Pigmentation and Melasma: How to Treat Them Without Making Them Worse

Part of: Melasma & pigmentation

Melasma and dark spots: diagnosis, iron-oxide sunscreen, treatments and oral tranexamic acid risks.

Flagship Guide · 3 min read · August 22, 2026

Written and medically reviewed by Dr. Yousef Abo Zarad · German board-certified dermatologist · Last reviewed: August 2026

The short answer

Not every brown patch is melasma, so the plan starts by working out the type of pigmentation. Next come daily sun protection and a gradual topical treatment, and procedures and lasers are kept for cases creams cannot manage.12

Melasma tends to come back, so the goal is strong improvement with a plan that prevents relapse, not one session that wipes the colour out.1 Results usually take between 3 and 12 months.4

What type of pigmentation is it?

Brown melasma patches on the cheek, circled in red
Melasma patches on the cheek. Melasma often appears on the cheeks, forehead or upper lip, and it is treated differently from freckles or post-acne marks. Image: Elord (WikiDoc) / Wikimedia Commons · CC BY-SA 3.0
  • Melasma: symmetrical patches on the cheeks and forehead that often return and are affected by sun and hormones.1
  • Post-inflammatory hyperpigmentation: appears after a spot, inflammation or irritation, and is treated by dealing with the cause first.2
  • Sun spots and sun-related pigment: well-defined patches that build up with sun exposure over the years.2
  • Pigment around the eyes and in skin folds: each needs its own assessment and treatment.2
  • A new patch with uneven colour, or one that changes: needs a medical examination before any cosmetic treatment.

How to start: sun protection first

  • Broad-spectrum sunscreen: SPF 30 or higher every day; reapply every two hours outdoors and after swimming or sweating.46
  • Tinted sunscreen: iron oxides help protect against visible light, which can worsen melasma, especially in darker skin. An untinted mineral sunscreen does not necessarily provide the same visible-light protection.6
  • Extra protection: a wide-brimmed hat, shade and avoiding prolonged sun exposure. Treating melasma without consistent protection weakens results and raises relapse risk.14

What is the topical treatment?

  • Triple-combination cream: contains hydroquinone, tretinoin and a mild topical corticosteroid for a clinician-defined course. It is an effective melasma option, not an indefinite unsupervised lightening cream; hydroquinone rules vary by country.14
  • Alternatives: azelaic acid, kojic acid and vitamin C.14
  • Tretinoin with a mild steroid: another option.4
  • Irritation: raises the risk of dark marks, especially in darker skin, so several strong products are not added at once.5
  • More detail: in the hydroquinone guide and the azelaic acid guide.

When do procedures and lasers come in?

  • Chemical peels or microneedling: are not automatic first-line treatments; consider them only for selected patients after photoprotection and topical care, because irritation can worsen pigmentation.146
  • Lasers: reserved for resistant cases after good protection and topical treatment,1 and a few studies found better results when added to medicine and sun protection.4
  • The risk: high energy can trigger inflammation and more pigment in skin prone to pigmentation.
  • Who performs them: a dermatologist.4

Is tranexamic acid suitable for melasma?

Oral tranexamic acid may be considered for selected resistant melasma, but melasma is an off-label indication in the United States. A studied expert-consensus regimen is 250 mg twice daily; that is not a patient-specific prescription and must not be started without clinical assessment.37

  • Avoid with active or previous thromboembolic disease, important clotting risk or combined hormonal contraception under the expert consensus.7
  • Before prescribing: review thrombosis, medicines, smoking and risk factors; investigations are individualized, not one mandatory coagulation panel for everyone.37
  • Follow-up: reassess benefit and risk; oral treatment does not replace sunscreen or topicals, and melasma may relapse after stopping.17

Can melasma disappear permanently?

  • Time: between 3 and 12 months with a treatment plan, longer if the melasma is long-standing.4
  • Return: melasma often comes back after improving,1 and can last for years or a lifetime.4
  • Prevention: sun protection helps it fade and helps stop it returning.4
  • Pregnancy: can trigger melasma, which may fade after delivery or after stopping the medicine that caused it.4
  • Realistic goal: strong improvement and as much relapse prevention as possible, not permanent disappearance after one session.

When should you see a doctor?

  • A new patch, or one that changes in colour or shape.
  • Persistent burning, redness or peeling from treatment.
  • No improvement after 3 months of regular protection and treatment.
  • A history of blood clots, or interest in tranexamic acid.4
  • Pregnancy or pregnancy planning during any prescribed treatment.

Medical Evidence

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