Melasma is driven by sun and hormones on ageing skin — and no cream fully clears it

Melasma is the symmetrical brown or grey-brown patchiness that appears on the cheeks, forehead, upper lip and jaw, usually in women and usually in midlife. It is an acquired pigmentary disorder in which confluent grey-brown patches appear on the face, and the blunt truth from the evidence is that available treatments are unsatisfactory [s1]. That is not a counsel of despair — several things genuinely lighten it — but it sets the honest expectation: this is a condition you fade and manage, not one you erase.

What causes it

Melasma is not simply "too much pigment". A 2026 review reframes it as a disorder of persistent melanocyte activation sustained within a photoaged dermal microenvironment [s2]. The idea is that sun-damaged deeper skin — senescent fibroblasts, UV-activated oil-producing cells and blood vessels — acts as a "dermal melanogenic field" that keeps signalling the pigment cells to switch on [s2]. The review proposes that melasma arises in a "melanogenic window," when a photoaged dermis meets melanocytes that still respond to stimulation, which would explain its characteristic midlife onset, its chronic relapsing course, and why it eases again in later life [s2].

Three drivers sit behind that: ultraviolet and visible light, hormonal shifts (pregnancy and the combined pill are classic triggers), and genetic susceptibility, all landing on skin that has accumulated sun damage. The practical consequence is that light exposure is not a background factor but part of the engine, which is why every serious treatment plan starts and ends with sun protection.

What actually helps

The reference point is the Cochrane review of melasma treatments, which included 20 randomised studies with 2125 participants across 23 different treatments [s1]. It could not statistically pool most results because each study tested a different combination — itself a sign of how unsettled the field is [s1].

The strongest single finding is for triple-combination cream, which pairs a bleaching agent (hydroquinone) with a retinoid (tretinoin) and a mild steroid (fluocinolone acetonide). It was significantly more effective at lightening melasma than hydroquinone alone, with a risk ratio of 1.58 (95% confidence interval 1.26 to 1.97), and it beat the two-drug combination of tretinoin and hydroquinone, risk ratio 2.75 (1.59 to 4.74) [s1]. Azelaic acid 20% outperformed 2% hydroquinone, risk ratio 1.25 (1.06 to 1.48), though it did not clearly beat the stronger 4% hydroquinone, 1.11 (0.94 to 1.32) [s1]. Tretinoin alone reduced severity on objective measures, with participants in one study rating their melasma as significantly improved, risk ratio 13 (1.88 to 89.74) — a huge point estimate wrapped in a very wide interval [s1]. The commonest side effects across treatments were mild and transient: irritation, itching, burning and stinging [s1].

Since that review, tranexamic acid has become the notable addition. A 2026 review of tranexamic acid for pigment disorders reports that oral, topical and intradermal forms significantly reduce pigmentation scores and improve quality of life, with oral doses of 250–500 mg twice daily giving sustained improvement and mostly mild adverse effects — chiefly gastrointestinal symptoms and menstrual irregularity [s3]. Topical and intradermal tranexamic acid performed comparably or better than hydroquinone with fewer irritant reactions, and combining it with hydroquinone or laser produced longer-lasting results [s3]. A 2025 meta-analysis of trials measured by the Melasma Area and Severity Index found that oral treatment, topical treatment and chemical peels all lowered both severity and quality-of-life scores, while cautioning about high heterogeneity across studies [s4].

The honest plan, and the caution on quality

The evidence supports a layered approach: rigorous daily sun protection against UV and visible light, a first-line lightening agent — triple-combination cream or azelaic acid — and tranexamic acid as an add-on for stubborn cases, with peels or lasers handled cautiously by a clinician because they can worsen pigment if mishandled, especially on darker skin. Relapse when treatment or sun protection lapses is the norm, not a treatment failure.

The caveat that should temper all of it is the one the Cochrane authors stated plainly: the quality of studies was generally poor and available treatments inadequate, and high-quality trials with long-term outcomes are still needed [s1]. Melasma is benign — it carries no health risk beyond its appearance — but it is genuinely hard to shift, and any product promising to "cure" it is overselling. See a dermatologist if the pigment is spreading, if it appeared without an obvious trigger, or before starting hydroquinone or tranexamic acid, which are prescription decisions in many places.

This article is informational and is not medical advice.

Sources

• [s1] Interventions for melasma — Cochrane Database of Systematic Reviews, 7 July 2010. https://doi.org/10.1002/14651858.CD003583.pub2
• [s2] Melasma: When Dermal Photoageing Precedes Melanocyte Ageing — Experimental Dermatology, 1 September 2026. https://doi.org/10.1111/exd.70364
• [s3] Tranexamic Acid for Hyperpigmentation Disorders: A Literature Review on Efficacy and Safety in Melasma and PIH — Journal of Cosmetic Dermatology, 1 February 2026. https://doi.org/10.1111/jocd.70692
• [s4] Systematic Review and Meta-Analysis of Treatments on Melasma Area Severity Index and Quality of Life — Pharmaceutics, 16 December 2025. https://doi.org/10.3390/pharmaceutics17121619