What melasma is and why Indian patients are at higher risk
Melasma is a chronic acquired disorder of pigmentation characterised by symmetric, irregular patches of hyperpigmentation on sun-exposed areas — most commonly the cheeks, upper lip, forehead, and nose. It affects predominantly women (90% of cases), though men are not exempt.
The condition results from the overactivation of melanocytes — the pigment-producing cells in the epidermis — in response to ultraviolet radiation and hormonal signals. Indian skin types (Fitzpatrick types IV and V) contain more active melanocytes and are inherently predisposed to hyperpigmentation responses. The combination of high UV exposure, hormonal triggers, and skin type makes melasma significantly more prevalent in India than in Western populations.
The triggers and aggravating factors
Several factors reliably trigger or worsen melasma:
UV radiation. The most powerful and consistent trigger. Even brief unprotected UV exposure activates melanocytes in affected skin, producing visible darkening. Patients who manage melasma without consistent, broad-spectrum photoprotection will see their condition relapse regardless of what topical treatment they use.
Hormonal factors. Oestrogen and progesterone stimulate melanocyte activity. Melasma is strongly associated with oral contraceptive pills (particularly older formulations), pregnancy (chloasma or the "mask of pregnancy"), and hormone replacement therapy. The relationship with hormones explains why the condition predominantly affects women of reproductive age and why some patients improve after discontinuing hormonal contraception.
Heat. Visible light and infrared radiation from heat sources — sun, cooking, indoor lighting — can trigger melanocyte activation independently of UV. This is clinically relevant in India, where patients may protect against UV but continue to have heat-related aggravation.
The clinical evaluation
Before recommending treatment, a doctor assessing melasma evaluates:
Type by depth. Wood's lamp examination can distinguish epidermal melasma (excess melanin in the epidermis, relatively superficial) from dermal melasma (melanin in the dermis, deeper, more resistant to treatment) or mixed type. Epidermal melasma responds better to topical treatments. Dermal melasma is more difficult to treat and prone to recurrence.
Pattern. Three classic patterns — centrofacial (cheeks, forehead, nose, upper lip, chin), malar (cheeks and nose), and mandibular — correlate with different hormonal trigger profiles and may guide management.
Medication history. Oral contraceptives and other hormonal medications are relevant. Switching to lower-oestrogen or progestogen-only formulations sometimes reduces melasma burden.
Other conditions. Differentiation from post-inflammatory hyperpigmentation (PIH), periorbital hyperpigmentation, drug-induced pigmentation, and other causes of facial darkening is necessary before treatment.
The treatment framework
Effective melasma management combines three elements: photoprotection, topical agents, and where appropriate, procedural options. All three are required; any two without the third gives incomplete results.
Photoprotection. The foundation of all melasma management. Broad-spectrum sunscreen (SPF 50+ with UVA-PF appropriate for the claimed SPF) applied consistently every morning, and reapplied every two to three hours during sun exposure. For patients in India's climate, mineral-based sunscreens (zinc oxide, titanium dioxide) provide some protection against visible light in addition to UV. No topical agent will produce sustained results if photoprotection is inadequate.
Topical depigmenting agents. The agents with the strongest evidence:
- Hydroquinone: the most studied and effective depigmenting agent; inhibits tyrosinase (the key enzyme in melanin synthesis). Available in 2% and 4% formulations. Long-term use requires monitoring for ochronosis (a paradoxical pigmentation that is rare but irreversible).
- Azelaic acid: inhibits tyrosinase and normalises keratinisation; well tolerated, appropriate for use in pregnancy.
- Tranexamic acid: available topically and, in resistant cases, orally under medical supervision. Inhibits the UV-triggered activation of melanocytes. The oral form (used off-label) has shown significant improvement in several randomised trials.
- Topical retinoids: tretinoin and adapalene accelerate epidermal turnover, reducing melanin in the epidermis. Used in combination regimens.
Combination formulations. The most evidence-supported topical regimen for melasma is the triple combination: hydroquinone + tretinoin + a mild topical corticosteroid (to reduce irritation). This combination has been shown in randomised trials to produce faster and more complete depigmentation than any single agent.
Procedural options. Chemical peels (glycolic acid, salicylic acid, TCA) and laser treatments may be used in resistant cases under specialist supervision. In Indian skin types, the risk of post-inflammatory hyperpigmentation from procedures is higher than in lighter skin types. Procedural options require careful patient selection and are typically third-line after topical management.
Managing expectations
Melasma is chronic. With optimal management, significant lightening can be achieved — but complete clearance is not guaranteed, particularly for dermal and mixed types. Recurrence is common with sun exposure, hormonal changes, or seasonal variation. Long-term maintenance therapy and consistent photoprotection are part of the ongoing management, not a sign of treatment failure.