Key takeaways

  • Protect against visible light as well as UV. DermNet specifies SPF50+ broad-spectrum sunscreen containing iron oxides, a broad-brimmed hat and lifelong, year-round protection. DermNet
  • Melasma is most common in Fitzpatrick III and IV skin. It affects women more often than men, typically starting between 20 and 40. DermNet
  • Family history and hormones matter. DermNet reports affected relatives in 60% and implicates pregnancy or hormone treatments in about a quarter of affected women. Discuss contraception changes with the doctor. DermNet
  • Combination treatment has the best topical record. Hydroquinone, tretinoin and a moderate-potency steroid together are reported to clear or improve 60 to 80% of cases. Use under supervision. DermNet
  • Avoid irritating or perfumed facial products. A phototoxic reaction to scented soaps, toiletries or cosmetics can trigger melasma. DermNet
  • Confirm what is causing the pigment. DermNet lists post-inflammatory pigmentation, solar lentigines and drug-induced pigmentation among lookalikes. DermNet
  • Plan for recurrence after a good response. Pigment may return with summer sun; the British Association of Dermatologists also describes relapse after treatment stops. DermNet, BAD

Ordinary sunscreen can leave the visible-light part of melasma unaddressed. That is why the recommendation names iron oxides as well as SPF50+. Skin that tans easily or is naturally brown is especially affected, which makes melasma a common concern for the many Gulf residents with those skin types.

What is melasma, and how do I know that is what I have?

A common acquired skin disorder presenting as blotchy, brownish facial pigmentation, usually symmetrical on both sides of the face.

DermNet describes it as bilateral, blotchy, brownish facial pigmentation. It was once called chloasma and is still widely known as the “mask of pregnancy”. It can also appear outside the face in sun-exposed areas: forearms, upper arms and shoulders.

Pigment depth helps explain different treatment responses. DermNet describes well-defined dark-brown epidermal melasma that becomes more obvious under a Wood lamp and usually responds well. Dermal pigment has less distinct borders, can look light brown or blue-grey, does not become more obvious under that lamp and usually responds poorly. Mixed melasma is the commonest type and usually improves partly. DermNet

A dermatologist can examine the skin with a Wood lamp or dermatoscope; a biopsy is occasionally used to exclude other conditions. DermNet’s lookalikes include post-inflammatory pigmentation after acne, drug-induced pigmentation, solar lentigines, naevus of Ota and naevus of Hori. These need different management. Confirm the diagnosis before starting a lightening regimen. DermNet

Melasma itself is not cancer or a sign of cancer. The affected patches are flat and, as the BAD leaflet explains, neither itchy nor painful. BAD

Why is it so common in this region?

Because the two strongest drivers, skin phototype and sun exposure, both point the same way here.

Melasma is most common in people who tan easily or have naturally brown skin, Fitzpatrick types III and IV. That describes much of the South Asian, Arab, Filipino and Mediterranean population of the Gulf. It is less common at both extremes: fair skin (types I and II) and black skin (types V and VI).

DermNet proposes a photoageing process in genetically predisposed people. Ultraviolet and visible light stimulate pigment production. Melanocytes make excess melanin, which may be taken up by epidermal keratinocytes or deposited deeper in the dermis. DermNet

Intense light through the year keeps that exposure present here. DermNet reports that 60% of people with melasma have affected family members; a mother or sister with melasma is therefore relevant history to mention at the appointment. DermNet

Why is my sunscreen not working?

Because most sunscreens are designed against ultraviolet, and visible light also drives melasma.

DermNet recommends:

  • Broad-spectrum, very high protection factor, SPF50+
  • Containing iron oxides, which is what provides meaningful visible-light protection
  • Combined with a broad-brimmed hat and sun-sensible behaviour
  • Year-round and lifelong, not just in summer

Iron oxides are what makes a sunscreen tinted, which is why tinted mineral sunscreens are recommended for melasma while clear chemical ones often disappoint. If your sunscreen is invisible on the skin, it is probably not giving you visible-light protection.

Visible light comes through windows, so a bright indoor space still matters. This does not mean every blue-light source has the same evidence: the BAD leaflet says there is no evidence that blue light from personal electronic devices affects the skin. BAD

Could my contraception or HRT be involved?

Possibly. Hormones are implicated in around one quarter of affected women.

DermNet lists pregnancy and the use of oestrogen or progesterone-containing oral contraceptives, intrauterine devices, implants and hormone replacement therapy as implicated in about a quarter of affected women. It also notes that thyroid disorders can be associated with melasma.

Among the general measures for treatment is to discontinue hormonal contraception if possible. That “if possible” is doing real work: it is a decision to make with a doctor, weighing what the contraception is for against how much the melasma is affecting you. It is not a reason to stop something abruptly.

Two other triggers worth knowing: some medicines, including newer targeted cancer therapies, and perfumed soaps, toiletries and cosmetics, which can cause a phototoxic reaction that triggers melasma. If you use scented products on your face and have melasma, that is worth changing before escalating treatment.

What actually treats it?

A combination, because no single measure does enough on its own.

General measures come first and are not optional: the sun protection described above, considering hormonal contraception, and cosmetic camouflage where wanted.

Topical therapy. The most successful formulation has been a combination of hydroquinone, tretinoin and a moderate-potency topical steroid, reported to clear or improve melasma in 60 to 80% of cases. That is a prescribed combination, used under supervision, not something to assemble yourself, and topical steroids on facial skin need a clinician deciding potency and duration.

Other topical agents, used alone or more commonly in combination, include azelaic acid, kojic acid, thiamidol, cysteamine, ascorbic acid, tranexamic acid, methimazole, glutathione and soybean extract.

Two cautions specific to this area. Skin-lightening products sold informally can contain undeclared ingredients, including unlabelled steroids or mercury, and the consequences of long-term unsupervised use include the pigmentation getting worse. And treatment aimed at pigment can itself provoke pigmentation if it irritates the skin, which is why “stronger and faster” is the wrong instinct here.

Will it come back?

Very likely, and knowing that in advance is part of the treatment.

DermNet is candid: melasma can be frustrating to treat for both patient and practitioner, it is slow to respond, especially if it has been present a long time, and even in those who get a good result, pigmentation may reappear on exposure to summer sun. The chronicity and relapse risk, with the need for lifelong sun protection, should be emphasised to set realistic goals.

Sun protection continues after the cream course. To track response, DermNet describes serial photographs and measures such as the Melasma Area and Severity Index (MASI) or modified MASI. These give the clinician a record to compare over time. DermNet

Do and don’t

Do:

  • Use SPF50+ broad-spectrum sunscreen containing iron oxides, year-round.
  • Wear a broad-brimmed hat and avoid peak sun.
  • Get the diagnosis confirmed, since other pigmentary conditions look similar.
  • Discuss hormonal contraception or HRT with your doctor as a possible factor.
  • Switch to unscented facial products.
  • Expect slow improvement and plan for maintenance.

Don’t:

  • Don’t assume an ordinary clear sunscreen is enough.
  • Don’t buy unregulated skin-lightening creams from informal sellers.
  • Don’t use a potent topical steroid on your face without supervision.
  • Don’t escalate treatment because it is working slowly.
  • Don’t stop hormonal contraception abruptly without advice.

Frequently asked questions

Will it fade after pregnancy? Melasma that appears in pregnancy often improves afterwards, but not always and not entirely, and it can recur with later pregnancies or hormonal contraception. Sun protection during and after makes a difference either way.

Do laser treatments work? They are used, but melasma is notoriously prone to rebound and lasers can worsen pigmentation if wrongly chosen. This is a decision for a dermatologist who has assessed whether your pigment is epidermal, dermal or mixed, not a walk-in purchase.

Compare the ingredient and strength, since the same ingredient comes in different concentrations.

The skin care category is our second largest and lists what is stocked here, and melasma approaches it from the diagnosis. Sun and heat affect medicines as well as skin, which is covered in storing medicine in a Gulf summer.

MedicForce option: our skin listings are organised by active ingredient and strength, which matters for a condition where the same ingredient is sold at several concentrations.