menopause and melasma

Brown patches across your cheekbones, above your lip, on your forehead. Not freckles. Larger, softer edged, symmetrical, and they got noticeably worse after that week in the sun. Foundation does not really cover them and by the end of a day it has slid off anyway.

Melasma is a genuine dermatological condition rather than a cosmetic complaint, and it is one of the more stubborn ones. Here is what is actually known.

What is melasma?

Melasma produces tan, brown or gray-brown flat patches, usually on the cheeks, forehead, chin, above the upper lip and across the bridge of the nose. It sometimes appears on the arms and neck.

It is about nine times more common in women than men. According to the British Association of Dermatologists, around 50 percent of pregnant women develop it, which is where the old name, the mask of pregnancy, comes from.

The mechanism is that melanocytes, the pigment-producing cells in your skin, make too much melanin. Melanocyte stimulating hormone drives that activity. People with darker skin tones are more likely to develop melasma, because their melanocytes are more active to begin with.

Consultant dermatologist Dr Sajjad Rajpar describes it as "a really complex, chronic, inflammatory, serious skin condition" that "can seriously affect the quality of life of the people who develop the condition and it can impair social comfort because of the appearance of it."

Worth quoting in full, because melasma gets treated as vanity and it is not.

Why would it appear in menopause, when estrogen is falling?

This is the part that confuses people, and it is a fair question.

Melasma is driven by estrogen and progesterone stimulating melanocytes, which is why pregnancy and hormonal contraception trigger it. Menopause is falling estrogen, so on the face of it melasma should improve rather than start.

Several things explain what women actually experience:

Hormone therapy. This is the most common reason melasma appears or worsens around menopause. Menopausal hormone therapy reintroduces the exact stimulation that drives it. If your patches arrived within a few months of starting HRT, that timing is meaningful and worth raising, because the dose or route can sometimes be adjusted.

Melasma you already had, that never fully went. Many women carry faint melasma from pregnancy or the contraceptive pill for years, and it darkens with each summer.

Accumulated sun exposure. Decades of it, on skin that is now thinner and less protected.

Cortisol. Stress raises cortisol, which affects the hormonal environment melanocytes respond to. This is a genuine contributor rather than a throwaway line.

Other established causes include genetics, which is thought to be a major factor, ultraviolet radiation, some cosmetics, and phototoxic or anti-seizure medications.

Sun protection is not one tip among several. It is the whole thing.

Everything else on this page is secondary to this, and it is the reason most melasma treatment fails.

Melasma is exquisitely sensitive to ultraviolet light. You can spend months and a great deal of money lightening it and undo all of it in one unprotected weekend. It also responds to visible light, particularly blue light, which is why some dermatologists recommend tinted sunscreens containing iron oxides, since those block visible light in a way clear mineral sunscreens do not.

So: broad spectrum SPF 30 or higher, every single day, all year, cloudy days included, reapplied. A wide-brimmed hat. Sunglasses. A mineral sunscreen containing titanium dioxide or zinc oxide protects against both UVA and UVB and is less likely to irritate, and a tinted one adds the visible-light protection.

Heat matters too. Melasma can flare from heat alone, which is worth knowing when you are already having hot flashes, and it is why some women find it worse in summer regardless of how careful they are with sunscreen.

What are the medical treatments?

Melasma is chronic and it recurs, and the honest framing is management rather than cure. Real treatments exist, so it is worth seeing a dermatologist rather than working through the internet.

Hydroquinone is the long-standing first-line topical treatment for lightening the pigment.

Triple combination cream, combining hydroquinone with a retinoid and a mild steroid, is more effective than hydroquinone alone for many people.

Tranexamic acid, oral or topical, has become one of the more interesting options in recent years and has reasonable supporting evidence. It is not suitable for everyone, particularly with a history of clotting problems, so it needs a proper prescriber.

Azelaic acid is a gentler option that can be used long term.

Chemical peels and certain lasers are used, and this is where the risk is. The wrong laser on melasma, particularly on darker skin, can make it substantially worse. Go to someone who treats melasma specifically rather than a general aesthetics clinic.

What about topical and supplement options?

Some of these have real support and some are hopeful. Sorting them honestly:

Niacinamide, vitamin B3. Reasonable evidence as a topical for pigmentation, it interferes with pigment transfer to skin cells, and it is well tolerated on sensitive skin. One of the better bets here.

Vitamin C, as L-ascorbic acid. A topical antioxidant that interferes with melanin formation and works well alongside sunscreen. Unstable in light and air, so packaging matters.

Kojic acid, found naturally in mushrooms and soy, reduces pigment production in melanocytes. It commonly irritates, which on inflamed skin can worsen the pigmentation it is meant to treat.

Polypodium leucotomos, a fern extract taken orally, has some evidence for reducing UV-induced skin damage. It supplements sunscreen rather than replacing it.

Glutathione. A randomized controlled trial found oral glutathione reduced melanin compared with placebo over four weeks. One short trial, and the general skin-lightening industry built around glutathione has run far ahead of the evidence, including injectable forms that carry real risk and are not something we would go near.

Green tea extract, astaxanthin and grape seed extract. Antioxidants with plausible mechanisms and limited direct evidence in melasma specifically. Reasonable to take, not reasonable to expect much from on their own.

Two general points. First, an anti-inflammatory way of eating, plenty of vegetables and fruit, healthy fats, oily fish, supports skin generally, and none of it replaces sun protection. Second, be careful with cosmetics on reactive skin and avoid routine use of creams containing steroids, which can worsen things over time. There is more in our piece on supplements to improve skin during menopause.

When should you see a doctor?

Melasma does not cause physical harm, but it can cause real distress, and that is reason enough. A dermatologist can confirm it is melasma rather than something else and discuss prescription options.

Go sooner if a patch is changing in shape, color or size, if it has an irregular border, if it bleeds, itches or crusts, or if one spot behaves differently from the others. Those need looking at rather than assuming.

If it appeared or worsened after starting hormone therapy or a contraceptive, say so, since the timing is directly relevant.

The short version

Melasma is a chronic inflammatory condition, not a cosmetic complaint, and it is nine times more common in women. It is driven by hormonal stimulation of pigment cells, which is why it usually appears around menopause because of hormone therapy or because pre-existing melasma is darkening, rather than because estrogen is falling. Sun protection is not one tip among several, it is the foundation, and one unprotected weekend can undo months of work. Tinted sunscreens with iron oxides also block visible light, which clear ones do not. Real prescription treatments exist including hydroquinone, triple combination cream and tranexamic acid, and the wrong laser can make it worse, so see someone who treats melasma specifically.

Related perimenopause and menopause symptoms

• Menopause and acne
• Menopause and eczema, psoriasis and rosacea
• Menopause and dry, itchy skin
• Menopause and hot flashes

Frequently Asked Questions

What causes melasma in menopause?

Melasma is driven by estrogen and progesterone stimulating pigment-producing cells, so falling estrogen alone does not explain it. Around menopause it usually appears or worsens because of hormone therapy, which reintroduces that stimulation, because pre-existing melasma from pregnancy or the pill is darkening, or from accumulated sun exposure. Raised cortisol from chronic stress also contributes.

Can HRT cause melasma?

It is the most common reason melasma appears or worsens around menopause, because hormone therapy reintroduces the hormonal stimulation that drives pigment production. If patches appeared within a few months of starting it, mention that timing to your prescriber, since the dose or route can sometimes be adjusted.

What is the most important thing for melasma?

Daily sun protection, without exception. Melasma is extremely sensitive to ultraviolet light and one unprotected weekend can undo months of treatment. It also responds to visible light, particularly blue light, so tinted sunscreens containing iron oxides give protection that clear mineral sunscreens do not.

What are the medical treatments for melasma?

Hydroquinone is the long-standing first-line topical treatment. Triple combination cream, adding a retinoid and a mild steroid, is more effective for many people. Tranexamic acid, oral or topical, has reasonable supporting evidence but is unsuitable for people with a history of clotting problems. Azelaic acid is a gentler long-term option.

Can lasers make melasma worse?

Yes. The wrong laser, particularly on darker skin, can worsen melasma significantly. If you are considering laser or chemical peel treatment, go to a practitioner who treats melasma specifically rather than a general aesthetics clinic.

Does melasma go away?

It can fade, and it is chronic and prone to recurring, so the realistic framing is management rather than cure. Consistent daily sun protection is what keeps results once you have them, and stopping it is the most common reason treatment appears to fail.