Aging is a gift, but that doesn’t always mean we’re thrilled to see it manifest on our faces. And perhaps one of the most frustrating signs of getting older is dark spots: There are multiple underlying causes that require different treatments, which can make them feel more difficult to properly address.
Unwanted hyperpigmentation can result from exposure to the sun’s harmful ultraviolet rays, for instance. The underlying culprit can also be inflammation caused by injuries to the skin or acne, as well as plain ol’ luck of the draw based on your genetics.
Melasma, a skin condition often characterized by symmetrical, blotchy, brownish-gray dark spots on the face, is another common cause—especially for pregnant women. In fact, up to one-third of general population may develop melasma, and as many as half of all pregnant women will experience it, according to the Cleveland Clinic.
Unfortunately, this condition can be a stubborn one to treat, which is why “most patients are very motivated to just get something that works,” says Efe Kakpovbia, MD, an assistant professor of dermatology at NYU.
Meet the experts: Efe Kakpovbia, MD, is an assistant professor of dermatology at NYU. Gina Charles, MO, is a family physician specializing in skincare. Jessica Dowling, MD, is a New York-based board-certified dermatologist.
But as our understanding of the condition has improved with time, experts have developed a plethora of strategies to tackle the pesky dark spots and help them fade. The range of solutions include medications your doctor can prescribe, cosmetic procedures you can undergo at a dermatologist’s office, and active skincare ingredients you can buy from the store and incorporate into your daily routine.
To help you better understand melasma, and which treatment might make the most sense for you, Women’s Health consulted two dermatologists and a family physician. Here’s what they want you to know.
What is melasma and what causes it?
Melasma is a chronic skin condition that typically appears as dark spots on the face due to an overproduction of melanin, the natural pigment in our skin, hair and eyes, explains Gina Charles, MO, a family physician specializing in skincare. It usually appears in patches on the face, specifically around the upper lip, cheeks, and forehead.
We don’t fully understand what causes melasma, Dr. Kakpovbia says, but there are several factors that tend to trigger the condition or make it worse. Most often, melasma results from hormonal fluctuations women experience during perimenopause, when starting, stopping or changing their birth control, or while pregnant—which is why the condition is often referred to as “the mask of pregnancy,” Dr. Kakpovbia says. (The heightened levels of estrogen stimulate pigment-producing skin cells, research suggests.) Melasma also tends to flare after exposure to the sun or intense heat during summer months, she adds.
The condition also runs in families, according to the National Library of Medicine, meaning your genes can make you more susceptible as well.
It’s important to keep in mind that people of any sex or skin tone can develop melasma, but it’s far more common in women “of childbearing ages” says Jessica Dowling, MD, a New York-based board-certified dermatologist. It also crops up more in “patients with more melanin, more melanocytes, so patients of Black descent, Hispanic descent, Asian descent,” Dr. Kakpovbia says.
And even though melasma creates distinct dark spots that you could possibly spot on your own, it’s still important to visit a dermatologist to be sure that’s actually what you’re dealing with. There are a variety of types of hyperpigmentation, Dr. Kakpovia says, and “it is important to get the right diagnosis before you even start trying all these different treatment algorithms.”
Once you’re at the doctor’s office, they’ll likely use a specialized tool called a Woods Lamp to assess the melanin in your skin, Dr. Charles says. The process is quick and painless, according to the Cleveland Clinic: The lamp emits ultraviolet light in order to illuminate the melanin in your skin, and its used to determine how deeply the pigment sits in your skin. “The Woods Lamp can really help guide you in terms of how aggressive you may want to be with treatment,” Dr. Kakpovbia says, since the deeper the pigment, the trickier the hyperpigmentation is to treat. The tool also helps the dermatologist “set expectations with the patient” regarding how long the treatment process might take, she adds.
Ways to Treat Melasma
Before we dive in to the various treatment options for melasma, it’s important to understand that there isn’t a cure for the condition given the varying underlying factors at play, Dr. Kakpovbia says. Instead, treatments are intended to manage dark spots by slowing or stopping the overproduction of melanin in the skin, but they don’t always address the underlying factors that cause flare ups. And generally speaking, the severity of melasma “tends to fluctuate” even when treatments are involved, Dr. Kakpovbia says. “A lot of melasma patients will have times when it’s better and times when it’s worse.”
It can be disappointing knowing there’s no silver bullet, but there are options that can help. Here is a breakdown of your choices:
Prescription Medications
The gold standard treatment for melasma is a topical prescription medication called hydroquinone, says Dr. Kakpovbia. It’s a skin-lightening agent that’s been used for decades to treat various forms of hyperpigmentation, Women’s Health previously reported. It works by inhibiting the activity of tyrosinase—a special enzyme responsible for controlling the production of melanin. “The thing that I know is most effective, it’s going to be hydroquinone. I’m going to recommend that for most people,” Dr. Kakpovbia adds.
But keep in mind that hydroquinone can cause skin sensitivity, irritation, and even a little redness in some people. These are common side effects that don’t necessarily indicate you’re allergic to the ingredient, she says, but could be a sign that you need to reduce how frequently you use it. Also, the ingredient is so effective that it’s known to sometimes create a “halo effect,” Dr. Kakpovbia says, a ring of unnaturally light skin surrounding a dark spot. To avoid this, hydroquinone needs to be carefully applied within the borders of the dark spot, and not to normally pigmented skin, she adds.
Those are a couple of the reasons why it’s important to use hydroquinone under the supervision of a dermatologist. They can help create a safe treatment cadence that’ll ensure you enjoy the perks of ingredient while avoiding the aforementioned side effects, as well as more severe reactions such as ochronosis—a permanent bluish-black discoloration of the skin that results from long-term use of hydroquinone, Dr. Kakpovbia says. “Everyone does their counseling a little bit differently,” she adds, but usually patients are recommended to use it “for three, maybe four months, take a break for a month or two, and then restart it after that if needed.”
In more severe melasma cases, hydroquinone may be prescribed alongside other medications such as fluocinolone, a steroid, and tretinoin, a potent vitamin-A derived topical retinoid, according to the Mayo Clinic. Similarly to using hydroquinone alone, “these creams are usually used once a day at night for three months at a time,” Dr. Dowling says.
And hydroquinone isn’t your only prescription option, either. A similarly effective “second-line” treatment is taking an oral tranexamic acid pill, Dr. Kakpovbia says. “It actually does work very well, if not maybe better for a lot of people.” But it’s always worth talking to a doctor to determine whether that’s the best option for you, since each treatment comes with its own set of risks. For instance, studies show that people may experience gastrointestinal discomfort such as bloating, nausea, diarrhea and vomiting when taking this medication. And since tranexamic acid was originally developed as a medication to reduce excessive bleeding, it inherently increases the risk of blood clots as well, Women’s Health previously reported.
Over the Counter Topical Treatments
Research shows the United States has a severe shortage of dermatologists, meaning prescription medications aren’t easy to access for everyone. Luckily, adjusting your skincare routine to contain sunscreen and effective skin brightening ingredients is another way to manage melasma. Here are the tweaks you’ll want to prioritize:
- Wear sunscreen daily: This is the single most important thing you can do to manage your dark spots, Dr. Kakpovbia says. “If a patient is coming to see me and they’re not wearing sunscreen and they don’t want to wear it, I say we’re wasting our time,” she says. For the best protection, Dr. Dowling and Dr. Kakpovbia both recommend a tinted mineral sunscreen, which contains active ingredients like zinc oxide or titanium dioxide, as well as iron oxide. The former ingredients reflect and scatter the sun’s invisible ultraviolet rays, while the latter helps protect your skin from the sun’s visible light, which tends to make melasma worse, Dr. Kakpovbia says. You’ll also want to wear sunscreen with a minimum sun protection factor (SPF) of 30 to ensure you get adequate protection, according to the American Academy of Dermatology.
- Try retinol: Retinol, an over-the-counter retinoid, and one of the only skincare ingredients actually proven to work, can fade dark spots by increasing skin cell turnover, the natural process of old skin cells getting replaced by new ones, says Dr. Charles. Retinol is also anti-inflammatory and is thought to help block the activity of tyrosinase. But keep in mind that retinol can make your skin more sensitive to the sun, so you should always be following up with your daily sunscreen.
- Use a dark spot serum: There are no shortage of active ingredients to look out for on the label of your dark spot serum. Some of the heavy hitters include azelaic acid, which lightens dark spots by inhibiting tyrosinase activity and lowering inflammation, Dr. Kakpovbia says; vitamin C, which prevents new dark spots from forming by providing antioxidant protection from the sun’s ultraviolet rays; kojic acid, another active ingredient that inhibits the activity of tyrosinase; and exfoliating acids such as glycolic acid, which slough off dead skin cells and reveal brighter skin underneath. Certain brands also utilize proprietary active ingredients in their serums designed specifically to address hyperpigmentation as well. One example that Dr. Kakpovbia approves of is Melasyl, a molecule found in La Roche-Posay products that’s developed specifically to target dark spots by once again inhibiting tyrosinase, she explains.
Creating a skincare routine tailored to addressing melasma can feel overwhelming. Here are some Women’s Health-approved picks to make the process easier:
Expert-Approved Skincare Products to Manage Melasma
This lightweight sunscreen features niacinamide and zinc oxide to protect your skin from both UVA and UVB rays. It also includes iron oxides to protect your complexion from visible light, which worsens melasma.
To improve the look of dark spots and skin discoloration, using this daily facial serum packed with retinol and vitamin C, active ingredients that speed up skin cell turnover and protect against oxidative stress, respectively. You’ll notice more even-looking skin in just one week of use.
This serum contains Melasyl, an exclusive ingredient formulated to combat discoloration and give your brighter, more radiant skin. To get the best results, apply a few drops of the serum both morning and night. In the a.m., be sure to pair it with your daily sunscreen.
In-Office Procedures
Keep in mind that most experts agree in-office treatments aren’t a first-line treatment for melasma, Dr. Kakpovbia explains. After all, certain treatments, particularly aggressive laser facials, come with the risk of inadvertently making hyperpigmentation worse, she says, especially if the treatment isn’t performed by a qualified professional. “I’ve seen that happen to one or two of my patients and it just feels awful,” she adds.
As such, Dr. Kakpovbia generally recommends patients only consider in-office treatment in cases where hyperpigmentation is concentrated in deeper layers of the skin that are impossible to target with topical treatments. And in those cases, she generally only recommends laser treatments utilizing a Q-switched or Pico laser: They emit ultra-rapid pulses of light that shatter pigment deposits in the skin. Pico lasers are particularly beneficial, she adds, because they generate less heat and carry a lower risk of damaging surrounding tissue or causing post-inflammatory dark spots.
Professional chemical peels, particularly ones containing alpha hydroxy acids, are another option, Dr. Kakpovbia says. “They help exfoliate the skin and really just lift off that pigment,” she explains. “Underneath that is usually brighter, more even pigment and skin tone.” The safest, most effective chemical peels usually contain glycolic acid, lactic acid or mandelic acid, she says. Just keep in mind that chemical peels need to be performed by a qualified skincare professional, such as a board-certified dermatologist, a plastic surgeon, a licensed medical esthetician, or a physician assistant. And be sure to talk to your dermatologist about the appropriate depth and strength of the peel to address your dark spots: Using one that’s too strong can lead to severe side effects such as scarring, Dr. Kakpovbia adds.
The bottom line: You have options.
Melasma may be chronic, but it's far from unmanageable: The key is assessing your choices, determining the best one for you, and playing the long game. And remember—what triggers dark spots and makes them look better can vary from person to person. So be patient with your skin, consider building a treatment plan with a dermatologist, and never forget your SPF. “Before you reach for all those products at Sephora,” Dr. Kakpovbia says, “you have to be consistent with your sunscreen.”
Katie Mogg is the beauty editorial assistant at Women’s Health. Since starting college at Northeastern University in 2020, her bylines have appeared in The New York Times, The Wall Street Journal, NBC News and The Boston Globe. She strives to help readers lead happier and healthier lives through science-backed stories that explain how to care for hair, skin and nails. When she’s not working, Katie enjoys live music, strolling through Central Park, planning her next beach getaway, and sharing hotpot with friends.
Sabrina Talbert is the beauty editorial assistant at Women’s Health. With over five years of experience, her bylines have appeared in Byrdie, Nylon, Daily Front Row, and more. She’s passionate about covering topics related to haircare, skincare, and the latest happenings at the intersection of beauty and sports. When she’s not working, you can catch her training for her next race (NYC Marathon loading!) and binge-watching F1 or combat sports.
