen, controlling hormonal triggers and the drugs your doctor chooses.
Is laser good for melasma, and why do some people get darker after it?
Laser is not the first-line treatment for melasma. A doctor may consider low-energy picosecond laser as an add-on when topical drugs and sunscreen for 8–12 weeks are not enough. Several sessions are needed and topical drugs must continue. People who get darker usually have too much energy, treatment that is too frequent, sun exposure after treatment, or skin that is prone to inflammation, leading to rebound melasma or dark marks. Some have white spots. Before treatment, always have a doctor assess contraindications and the type of mark. Results vary from person to person.
Read related articles
The information in this article is general knowledge, not a diagnosis or an individual treatment order. Treatment results vary from person to person. The choice of drugs and procedures must be assessed by a doctor.
Written by Dr. Patara Voravutinon, Dermatologist · Last reviewed 4 November 2026
Warning: laser and other procedures for melasma carry a risk of not giving the expected result, and may cause harm or side effects. Results vary from person to person. They should always be assessed and performed by a doctor.
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