Melasma

Diagnose melasma when acquired, usually symmetric brown-to-gray macules or patches involve sun-exposed facial sites in a compatible setting. Record distribution and severity at baseline; MASI or modified MASI can standardize longitudinal assessment, while MELASQoL can identify clinically meaningful psychosocial burden that warrants more active management. PubMed+1PubMedMelasma - StatPearls - NCBI BookshelfPubMedA Scoping Review on Melasma Treatments and Their Histopathologic Correlates

Do not obtain routine laboratory studies for a typical presentation. Instead, take a directed history of pregnancy, oral contraceptive use, family history, ultraviolet and visible-light exposure, tanning exposure, facial inflammation, phototoxic medications or products, and prior topical corticosteroid use. Pregnancy, oral contraceptive use, female sex, family history, and light exposure are established associations or triggers. ScienceDirect+2ScienceDirectBest practices in the treatment of melasma with a focus on patients with skin of color - ScienceDirectPubMedMelasma - StatPearls - NCBI BookshelfPubMedMelasma: A Step-by-Step Approach Towards a Multimodal Combination Therapy

Escalate diagnostic evaluation when pigmentation is asymmetric, sharply circumscribed, blue-gray rather than brown, temporally linked to dermatitis or a drug exposure, or accompanied by scale, erythema, scarring, papules, or other signs of active dermatosis. In these cases, reframe the diagnosis toward post-inflammatory hyperpigmentation, phototoxic dermatitis or phytophotodermatitis, drug-induced pigmentation, lichen planus pigmentosus, erythema dyschromicum perstans, pigmented contact dermatitis, discoid lupus erythematosus, ochronosis, Hori nevus, nevus of Ota, argyria, or macular amyloidosis. PubMed+1PubMedMelasma - StatPearls - NCBI BookshelfPubMedMelasma: A Step-by-Step Approach Towards a Multimodal Combination Therapy

Dermoscopy can support the diagnosis and characterize pigment and vascular patterns. Reported epidermal-pattern findings include a brown reticuloglobular network; mixed patterns may show patchy brown reticuloglobular pigmentation with gray areas or granules; dermal-pattern descriptions include brown-gray reticuloglobular pigmentation, gray granules, arcuate or honeycomb structures, and perifollicular pigmentation. PubMedPubMedComparison of Dermoscope and Woods Lamp as A Tool to Study Melanin Depth in Melasma

Wood lamp may accentuate epidermal pigmentation, but do not use epidermal, dermal, or mixed Wood lamp classification to predict prognosis or select therapy. Findings are inconsistent, particularly in darker phototypes, and Wood lamp evaluation is not suitable for Fitzpatrick skin types V and VI in one comparative study. PubMed+1PubMedMelasma - StatPearls - NCBI BookshelfPubMedComparison of Dermoscope and Woods Lamp as A Tool to Study Melanin Depth in Melasma

Consider reflectance confocal microscopy or other advanced imaging only when available and when a noninvasive diagnostic question remains after examination; reflectance confocal microscopy can demonstrate activated melanocytes, melanophages, and solar elastosis. These techniques do not replace selective biopsy for persistent diagnostic uncertainty or concern for another disorder. PubMed+1PubMedMelasma: A Step-by-Step Approach Towards a Multimodal Combination TherapyPubMedMelasma - StatPearls - NCBI Bookshelf

Make broad photoprotection a nonnegotiable component of every regimen. Ultraviolet radiation is a major driver of melasma, and visible light can also stimulate pigmentation; therefore, treatment plans should explicitly address both exposures rather than relying on depigmenting medications alone. ScienceDirectScienceDirectBest practices in the treatment of melasma with a focus on patients with skin of color - ScienceDirect

Review whether pregnancy or hormonal contraception temporally correlates with onset or worsening. These associations do not establish that a hormonal therapy must be stopped, but they justify counseling that persistent exposure may complicate pigment control and should be considered alongside contraceptive and reproductive priorities. PubMed+1PubMedMelasma - StatPearls - NCBI BookshelfPubMedMelasma: A Step-by-Step Approach Towards a Multimodal Combination Therapy

Choose a topical regimen that the patient can tolerate consistently. Hydroquinone, retinoids, azelaic acid, and topical tranexamic acid are recognized topical options, but hydroquinone, retinoic acid, and azelaic acid can cause irritation or contact dermatitis. Reduce irritant burden and support the skin barrier if treatment produces inflammation, because inflammation is itself a contributor to hyperpigmentation. Nature+1NatureMelasma Treatment Strategies in Skin Health | Dermatology | Clinical Sciences | Health sciences | Topics | Nature IndexPubMedThe Application of Skin Care Product in Melasma Treatment - PMC

Set expectations at initiation: melasma is chronic and relapsing, responses vary, and no single modality is uniformly effective. Use serial photographs and MASI or modified MASI rather than premature switching based on day-to-day pigment variation. PubMed+2PubMedMelasma - StatPearls - NCBI BookshelfPubMedA Scoping Review on Melasma Treatments and Their Histopathologic CorrelatesPubMedThe Application of Skin Care Product in Melasma Treatment - PMC

Consider oral tranexamic acid only for severe or refractory melasma as an adjunct to continued photoprotection and topical management. Oral use for melasma is not first-line, and the decision requires individualized assessment of thrombotic risk and counseling that relapse can occur after treatment cessation. JAMA+1JAMAManaging Facial Hyperpigmentation - JAMA NetworkPubMedThe Application of Skin Care Product in Melasma Treatment - PMC

A reported procedural practice uses oral tranexamic acid 325 mg twice daily for 3 months in patients with a history of melasma to prevent rebound or exacerbation around a procedure. This is a procedure-specific approach rather than a universal melasma regimen; use requires the same thrombotic-risk consideration and careful reconciliation of patient-specific contraindications. Wolters Kluwer+1Wolters KluwerOral Tranexamic Acid for Prevention and Treatment... - OvidJAMAManaging Facial Hyperpigmentation - JAMA Network

Chemical peels, laser and light-based therapies, and microneedling are adjunctive options for stable or treatment-resistant disease, not substitutes for photoprotection and maintenance topical therapy. Because melasma is recalcitrant and recurrent and patients with skin of color may experience treatment-related adverse effects, procedural selection should emphasize conservative technique, informed consent, and close assessment for inflammatory pigment worsening. Nature+2NatureMelasma Treatment Strategies in Skin Health | Dermatology | Clinical Sciences | Health sciences | Topics | Nature IndexScienceDirectBest practices in the treatment of melasma with a focus on patients with skin of color - ScienceDirectPubMedThe Application of Skin Care Product in Melasma Treatment - PMC

Reassess the diagnosis before repeated procedures or repeated systemic therapy when pigment becomes more gray, asymmetric, inflammatory, or treatment-resistant. A dermal pigment disorder, medication-associated pigmentation, contact dermatitis, or steroid-related facial dermatitis can produce an apparent treatment failure that will not be corrected by simply increasing pigment-directed treatment intensity. PubMed+2PubMedMelasma - StatPearls - NCBI BookshelfPubMedEvaluation of Dermoscopic Features in Facial Melanosis with Wood Lamp ExaminationPubMedMelasma: A Step-by-Step Approach Towards a Multimodal Combination Therapy

At each follow-up, compare standardized photographs and a consistent MASI or modified MASI score with baseline, then ask specifically about pruritus, burning, erythema, scale, new acneiform or rosacea-like change, and treatment adherence. A worsening inflammatory examination should trigger regimen simplification and reassessment for contact dermatitis or another diagnosis rather than automatic escalation. PubMed+2PubMedA Scoping Review on Melasma Treatments and Their Histopathologic CorrelatesPubMedThe Application of Skin Care Product in Melasma Treatment - PMCPubMedEvaluation of Dermoscopic Features in Facial Melanosis with Wood Lamp Examination

When pigment improves, continue trigger control and maintenance-oriented skin care because recurrence is characteristic and photic exposure remains a continuing stimulus. Topical skin care support may reduce adverse effects and can be incorporated into maintenance strategies. PubMed+1PubMedThe Application of Skin Care Product in Melasma Treatment - PMCScienceDirectBest practices in the treatment of melasma with a focus on patients with skin of color - ScienceDirect

Reassess quality-of-life burden with MELASQoL when clinical severity and patient distress diverge. Visible facial pigment may have substantial psychosocial consequences, and patient-reported burden can appropriately influence the choice to intensify, simplify, or defer treatment. PubMed+1PubMedMelasma - StatPearls - NCBI BookshelfPubMedA Scoping Review on Melasma Treatments and Their Histopathologic Correlates