Melasma is a common, harmless condition with symmetric brown or gray-brown patches on the face, mostly in women with darker skin types. Sun and visible light, pregnancy, hormonal birth control and genetics drive it, and it often comes back.
Key symptoms
- Brown patches on the cheeks, forehead, upper lip or chin
- No itch or pain
- Darker in summer or after time in the sun
- Started with pregnancy or hormonal birth control
What you find on exam
- Symmetric, irregular light to dark brown patches
- Central face, cheek or jawline pattern
- Wood lamp: the epidermal type looks darker, the dermal type does not
- Rule out other causes: pigment after inflammation, drug pigment, lupus
Tests
- Diagnosis is clinical
- Thyroid tests if symptoms suggest thyroid disease
- Biopsy only if a lesion looks atypical
Treatment basics
- Daily tinted broad-spectrum sunscreen with iron oxides, SPF 30 or higher, plus a hat
- Topical hydroquinone 4 percent for a limited time
- Triple combination cream: hydroquinone, tretinoin and fluocinolone
- Azelaic acid as an option, including during pregnancy
- Oral tranexamic acid for resistant cases after checking clot risk
Red flags
- Single dark spot with an irregular border or recent change (rule out melanoma)
- Darker skin with fatigue, low blood pressure or salt craving (Addison disease)
- Facial rash with joint pain or sun sensitivity (lupus)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.