Melasma and Hyperpigmentation: What Causes It and What Works
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Melasma is a common acquired pigmentation disorder that causes brown or greyish-brown patches on the skin, most often on the face. It is sometimes called chloasma, particularly when it occurs during pregnancy, where it has historically been referred to as the "mask of pregnancy." The condition is chronic and tends to recur, especially with sun exposure or hormonal changes.
The patches typically appear in a symmetrical pattern. The most common distribution is centrofacial, affecting the forehead, cheeks, nose, upper lip, and chin. Some people develop melasma on the jawline or, less commonly, on the forearms and neck. The patches are flat, not raised, and do not cause pain or itch.
Melasma is classified by depth. Epidermal melasma involves excess pigment in the outer layer of the skin and tends to appear brown with well-defined borders. Dermal melasma sits deeper in the skin and often looks greyish or bluish-brown with less distinct edges. Mixed melasma, the most common type, involves both layers. The depth of pigment matters because it influences how the skin responds to treatment. Epidermal melasma generally responds more readily to topical treatments, while dermal melasma can be more persistent.
According to the Australasian College of Dermatologists, melasma affects an estimated five million Australians, with a strong predominance in women. It can occur in all skin types but is more common in people with Fitzpatrick skin types III to V, which includes many Australians of Mediterranean, Middle Eastern, South Asian, East Asian, and Indigenous background. While melasma can affect men, approximately 90 per cent of cases occur in women, reflecting the significant role that hormonal factors play in its development.
The terms melasma and hyperpigmentation are sometimes used as though they are interchangeable, but they describe different things. Understanding the distinction is useful because it shapes both the approach to treatment and the expectations around outcomes.
Hyperpigmentation is a broad, umbrella term for any condition in which patches of skin become darker than the surrounding area. It occurs when excess melanin, the pigment that gives skin its colour, is deposited in the skin. Hyperpigmentation can result from a wide range of causes, including sun damage, inflammation, injury, hormonal changes, and certain medications.
Common forms of hyperpigmentation include:
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Post-inflammatory hyperpigmentation (PIH): Dark marks left behind after acne, eczema, burns, or other skin injuries. PIH is reactive, meaning it follows a specific trigger, and it often fades over time, though the timeline can stretch to months or years depending on skin type and depth.
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Solar lentigines (sun spots or age spots): Flat, brown spots caused by cumulative UV exposure. They tend to appear on sun-exposed areas such as the face, hands, shoulders, and forearms. Unlike melasma, they do not fluctuate with hormonal changes.
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Freckles (ephelides): Small, flat spots that darken with sun exposure and lighten in winter. They are genetically determined and most common in fair-skinned individuals.
Melasma is a specific type of hyperpigmentation, but it has distinct features. Its strong hormonal component sets it apart. Melasma patches are often larger and more diffuse than sun spots, tend to appear symmetrically on the face, and commonly fluctuate in intensity with hormonal shifts, seasons, and UV exposure. Where PIH follows a known trigger and sun spots accumulate gradually over decades, melasma can appear relatively suddenly and behave unpredictably.
The practical significance of this distinction is important. A brightening serum that fades a post-acne mark may have limited effect on hormonally driven melasma. Treatment plans for melasma need to account for its chronic, relapsing nature in ways that treatment for other pigmentation types may not. A GP can help determine which type of pigmentation is present and recommend an approach tailored to the specific condition.
Melasma is a multifactorial condition. There is no single cause. Instead, several factors interact to trigger and sustain the overproduction of melanin in affected areas of the skin.
Hormonal Influences
Hormones are the most significant driver of melasma, which is why the condition disproportionately affects women. Oestrogen and progesterone stimulate melanocytes, the cells responsible for producing melanin, to increase pigment production. This explains why melasma commonly develops or worsens during:
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Pregnancy. Melasma affects an estimated 15 to 50 per cent of pregnant women, according to DermNet. The hormonal changes of pregnancy, particularly rising oestrogen and progesterone levels, can trigger significant pigmentation changes that may persist after delivery or recur in subsequent pregnancies.
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Oral contraceptive use. Combined hormonal contraceptives containing oestrogen and progesterone are a well-recognised trigger. Healthdirect Australia notes that melasma can develop in women taking the oral contraceptive pill, and the pigmentation may not fully resolve after stopping the medication.
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Hormone replacement therapy (HRT). Women using HRT during perimenopause or menopause may notice new or worsening melasma. The hormonal supplementation can reactivate melanocyte activity in predisposed individuals.
Ultraviolet Radiation
Sun exposure is both a trigger and an aggravating factor. UV radiation stimulates melanocytes to produce more melanin, and in skin that is already predisposed to melasma, even modest sun exposure can darken existing patches or trigger new ones. This is particularly relevant in the Australian context, where UV levels are among the highest in the world. The Cancer Council Australia reports that Australia's UV index regularly exceeds the level at which skin protection is recommended, and for people managing melasma, sun protection is not optional but central to any treatment plan.
Both UVA and UVB radiation contribute to melasma, and there is growing evidence that visible light, particularly high-energy blue light, can also stimulate melanin production in darker skin types. This has implications for daily sun protection choices, as standard sunscreens primarily target UV radiation and may not fully block visible light.
Genetic Predisposition
Family history plays a role. Studies suggest that a significant proportion of people with melasma have a first-degree relative with the condition. DermNet notes that genetic susceptibility influences how melanocytes respond to hormonal and environmental triggers, which partly explains why melasma is more prevalent in certain ethnic groups.
Other Contributing Factors
- Heat. Infrared radiation and ambient heat can worsen melasma independently of UV exposure. This is relevant for people who work near ovens, in kitchens, or in hot outdoor environments.
- Certain medications. Some anti-seizure drugs and photosensitising medications can increase the risk of pigmentation changes.
- Thyroid conditions. There is an association between thyroid dysfunction and melasma, though the relationship is not fully understood. A GP may consider thyroid function as part of a broader assessment.
Melasma treatment is a long-term commitment rather than a quick fix. The goal is to reduce visible pigmentation, prevent darkening, and manage the condition over time. Because melasma is chronic and influenced by ongoing hormonal and environmental factors, treatment usually involves a combination of approaches.
Sun Protection: The Foundation
No melasma treatment will be effective without rigorous sun protection. This is the single most important step, and it applies to every patient, regardless of the other treatments being used. The Australasian College of Dermatologists recommends:
- A broad-spectrum sunscreen with SPF 50+ applied daily, even on cloudy days and during winter, reapplied every two hours during outdoor activity
- Physical sun protection including a broad-brimmed hat, sunglasses, and seeking shade where possible
- For people with darker skin types, tinted sunscreens containing iron oxide may offer additional protection against visible light
Sun protection alone can prevent melasma from worsening and, in some cases, allow mild patches to fade gradually over months.
Topical Prescription Treatments
Prescription topical agents are the first-line medical treatment for melasma. These require a doctor's consultation and prescription.
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Hydroquinone. Hydroquinone is the most extensively studied topical agent for melasma. It works by inhibiting tyrosinase, an enzyme involved in melanin production. In Australia, hydroquinone at concentrations above two per cent requires a prescription. The Therapeutic Goods Administration (TGA) regulates its availability, and treatment is typically prescribed for defined periods to minimise the risk of side effects, including a rare condition called ochronosis with prolonged use. A GP can determine whether hydroquinone is appropriate and monitor its use.
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Tretinoin (topical retinoid). Tretinoin promotes skin cell turnover, helping to disperse pigment and improve the penetration of other topical agents. It is often used in combination with hydroquinone.
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Triple combination therapy. The combination of hydroquinone, tretinoin, and a mild topical corticosteroid is considered the gold standard for topical melasma treatment. Research published in the Journal of the American Academy of Dermatology supports its efficacy, with studies showing significant improvement in pigmentation scores compared with single-agent treatment. The corticosteroid component helps reduce irritation from the other two agents and has a mild depigmenting effect of its own. This combination requires medical supervision.
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Azelaic acid. Available by prescription or in lower-strength over-the-counter formulations, azelaic acid inhibits tyrosinase and has anti-inflammatory properties. It is considered a suitable option during pregnancy under medical guidance, as it has a favourable safety profile compared with hydroquinone and retinoids.
Over-the-Counter and Cosmetic Options
Several ingredients available without prescription may help manage mild hyperpigmentation, though expectations should be realistic. These products tend to work more slowly and less dramatically than prescription treatments.
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Vitamin C (ascorbic acid). An antioxidant that can inhibit melanin production and protect against UV-induced pigmentation. It works best as an adjunct to sunscreen and prescription treatment rather than as a standalone therapy.
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Niacinamide (vitamin B3). May help reduce the transfer of melanin to skin cells and has anti-inflammatory properties. It is well tolerated and commonly found in Australian skincare products.
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Alpha hydroxy acids (AHAs). Glycolic acid and lactic acid exfoliate the outer layer of the skin, which can help improve the appearance of superficial pigmentation over time.
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Tranexamic acid (topical). An emerging treatment that is gaining clinical interest. Originally used as an oral medication to manage heavy bleeding, topical and oral tranexamic acid have shown promise in reducing melasma pigmentation in several clinical studies. Oral tranexamic acid for melasma is considered off-label in Australia and should only be used under medical supervision.
Procedural Treatments
For melasma that does not respond adequately to topical treatment, procedural options may be considered, usually through a dermatologist:
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Chemical peels. Superficial peels using glycolic acid or other agents can help improve epidermal pigmentation. Deep peels carry a risk of post-inflammatory hyperpigmentation, particularly in darker skin types, and should be approached with caution.
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Laser and light therapies. Some laser treatments, particularly low-fluence Q-switched lasers, have been used for melasma. However, the evidence is mixed, and there is a real risk of worsening pigmentation or triggering rebound. The Australasian College of Dermatologists advises caution with laser treatment for melasma, and it is generally considered a second or third-line option.
The key message is that melasma treatment is not one-size-fits-all. What works for one person may not work for another, and the best approach is usually a combination of strategies tailored to the individual's skin type, melasma depth, triggers, and lifestyle.
Managing expectations is an important part of melasma care. The condition is chronic and tends to recur, and treatment timelines are measured in months rather than weeks.
Realistic timeframes. Most topical treatments require a minimum of eight to twelve weeks of consistent use before visible improvement becomes apparent. Some patients see gradual lightening that continues over six to twelve months. The pace of improvement depends on the depth of pigmentation, adherence to the treatment regimen, and the effectiveness of sun protection.
Maintenance is ongoing. Even when melasma has faded significantly, maintenance treatment is usually necessary. This might involve continued use of sunscreen, periodic use of a topical treatment, and avoidance of known triggers. Without maintenance, melasma commonly returns, particularly during the Australian summer months when UV exposure is highest.
Flare-ups happen. Hormonal changes, sun exposure, stress, and heat can all trigger a flare even in well-managed melasma. This does not mean the treatment has failed. It means the condition is behaving as expected, and the management plan may need temporary adjustment.
Combination treatment works best. The evidence supports using multiple strategies together. Sun protection combined with prescription topicals, and potentially an over-the-counter adjunct, tends to produce better results than any single approach used in isolation.
Individual variation is significant. Two people with similar-looking melasma may respond very differently to the same treatment. Skin type, hormonal status, depth of pigment, and genetic factors all influence the outcome. A GP can help set realistic expectations based on the individual presentation and adjust the plan over time.
Side effects are manageable. Topical treatments can cause initial dryness, redness, or mild irritation, particularly retinoids and hydroquinone. These side effects are usually temporary and can be managed by adjusting the frequency of application or using a moisturiser. A GP can provide guidance on how to introduce treatments gradually to minimise discomfort.
Want clearer skin?
Melasma and hyperpigmentation are well suited to online GP consultations. The condition is diagnosed primarily through visual assessment and clinical history, both of which can be conducted effectively through video. A GP can examine the skin via high-quality video, review photographs the patient has taken in natural light, discuss the history of the pigmentation, assess potential triggers such as hormonal contraceptive use or sun exposure patterns, and prescribe appropriate treatment.
For many Australians, an online consultation removes barriers that might otherwise delay care. For people in regional and rural areas, where specialist dermatology services may involve long wait lists and significant travel, an initial GP assessment online can provide timely guidance and a treatment plan. For women managing melasma alongside work, parenting, or other commitments, the flexibility of an online appointment means the consultation fits around their schedule rather than the other way around.
An online melasma consultation typically covers:
- Visual assessment of the pigmentation pattern and distribution
- Discussion of when the patches appeared and how they have changed over time
- Review of potential hormonal triggers, including contraception, pregnancy history, and HRT
- Assessment of current skincare routine and sun protection habits
- Prescription of topical treatments if clinically appropriate, with electronic prescriptions sent directly to the patient's preferred pharmacy
- A management plan that includes sun protection recommendations, treatment instructions, and a timeline for review
If specialist referral is needed, the GP can arrange this and provide a referral letter to a dermatologist. For many patients, however, first-line melasma treatment can be effectively initiated and monitored by a GP.
Abby Health is an online-first clinic offering GP consultations seven days a week, 365 days a year, through a care network of over 300 clinicians. Consultations can be bulk billed for eligible patients with a valid Medicare card, and electronic prescriptions can be issued during the consultation and sent directly to the patient's preferred pharmacy.
For a condition like melasma, where treatment is refined over time and progress is measured in months, continuity of care matters. Abby Health's model is built around the idea that patients should be able to see the same GP over time, building a relationship where the clinician understands the patient's skin, their treatment history, and what has worked or not worked in the past. The clinic's 71 per cent rebook rate reflects this: three in four patients choose to return to the same doctor.
Abby AI, the clinic's medical AI decision-support tool, supports each consultation by surfacing relevant patient history, previous prescriptions, and clinical notes so the GP arrives informed. It does not diagnose or prescribe. It ensures the clinician has the full picture, so the conversation can focus on what matters: how the skin is responding, whether the current plan is working, and what to adjust next.
Whether the concern is new pigmentation that has appeared during pregnancy, patches that have worsened over summer, or a desire to understand treatment options for long-standing melasma, a consultation is a practical first step. The GP can assess the presentation, discuss options, and create a plan that fits the patient's skin type, lifestyle, and goals.
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