Melasma and Dark Spots

What it is

Melasma is a pattern of brown or gray-brown patches on the face. Post-inflammatory hyperpigmentation is the darker mark left behind after the skin has been injured or inflamed, and both happen because something has triggered the skin to make extra melanin [1][3].

Why this guide is written for Black patients

Melasma is most common in women, and women with medium to dark skin tones are most likely to develop it [1]. It often starts during pregnancy or after starting birth control pills, and it commonly returns when someone spends time outdoors without protecting the skin from the sun [1]. It usually appears on the cheeks, forehead, chin and above the upper lip [1].

Dark spots are the other half of the picture and they have many triggers: healing acne, psoriasis, wounds, some medicines, irritating skin care products, and hormonal change including pregnancy [3]. In darker skin, the mark often outlasts the thing that caused it by months, which is why the marks, rather than the spots, are frequently what brings someone in.

What to ask a clinician

• Is this melasma, post-inflammatory hyperpigmentation, or something else?
• What is causing it, and what happens to the discoloration if we treat the cause first?
• Which prescription would you start with in my skin tone, and what is the risk of it lightening the skin around the patch?
• What sunscreen do you want me using, and how much?
• How long before we decide this plan is not working?

What good care looks like

Treatment starts with the cause. To clear hyperpigmentation caused by a skin condition, the skin condition has to be treated effectively first, and if you can remove the cause, many spots clear on their own and new ones stop appearing [3].

Sun protection is not an afterthought, it is the first step. Sunlight causes the skin to make more pigment, which can darken existing melasma and cause new patches [2]. The American Academy of Dermatology recommends a wide-brimmed hat, shade, and broad-spectrum sunscreen of SPF 30 or higher containing zinc oxide, titanium dioxide or iron oxide [2]. For dark spots in darker skin tones it recommends a tinted sunscreen with iron oxide, SPF 30 or higher, broad spectrum [3].

For fading, the useful ingredients named by the AAD are azelaic acid, glycolic acid, kojic acid, retinoids and vitamin C [3]. Prescription options for melasma include hydroquinone, tretinoin with a mild corticosteroid, or a triple combination cream, and procedures such as chemical peels, microneedling, laser and light treatments or platelet-rich plasma may be added [2].

Now the timelines, because this is where most people give up. A spot a few shades darker than your natural skin color will usually fade within 6 to 12 months, and deeper discoloration can take years [3]. When you follow a melasma treatment plan, it usually takes between 3 to 12 months to see results [2]. Non-prescription products should be given no longer than three to six months before you take the problem to a dermatologist [1].

One honest sentence about melasma is worth repeating: creams can help fade the discoloration, but treatment cannot make melasma go away forever [1]. That is not a failure of the plan, it is the nature of the condition, and it is why sun protection continues after the patches lighten.

When it is urgent

Pigment changes are not emergencies, but some things that look like a dark spot are not one. A spot that grows, changes shape or color, bleeds, itches persistently, or a dark streak appearing under a fingernail or toenail needs to be seen soon rather than watched, because those are the places skin cancer hides in darker skin. A new patch that appears with pain, blistering or a rash also needs a same-week appointment rather than a cream.

What to do next

Give a non-prescription product three to six months, with daily sunscreen, and then stop guessing [1].

Book with a dermatologist who treats skin like yours, and take unfiltered photographs in daylight from the beginning so that slow progress is visible to both of you. Start with Black dermatologists, and bring every product currently touching your face, including what a barber or stylist uses.