Melasma

Yes, as melasma is more commonly seen in pregnancy (also termed chloasma) & in women. Some cases are initiated by the oral contraceptive pill or HRT.

Melasma is a condition that can be initiated by hormones in genetically susceptible individuals (it’s in your DNA make up) that is always made worse with UV & heat related radiation. You can not control your genetics, removal of hormones in most cases is not practical (withdrawal of estrogen via chemical or surgical methods), hence the only instigating factor is the reduction of sources of radiation (absolute sun protection).

Most cases will recur after a period of remission. The remission period is highly variable, lasting between 4 to 80 weeks. Factors that determine remission include-

• Genetics (the biggest factor)
• Background radiation (equally as important) 
• Background cellular aging
• Age of patient (chronological)
• Hormonal influx

We can increase the remission period in most patients by remodeling the dermal structures of skin. This takes 6 to 18 months to achieve, using appropriate skin care, novel peels & lasers to stimulate collagen production in the deeper layers of skin. More at the very end of this page.

The natural history of melasma is to fade over time, typically after the 7th decade of life.

A simple skincare routine for pigment prones skin is-

AM: Sunscreen, SPF 50+ Tinted.
Midday: Sunscreen Stick SPF 50+
PM: Azelaic acid 20% nightly.
Once a week: AHA pulsed 10-16%. 

*The most overlooked aspect of melasma skincare is the proper use of sunscreen. 95% of patients do not get this right. Concentrate your efforts on adequate photoprotection prior to the consideration of skin care actives. 

Supplements can be considered as adjunctive therapy in melasma patients. They can provide marginal improvements in pigmentation, & can be considered as adjunctive therapy. The two most effective supplements are-

• Polypodium leucotomos extract
• Glutathione tablets 

*Supplements are best combined with medical therapies including pigment inhibitors, vascular modulators, lasers & novel peels. 

Microneedling is a good treatment for pores, scars & textural concerns. In the context of melasma pigmentation there are far better, safer & faster improving treatments. Microneedling works by increasing topical absorption of key ingredients as well as providing mild dermal remodeling. Here are some tips-

• You can DIY as microneedling is an entry level treatment that can be performed at home
• Start with 0.2 to 0.5 (max) mm needles. Stamping is best. 
• Apply a pigment corrector such as ascorbic acid or azelaic acid after microneedling. 
• Start off once a week, increasing to 3 times a week as tolerated. 
• Don’t go too deep or you will push pigment into the deeper layers of skin, making subsequent treatments more difficult.

Fraxel is an awesome laser for non-melasma pigmentation, namely sun damage, freckles, age spots & more. In the context of melasma pigmentation, Fraxel often worsens pigmentation. Pico lasers provide better outcomes with far less risks. In summary-

• Fraxel produces too much heat 
• Heat can potentially flare up melasma
• Fraxel can be considered in the second phase of melasma management, namely to remodel the dermis
• For dermal remodeling in melasma patients, special settings are employed
• 6-8 sessions are required, flare ups are not uncommon

It can, but in 99% of cases (usually when performed by a non-dermatologist), IPL usually flares up melasma. This is because IPL causes too much heating of the skin (as compared to pico lasers). 

IPL is an excellent treatment for other forms of pigmentation, however it is not frequently employed to treat melasma. 

Silfirm X is an FDA approved treatment for melasma. We have used & tried this device, with further studies due in 2025. This device is classified as RF microneedling using non-insulated tips that penetrate between 0.3 to 0.5 mm. The split pulse delivery of Sylfirm reduces heat build up in the skin.  

Sylfirm works by- 

1. Remodeling the BM or basement membrane of the skin, providing resilience. 
2. Remodeling the dermis, reducing skin aging or cellular senescence. 
3. Removing pigment via channels in the skin. 
4. Modulation of cross taking or cytokines in the skin, reducing inflammation & pigment production. 

Though this treatment can be effective, we prefer pico lasers & novel peels as, in our hands, they are more predictable in reducing melasma pigment. 

Tranexamic acid has emerged as a leading treatment for melasma and pigmentation disorders, gaining popularity over the past few years. Here’s why it’s become the top choice for many dermatologists:

Tranexamic acid is known as a depigmenting agent (Indirectly). It disrupts various points in the chemical pathway responsible for pigmentation, making it effective in treating conditions like melasma and post-inflammatory hyperpigmentation. Additionally, it complements other pigment correctors, lasers, and chemical peels.

Forms of Tranexamic Acid: This ingredient is available in three formulations: tablets, serums, and injectables. 

1. Serums:These are the most commonly used form and do not require a prescription.
2. Tablets: Prescribed by dermatologists for systemic treatment.
3. Injectables: Primarily used for research purposes, the short half life of TA means injections every 2-4 days, highly impractical!

Exosomes are trending in 2025 as a do it all treatment for melasma, pigmentation, wrinkles, scars & hair loss. The evidence regarding melasma treatment is dismal at best, with some improvement in pigmentation in the minority of patients. As a guide-

• Exosomes are delivered via microneedling
• 3-6 sessions are required over 6 months
• Medical therapy has far superior outcomes compared to exosomes

*We do stock & use exosomes (primarily for hair loss), if your research has led you towards exosomes, ask our clinicians for this add on. Placebo can work in around 25% of melasma cases. 

Rejuran is a polynucleotide injectable that can improve skin quality & brighten the skin. As a stand alone product for melasma, the results are somewhat unpredictable. Rejuran is better for fine lines, enlarged pores & textural changes such as scars. 

In our practice – 

• Rejuran is always combined with pico lasers (for melasma)
• Rejuran can be considered for stubborn cases of melasma that fail medical therapy. 
• 2-4 sessions are required for optimal results
• Results will vary

Platelet-rich plasma (PRP) has been explored as a treatment option for various skin conditions, including melasma. PRP is derived from the patient’s own blood and is rich in growth factors that can aid in tissue repair and regeneration. Here’s an overview of its effectiveness for melasma:

Mechanism of Action; PRP is believed to work for melasma through several mechanisms:

1. Promoting Skin Regeneration: The growth factors in PRP can stimulate collagen production and skin cell turnover, potentially leading to improved skin texture and reduced pigmentation.
2. Anti-inflammatory Effects: PRP may help reduce inflammation, which is a contributing factor in melasma.
3. Enhancing Skin Healing: By promoting a healthy healing environment, PRP might improve the skin’s overall appearance and reduce hyperpigmentation.

Clinical Evidence

1. Studies and Trials: Some clinical studies have shown promising results in using PRP for melasma. For instance, a study published in the *Journal of Cosmetic Dermatology* reported that PRP injections combined with microneedling significantly improved melasma in participants. Another study found that PRP was effective when used in conjunction with laser treatments.
2. Combination Treatments: PRP is often used in combination with other treatments such as microneedling or laser therapy. These combinations can enhance the effectiveness of both treatments and provide better outcomes than PRP alone.

Pros and Cons

Pros:

• Natural Treatment: PRP is derived from the patient’s own blood, reducing the risk of allergic reactions or adverse effects.
• Minimal Downtime: PRP treatments typically have minimal downtime and side effects.
• Potential Improvement in Skin Quality: Beyond treating melasma, PRP can improve overall skin texture and tone.

Cons:

• Variable Results: The effectiveness of PRP can vary between individuals. Limited Standalone Efficacy: PRP may be more effective when combined with other treatments rather than used alone.

• PRP shows promise as a treatment for melasma, particularly when combined with other therapies like microneedling or laser treatments. However, the results can vary, and more extensive research is needed to fully establish its efficacy. Overall, if you want an effective treatment for melasma, give PRP a pass. 

LED masks have gained popularity as a non-invasive treatment for various skin conditions, including melasma. They work by emitting different wavelengths of light that penetrate the skin and target specific skin issues. Here is an overview of the effectiveness of LED masks in treating melasma:

Mechanism of Action

1. Red Light Therapy: Red light at wavelengths of 630-660 nm penetrates the skin to a depth of about 8-10 mm, which can help in reducing inflammation and promoting collagen production.
2. Blue Light Therapy: Blue light at wavelengths of 405-420 nm targets the surface of the skin, primarily used for its antibacterial properties and treating acne. Blue light however, will also increase pigmentation & worsen melasma. 
3. Near-Infrared Light Therapy: Near-infrared light at wavelengths of 800-900 nm penetrates deeper into the skin and may help in reducing pigmentation and improving skin texture.

Effectiveness for Melasma

Clinical Studies: Some studies have shown that red and near-infrared light therapy can be beneficial for melasma by reducing pigmentation and inflammation. However, these studies are relatively limited and often combined with other treatments like topical agents.

Patient Reports: Anecdotal evidence and patient reports suggest some improvement in melasma symptoms with consistent use of LED masks. However, results can vary widely depending on the severity of melasma and individual skin response.

Pros and Cons

Pros:

Non-invasive:LED masks are a painless, non-invasive treatment option with minimal side effects.

Convenient: They can be used at home, making them a convenient option for ongoing treatment.

Cons

Variable Results:The effectiveness of LED masks for melasma can vary significantly from person to person.

Limited Evidence: There is a lack of extensive clinical trials specifically focusing on the use of LED masks for melasma compared to other established treatments.

Conclusion

While LED masks show promise for treating melasma, particularly through red and near-infrared light therapy, the evidence supporting their effectiveness is still emerging. They can be a complementary treatment to other established therapies such as topical agents, chemical peels, and laser treatments.

Azelaic acid is a well-established treatment option for melasma and has demonstrated considerable effectiveness in reducing pigmentation. Here’s an overview of its efficacy:

Mechanism of Action

1. Inhibition of Tyrosinase: Azelaic acid inhibits tyrosinase, an enzyme critical for melanin production, thereby reducing the synthesis of melanin.
2. Anti-Inflammatory Properties: It possesses anti-inflammatory properties, which help in reducing the inflammatory component of melasma.
3. Keratinocyte Normalization:  Azelaic acid normalizes the growth of keratinocytes (skin cells), which can help in improving skin texture and reducing hyperpigmentation.

Clinical Studies

1. Comparative Efficacy:Studies have compared azelaic acid to other treatments like hydroquinone and found it to be similarly effective. For instance, a study published in the International Journal of Dermatology found that 20% azelaic acid was as effective as 4% hydroquinone in treating melasma with fewer side effects  .
2. Long-Term Benefits: Another study demonstrated that long-term use of azelaic acid led to significant improvement in melasma with minimal irritation, making it a safe option for prolonged use .

Usage and Tolerability

1. Topical Application: Azelaic acid is available in various topical formulations, typically in concentrations of 15-20%. It is applied twice daily to the affected areas.
2. Safety Profile:It is generally well-tolerated, with common side effects being mild and including local irritation or redness. Unlike hydroquinone, azelaic acid does not carry the risk of ochronosis (a form of skin darkening) .

Combination Therapy

1. Enhanced Efficacy: Combining azelaic acid with other treatments like retinoids or chemical peels can enhance its efficacy in melasma treatment. Studies have shown that such combination therapies can provide better results than monotherapy .
2. Sun Protection: As with all melasma treatments, using azelaic acid in conjunction with strict sun protection measures is crucial to prevent further pigmentation.

Conclusion

Azelaic acid is an effective and safe treatment for melasma pigmentation. It works by inhibiting melanin production and providing anti-inflammatory benefits. Its efficacy is comparable to hydroquinone at a very low concentration. Azelaic acid has fewer side effects, making it a suitable option for long-term management of melasma. For optimal results, azelaic acid should be part of a comprehensive skincare regimen that includes sun protection & rotational therapy. We highly recommend this ingredient & rate it a 6/10 for melasma patients. 

Retinol as a stand alone is dismally ineffective for melasma pigment, however it can be used as an adjunct. If you have pigmentation, focus your skin care routine on products that suppress pigmentation or block UV & visible light. 

A more effective retinoid for melasma is tretinoin, which is 50 to 100 times more powerful than retinol. Retinoids are part of the formulation of TriLuma, along with hydroquinone & a corticosteroid. 

TriLuma is a topical medication specifically formulated for the treatment of melasma. It combines three active ingredients: fluocinolone acetonide (a corticosteroid), hydroquinone (a skin-lightening agent), and tretinoin (a retinoid). Here is an overview of its effectiveness:

Mechanism of Action

1. Fluocinolone Acetonide: This corticosteroid helps reduce inflammation and erythema, which are often associated with melasma.
2. Hydroquinone: This ingredient inhibits the enzyme tyrosinase, which is crucial for melanin production, thus reducing hyperpigmentation.
3. Tretinoin: A retinoid that promotes cell turnover, which helps in the removal of pigmented keratinocytes and enhances the penetration of hydroquinone.

Clinical Studies and Effectiveness

Multiple clinical studies have demonstrated the efficacy of TriLuma in treating melasma. One pivotal study published in the *Journal of the American Academy of Dermatology* found that 70% of patients treated with TriLuma experienced complete or near-complete clearing of melasma after 8 weeks of treatment compared to only 47% of those treated with the dual combination of hydroquinone and tretinoin .

Comparison with Other Treatments: TriLuma has been shown to be more effective than treatments using only one or two of its components. This triple combination therapy is considered a gold standard for treating melasma due to its multi-faceted approach targeting different aspects of the pigmentation process.

Usage and Tolerability

1. Application: TriLuma is typically applied once daily at night to the affected areas. It is essential to follow the prescribed regimen and avoid excessive sun exposure.
2. Side Effects: Common side effects include redness, peeling, dryness, and burning sensation. These effects are usually mild and decrease with continued use. However, it is important to use sunscreen and protective clothing to minimize UV exposure and avoid potential exacerbation of side effects.

Long-Term Use and Maintenance

Treatment Duration:TriLuma is generally used for short-term treatment of melasma (up to 8 weeks). Long-term use may increase the risk of side effects associated with corticosteroids and retinoids.

Maintenance: After achieving the desired results, maintenance therapy with milder formulations or other melasma treatments, along with rigorous sun protection, is often recommended to prevent recurrence.

Conclusion

TriLuma is highly effective for the treatment of melasma due to its triple combination of fluocinolone acetonide, hydroquinone, and tretinoin. Clinical studies support its superiority over other treatments, showing significant improvement in melasma symptoms. However, due to potential side effects, it is important to follow the prescribed treatment regimen and ensure proper sun protection. For long-term management, transitioning to maintenance therapies and continued sun protection is crucial to prevent recurrence.

Niacinamide, also known as vitamin B3, has shown promise in the treatment of melasma due to its multiple beneficial effects on the skin. Here’s an overview of its effectiveness based on current research:

1. Reduction of Pigmentation: Niacinamide can inhibit the transfer of melanin (pigment) from melanocytes (pigment-producing cells) to keratinocytes (skin cells), which helps reduce pigmentation and lighten melasma spots  .
2. Anti-Inflammatory Properties:  Melasma often has an inflammatory component, and niacinamide’s anti-inflammatory properties can help reduce this inflammation, potentially improving melasma .
3. Barrier Function Improvement: Niacinamide strengthens the skin barrier, which can help protect against environmental triggers that might exacerbate melasma .
4. Overall Skin Health: Niacinamide enhances the overall health of the skin by increasing ceramide and free fatty acid levels in the skin, preventing water loss, and improving skin texture and elasticity.

Clinical Studies

A study published in the Journal of Cosmetic Dermatology compared 4% niacinamide with 4% hydroquinone (a common melasma treatment) and found that both were effective in reducing melasma, but niacinamide had fewer side effects  .

– Another study found that niacinamide significantly reduced melasma severity after 8 weeks of treatment, supporting its efficacy and safety for melasma management .

Usage

Topical Application:Niacinamide is commonly found in over-the-counter skin care products, including serums, moisturizers, and creams. It is generally well-tolerated and can be used alongside other melasma treatments like sunscreen and retinoids.

Combination Therapy: It can be effectively combined with other treatments such as tranexamic acid, kojic acid, and retinoids for enhanced results.

Our recommendations

Niacinamide is an effective, well-tolerated option for melasma treatment, particularly for those who experience side effects from stronger treatments like hydroquinone. Its multiple benefits on skin health make it a valuable addition to melasma management routines, however in our opinion, it rates a 3 out of 10 for effectiveness. Again, prescriptive pigment correctors are far more effective.

Kojic acid is a popular treatment for melasma due to its ability to inhibit the production of melanin. Here’s an overview of its effectiveness:

Mechanism of Action

Tyrosinase Inhibition: Kojic acid works by inhibiting tyrosinase, an enzyme crucial for melanin synthesis, thus reducing pigmentation.

Antioxidant Properties: It also has antioxidant properties, which help protect the skin from oxidative stress that can exacerbate pigmentation.

Clinical Studies

Effectiveness: Research has shown that kojic acid is effective in reducing melasma pigmentation. A study published in the *Journal of Cosmetic Dermatology* found that a cream containing kojic acid was significantly effective in reducing hyperpigmentation compared to placebo.

Comparative Studies:Kojic acid has been compared to other treatments like hydroquinone. A study in the *Journal of the American Academy of Dermatology* found that a combination of kojic acid and hydroquinone was more effective than hydroquinone alone .

Usage and Tolerability

Topical Application: Kojic acid is typically available in concentrations ranging from 1% to 4% in various creams and serums.

Safety Profile: Kojic acid is generally well-tolerated but can cause mild side effects such as irritation or redness in some individuals. It is important to perform a patch test before regular use .

Combination Therapy

1. Enhanced Results: Combining kojic acid with other treatments like glycolic acid or retinoids can enhance its depigmenting effects. Studies have shown that such combinations can provide better results for melasma than kojic acid alone.

Kojic acid is an effective treatment for melasma pigmentation. It reduces melanin production by inhibiting tyrosinase and has been shown to be effective in clinical studies. When used in combination with other treatments and proper sun protection, kojic acid can significantly improve melasma. However, it is essential to monitor for any skin irritation and perform a patch test before regular application.

Launched by La Roche Posay in Australia, MelaB3 is an over the counter cream that can address most forms of pigmentation, including melasma & post-inflammatory hyperpigmentation. It is readily available from most pharmacies, & is cost effective at around $55 AUD. MelaB3 can be used long term, unlike most prescriptive formulations.

The issue is complex, but here’s the essence:

Dermal melasma typically resists treatment, while mixed melasma can also be challenging. Factors contributing to ‘resistance’ (as opposed to true dermal melasma) include:

Lack of Medical Therapy: Melasma treatment should be guided by a dermatologist and may involve prescription topicals, systemic medications, and customized peeling or laser programs.  

Sun Protection: Effective melasma management hinges on diligent sun protection. Using the right sunscreen, applying it correctly, and reapplying it frequently is crucial. This is often neglected by patients.

Accidental Sun Exposure: Even brief unprotected exposure, such as 10 minutes, can trigger a significant pigment flare-up, undoing a month’s worth of care.

Heat and Infrared Radiation: Exposure to heat and IR radiation, common among cooks and those using saunas or hot yoga, can exacerbate melasma.  

Compliance with Medical Therapy:  Patients need to correctly use prescribed topicals and other therapies, which can be a challenge.

Dermal melasma is often resistant, but it should not be labeled as ‘dermal’ unless the pigmentation depth is confirmed.

There is a potential relationship between melasma & thyroid disease. Research suggests that thyroid dysfunction, particularly hypothyroidism, can be associated with the development of melasma.

Some studies have found a significant association between melasma and hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormones. The exact mechanism is not fully understood, but it is believed that hormonal imbalances, including thyroid hormones, can influence melanogenesis, the process by which melanin is produced in the skin.

Patients with melasma, especially those with persistent or resistant cases, may benefit from thyroid function testing to rule out or confirm thyroid abnormalities. Thyroid hormone replacement therapy in hypothyroid patients may help in managing melasma, though it is not a primary treatment for the skin condition itself.

Melasma itself is not dangerous and does not turn into skin cancer. However, it can be a cosmetic concern and affect a person’s self-esteem. 

Lifestyle changes such as avoiding excessive sun exposure, wearing protective clothing and hats, and avoiding known triggers like hormonal medications can help manage melasma. Stress reduction and a healthy diet may also play a role (as with any other skin condition). 

A diet high in antioxidants can help reduce the oxidative stress on skin cells, including pigment cells implicated in melasma. Dietary changes have more evidence in photoaging as compared to melasma pigmentation. 

Phenol peels can be effective for treating melasma due to their ability to penetrate deeply into the skin and remove layers of pigment. This depth of penetration can result in a dramatic improvement in skin texture and pigmentation issues, including deep dermal melasma. The flipside is that there are significant considerations & potential risks. 

Phenol peels work by causing controlled damage to the skin, which leads to the removal of the outer layers of the skin and the regeneration of new skin cells. This process can significantly reduce the appearance of hyperpigmentation and melasma.

Considerations and Risks

• Phenol peels are very intense and require a longer recovery time compared to other types of chemical peels. The skin may be red, swollen, and peeling for several weeks.
• There is a risk of complications such as scarring, infection, and changes in skin texture. Hypopigmentation (lightening of the skin) is also a common side effect.
• Phenol peels are generally more suitable for fair skin types. Darker skin types have a higher risk of complications such as post-inflammatory hyperpigmentation and scarring.
• Because of the depth and potential risks, phenol peels should only be performed by experienced dermatologists in an operating room as cardiac monitoring is mandatory. 

While phenol peels can treat melasma effectively, they come with significant risks and a lengthy recovery period. They are best suited for individuals with fair skin and should only be performed by highly skilled professionals. In our practice we prefer safer treatment options. 

Treating melasma during pregnancy requires careful consideration due to potential risks to both the mother and the developing fetus. Here are safe and effective ways to manage melasma during pregnancy:

Topical Treatments

Vitamin C: Topical Vitamin C can help lighten pigmentation and is generally considered safe during pregnancy.

Azelaic Acid: This is another safe option for treating melasma in pregnancy. It can help reduce pigmentation without harmful effects.

Niacinamide: Known for its anti-inflammatory properties, niacinamide can help improve skin tone and is safe to use during pregnancy.

Topical tranexamic acid & botanicals such as bearberry extract: may give marginal improvements, however they are safe in pregnancy .

Chemical Peels:Mild chemical peels using glycolic acid can be effective (&safe) in pregnancy, however retinoic acid peels are avoided as they contain high doses of vitamin A. Cosmelan peels are avoided in pregnancy as this formulation will cause significant skin irritation lasting up to 2 weeks. 

Post-Pregnancy Treatment

Prescription Treatments: After delivery and breastfeeding, more aggressive treatments like prescription creams containing hydroquinone, retinoids, and combination therapies may be considered.

Laser Therapy: Post-pregnancy, laser treatments can be effective in treating persistent melasma.

Note: retinoids, hydroquinone, oral tranexamic acid, lasers, & novel peels such as Cosmelan & Dermamelan are not prescribed in pregnancy. 

Melasma is more common in females than males, however up to 3% of men are affected with melasma pigmentation, most commonly in ethnic males (Indian, Sri Lankan, Nepalese). It can also affect fair skin males, especially in those with excessive sun exposure. 

Melasma in men can be more resistant to treatment, primarily because (most) men do not wear makeup or use tinted sunscreen. Tinting contains iron oxide, this key ingredient protects against HEV blue light, an instigating factor for melanin production. 

Melasma in men is treated in the same way as in females. 

Polypodium leucotomos, a tropical fern, has shown promise in treating melasma due to its antioxidant and photoprotective properties. Studies suggest that it can help reduce the appearance of melasma by protecting the skin from UV radiation and potentially inhibiting the pathways that lead to hyperpigmentation.

Mechanisms of Action

1. Antioxidant Properties. Polypodium leucotomos contain antioxidants that can neutralize free radicals and reduce oxidative stress in the skin, which is a contributing factor to melasma.
2. Photoprotection: It helps protect the skin from UV radiation, which can worsen melasma by increasing melanin production.
3. Anti-inflammatory Effects: Polypodium leucotomos has anti-inflammatory properties that can help reduce the inflammation that often accompanies melasma.

Studies and Efficacy

– A study published in the *Journal of Clinical and Aesthetic Dermatology* found that Polypodium leucotomos, when used in conjunction with topical treatments, showed a significant reduction in melasma severity.

– Another study in the *Journal of Drugs in Dermatology* highlighted that Polypodium leucotomos could be beneficial as an adjunctive treatment for melasma, particularly in preventing relapses during sun exposure.

Usage

Oral Supplements: Polypodium leucotomos is often available in oral supplement form. The typical dosage used in studies ranges from 240 mg to 480 mg per day.

Topical Applications.: Some formulations include Polypodium leucotomos in topical treatments including sunscreen.

Considerations

Complementary Treatment: It is generally used as a complementary treatment rather than a standalone solution. It works best when combined with other melasma treatments, such as topical hydroquinone, azelaic acid, or sunscreens.

Summary

Polypodium leucotomos shows potential as an effective adjunct treatment for melasma due to its antioxidant, photoprotective, and anti-inflammatory properties. However, it is most effective when used in combination with other treatments and sun protection measures. 

95% of melasma patients do not get the first step of pigment treatment, namely the correct use of sunscreen. Instead they are hyper focused on the magic ‘ingredient’. Here is news- you are far better off spending time & money on getting your sunscreen application correct before dropping hundreds & thousands of dollars on skin care, peels, & lasers, not to mention fees to see dermatologists. 

The rules of sun protection is super basic-

• Two finger-lengths of sunscreen.
• Tice a day at least, regardless of sun exposure.
• Tinted.

From there, you should aim for the path of medical therapy, not a skin care ingredient. Dermatologists prescribe TA & HQ, before pico & Cosmelan. Forget the fluffy crap like arbutin, licorice extracts & bearberries. It’s a medical condition, not a fairy convention. 

Natural treatments for melasma pigmentation focus on using plant-based ingredients, lifestyle modifications, & non-invasive therapies. These treatments are generally considered safer with fewer side effects compared to chemical-based (medical) therapies. Natural melasma treatments may be suitable for those who prefer fairy dust compared to real medical management.  Here are some natural options:

Topical Treatments

 Aloe Vera:

 Properties:Contains aloin, a compound with dismally ineffective depigmenting effects.

 Application: Apply fresh aloe vera gel to the affected areas daily.

Turmeric:

Properties:** Curcumin in turmeric has anti-inflammatory and antioxidant properties.

Application:** Mix turmeric powder with milk or yogurt to form a paste and apply it to the skin. Better as a food additive than a skin ingredient. 

Licorice Extract:

Properties: Contains glabridin, which inhibits the enzyme tyrosinase, reducing melanin production. Has the highest level of evidence of all natural ingredients. 

Application: Use licorice extract-based creams or serums.

Green Tea Extract:

Properties: Contains polyphenols with antioxidant properties that can help reduce pigmentation.

Application: Apply green tea extract or use products containing green tea.

Vitamin C:

Properties: An antioxidant that can brighten the skin and reduce hyperpigmentation.

Application:** Use serums or creams containing Vitamin C, 10-20%. Along with licorice extract, ascorbic acid has a high level of clinical evidence. 

Niacinamide (Vitamin B3):

Properties: Known to reduce pigmentation and improve skin barrier function.

Application:Topical creams or serums containing niacinamide, 5-10%.

AHA Chemical Peels 

Ingredients: Alpha hydroxy acids (AHAs) like glycolic acid derived from fruits.

Effect: Helps exfoliate the skin and reduce pigmentation. 5 to 70% formulations. Similarly, BHA peels (willowbark) contain salicylic acid, which is more anti-inflammatory. Salicylic acid peels are useful in patients with both acne & melasma. 

Mulberry Extract:

Properties: Contains arbutin, which helps in reducing melanin production.

Application:** Use creams or serums containing mulberry extract, great food for silkworms, next to useless when it comes to treating melasma pigmentation.