Melasma: Why Does It Keep Coming Back? An Evidence-Based Guide to Treatment
By Dr. Ichkal Bhudisaksang
What Is Melasma?
Melasma is a chronic pigmentary disorder characterized by symmetrical brown or gray-brown patches, most commonly affecting the cheeks, forehead, upper lip, nose, and chin.
Although melasma is harmless, it can have a significant psychological impact and is often one of the most challenging pigmentation disorders to treat because of its tendency to recur.
What Causes Melasma?
Melasma develops through the interaction of multiple factors rather than a single cause.
Current evidence suggests that important contributors include:
- Chronic ultraviolet (UV) exposure
- Visible light, especially blue light
- Hormonal influences (pregnancy, oral contraceptives, hormone therapy)
- Genetic predisposition
- Chronic skin inflammation
- Increased melanocyte activity
- Vascular changes within the skin
Melasma should therefore be viewed as a chronic skin condition requiring long-term management rather than a condition that can be permanently cured.
Who Is at Risk?
Melasma is more common in:
- Women
- Individuals with darker skin phototypes
- People with a family history of melasma
- Pregnant women
- Individuals with frequent sun exposure
Why Does Melasma Keep Coming Back?
One of the biggest frustrations for patients is recurrence.
Even after successful treatment, pigment-producing cells remain biologically active and can be reactivated by UV radiation, visible light, hormones, or inflammation.
This explains why maintenance therapy is often necessary.
How Is Melasma Diagnosed?
Diagnosis is usually made through clinical examination.
In selected patients, additional assessment with dermoscopy or Wood’s lamp examination may help evaluate pigment distribution, although these tools do not always predict treatment response.
Evidence-Based Treatment Options
Successful treatment usually combines multiple approaches.
Sun Protection
Daily use of a broad-spectrum sunscreen is the foundation of melasma management.
Sunscreens containing iron oxides may also provide protection against visible light.
Topical Medications
Evidence supports the use of:
- Hydroquinone
- Triple combination cream
- Azelaic acid
- Retinoids
- Tranexamic acid (topical formulations)
Treatment should always be individualized according to skin type and tolerance.
Oral Therapy
Oral tranexamic acid has shown promising results in selected patients with moderate-to-severe melasma.
However, it should only be prescribed after appropriate medical evaluation because it is not suitable for everyone.
Laser and Energy-Based Devices
Laser treatment can improve melasma in carefully selected patients but should never be considered a standalone treatment.
Inappropriate laser settings may worsen pigmentation.
Current evidence supports combining laser therapy with medical treatment and strict photoprotection for optimal outcomes.
Common Mistakes
Many patients unintentionally worsen melasma by:
- Using whitening creams without medical supervision
- Stopping sunscreen after improvement
- Overusing exfoliating products
- Seeking aggressive laser treatments without controlling underlying disease activity
Melasma management requires patience and consistency rather than quick fixes.
Dr. Ichkal’s Perspective
Melasma is one of the most misunderstood pigmentary disorders.
Patients often ask, “Can you remove it permanently?”
The more accurate question is, “How can we control it long term?”
Based on current evidence, successful melasma management relies on a combination of accurate diagnosis, individualized treatment, sun protection, and long-term maintenance—not a single cream or one laser session.
My goal is to help patients achieve healthier, more even-toned skin while minimizing recurrence through evidence-based, personalized care.
Key Takeaways
- Melasma is a chronic skin condition, not simply a cosmetic concern.
- Sun protection is the most important part of treatment.
- Combination therapy consistently produces better outcomes than single treatments.
- Maintenance therapy is often necessary to reduce recurrence.
- Evidence-based, individualized treatment provides the best long-term results.