Melasma in India: Causes, Treatments and Honest Expectations

• Melasma is a chronic, relapsing condition with three main drivers: ultraviolet and visible light, hormones (pregnancy, the pill), and a genetic predisposition common in Indian skin.
• Daily broad-spectrum SPF 50+ sunscreen, ideally tinted with iron oxides to block visible light, is the single most important treatment. Nothing else works for long without it.
• Evidence-based topicals include hydroquinone, tretinoin, azelaic acid, kojic acid, vitamin C and cysteamine. Oral tranexamic acid helps resistant cases under a doctor's supervision.
• Treatment reduces the patches; it cannot and should not lighten your overall skin tone. Improvement is partial, takes three to six months, and needs long-term maintenance.
• Avoid mercury creams, over-the-counter steroid "fairness" creams, DIY acid peels and lemon juice. These often make melasma worse and can cause permanent harm.

Melasma (also called chloasma, or the "pregnancy mask" when it appears in pregnancy) is a chronic condition in which pigment cells called melanocytes make extra melanin in certain areas, leaving visible brown or grey-brown patches with irregular borders. The patches are usually symmetrical across both sides of the face, range from light tan to dark brown, are flat (never raised), and do not itch or hurt. They most often sit on the cheekbones, forehead, upper lip and chin, and sometimes on the forearms, neck or chest.

Melasma is far more common in women than men, and much more common in deeper skin tones (Fitzpatrick types III to VI) than in fair skin. Most Indian skin falls in that higher-risk range, which is why community studies suggest a large share of Indian women develop melasma at some point, especially after pregnancy, hormonal contraception or heavy sun exposure.

Dermatologists describe three patterns based on how deep the pigment sits. Epidermal melasma is pigment in the upper skin layer, looks well-defined and brown, and responds best to creams. Dermal melasma is deeper, looks more grey-blue, and responds poorly to topicals alone. Mixed melasma combines both and is the most common in practice. A simple Wood's lamp (ultraviolet light) check in the clinic helps tell them apart. Modern research shows almost all melasma is mixed to some degree, which is exactly why even the best treatments usually give partial rather than complete clearance.

It helps to know what melasma is not. It is not a sign of liver disease (the old name "liver spots" refers to unrelated lentigines). It is not a fungal infection, not contagious, and not caused by being "unhygienic," by oily skin, by ghee or any food, or by not exfoliating. It is not corrected by fairness creams that promise to lighten your tone.

Most Indian women with melasma have a combination of three driver groups: light, hormones and genetics.

Light is the biggest trigger. Ultraviolet (UVA and UVB) light stimulates melanocytes, and UVA penetrates deeper to drive long-lasting pigment. Visible light, especially blue light from sunshine and screens, is now well established as a melasma trigger in deeper skin types, which is why modern melasma sunscreens contain iron oxides rather than UV filters alone. Heat itself, from cooking over an open flame, hot summers, saunas or hot yoga, can stimulate pigment independently of UV. India's high year-round sun, traditional flame cooking and low sunscreen use multiply every one of these.

Hormones are the second major group. Pregnancy's oestrogen and progesterone surge produces the classic pregnancy mask, usually appearing in the second or third trimester. Combined oral contraceptive pills trigger or worsen melasma in a meaningful share of users; if this affects you, it is worth discussing your options for birth control pills and the mini-pill with your gynaecologist. Menopausal hormone therapy and oestrogen-containing fertility protocols can also trigger it. Thyroid disease is linked to melasma in some studies, and untreated thyroid problems are common in Indian women, so it is reasonable to check.

Genetics and skin type set the baseline. Many women with melasma have a close relative with it. The more reactive melanocytes in deeper skin respond more dramatically to any trigger, so prevalence is naturally higher in Indian skin.

Other contributors include irritating cosmetics, certain medications (some seizure drugs, photosensitising drugs), and possibly chronic stress and poor sleep. Melasma can also overlap with other hormone-driven skin changes such as hormonal acne and the skin and hair changes of PCOS. The practical message: any plan that ignores sun protection will fail, because UV and visible light keep reactivating the pigment.

Melasma is usually diagnosed on sight. The dermatologist looks at the pattern of patches, asks about your history, may examine you under a Wood's lamp, and makes the diagnosis from the characteristic appearance. Expect questions about when the patches started (during pregnancy? after starting the pill?), your daily sun exposure and sunscreen habits, current and recent medications, family history, and whether you are pregnant or breastfeeding, since that changes which treatments are safe.

The doctor will examine all affected areas and usually take baseline photographs (with your permission) to track change over months. Blood tests are not needed for typical cases, but thyroid function or a hormone profile may be checked in atypical presentations, and a skin biopsy is rarely needed if the diagnosis is unclear.

A first private consultation in metro cities typically costs around 500 to 2,500 rupees, less in smaller cities, and is free or very low cost at government medical college dermatology departments and AIIMS. Chain skin clinics (Kaya, VLCC, Oliva and others) often advertise free first consultations and then sell treatment packages, so go in informed and do not feel pressured to buy on the first visit.

A good consultation sets honest expectations: melasma is chronic and tends to relapse, treatment usually gives partial rather than complete clearance, strict sun protection is permanent and not optional, visible improvement takes three to six months, and combination treatment beats any single agent. Be cautious of any clinic that promises complete clearance in a few sessions or pushes expensive proprietary creams and laser packages without explaining the evidence.

Sun protection is the most important treatment for melasma and the strongest predictor of success. Without it, nothing else holds; with it, even simple treatments produce real results. This is accepted across every dermatology guideline.

For melasma, good photoprotection means a broad-spectrum sunscreen covering UVA, UVB and ideally visible light, applied every morning, even on cloudy days and indoors near windows, and reapplied every two to three hours outdoors. Use SPF 50 minimum for the face, and use enough: roughly two finger-lengths of sunscreen for the face and neck (the "two-finger rule"). Most Indian women apply far too little, which gives a fraction of the labelled protection.

Standard mineral (zinc oxide, titanium dioxide) and chemical sunscreens block UV but not visible light. Because blue light is a major melasma trigger in Indian skin, tinted sunscreens containing iron oxides are now considered first-line, and randomised trials show they reduce melasma more than non-tinted versions. Widely available Indian and imported tinted options include La Shield SPF 50+ tinted, Re'equil Sheer Zinc tinted SPF 50, Heliocare 360 Color, and Avene Mineral Tinted Compact. Which brand matters far less than applying enough, every single day.

After sun protection, prescription creams are first-line medical treatment.

Hydroquinone is the most-studied depigmenting agent. It blocks tyrosinase, the key enzyme in melanin production. It comes as 2% and 4% (prescription-only in India; brands include Eldoquin Forte, Melalumin, Demelan), applied at night to the patches only, in courses of about 8 to 12 weeks with breaks in between to avoid the rare complication of ochronosis (paradoxical darkening with prolonged use). Hydroquinone is not used in pregnancy or breastfeeding and should be stopped if you are planning a pregnancy. The classic "Kligman" triple combination of hydroquinone, tretinoin and a mild steroid (Triluma, Demelan Combi) works better than hydroquinone alone but is used only under dermatologist supervision because of the steroid.

Tretinoin (a vitamin A derivative) speeds skin turnover and helps other actives penetrate; it causes peeling and sun sensitivity early on, so it is introduced gradually, and it is not used in pregnancy. Azelaic acid 15 to 20% is well-tolerated, also helps acne and post-inflammatory marks, and is one of the few melasma actives considered safe in pregnancy and breastfeeding. Kojic acid and vitamin C serums are gentle tyrosinase-targeting brighteners often layered with other actives; vitamin C is safe in pregnancy and is applied in the morning before sunscreen. Cysteamine is a newer, well-evidenced (but pricier) option used as a short daily contact application. Niacinamide is mild, well-tolerated and pregnancy-safe.

The honest framing: topicals work best in combination, take three to six months to show change, must be paired with strict sun protection, and need maintenance after the initial intensive phase. If you are pregnant or planning to be, check our guide to pregnancy-safe skincare and ingredients to avoid before starting anything new.

When photoprotection and creams are not enough, several add-on options exist, all best used alongside, not instead of, the basics.

Oral tranexamic acid was first used to reduce heavy bleeding and was found to also improve melasma by calming the vascular and melanocyte components. A common regimen is 250 mg twice daily for about three months, with the dermatologist screening for clotting risk first. Because it can rarely cause dangerous clots (deep vein thrombosis, pulmonary embolism), it is avoided in women with a personal or family history of clotting disorders, in smokers, and alongside oestrogen-containing pills. The evidence for it is now strong, with trials showing meaningful improvement.

Chemical peels use controlled acids (glycolic, lactic, mandelic, salicylic, or higher-strength TCA) to exfoliate and renew skin, usually as a course of four to six sessions. Mandelic acid is gentler and well-suited to deeper skin. Peels are useful adjuncts but must be done by experienced practitioners, because aggressive peels in Indian skin carry a real risk of post-inflammatory hyperpigmentation that can worsen the melasma. Never attempt DIY acid peels from online videos.

Microneedling (sometimes with radiofrequency) creates tiny controlled channels that let depigmenting serums penetrate, typically over four to six sessions. Lasers and light devices, including low-fluence Q-switched Nd:YAG "laser toning" and fractional non-ablative lasers, are reserved for resistant cases. Intense pulsed light can paradoxically worsen melasma in darker skin. Every laser carries a risk of post-inflammatory hyperpigmentation and should only be done by a dermatologist experienced in skin types IV to VI; devices run by untrained operators are a recipe for harm. Procedures help most as adjuncts, not standalone cures, and results vary widely.

Melasma that develops in pregnancy, the "pregnancy mask," is one of the most common skin changes of pregnancy. It usually appears in the second or third trimester and often fades in the months after delivery, though some pigment can persist or return with later pregnancies.

Treatment in pregnancy is deliberately limited because hydroquinone, tretinoin and oral tranexamic acid are all avoided. The pregnancy-safe approach focuses on prevention: daily broad-spectrum SPF 50+ tinted sunscreen (the single most important step), physical sun protection, gentle skincare, and the few actives considered safe, namely azelaic acid, vitamin C and niacinamide. After delivery, and once breastfeeding allows, the full range of treatments can resume; azelaic acid and vitamin C stay safe throughout. Pregnancy melasma sits alongside other temporary changes like pregnancy acne, stretch marks and postpartum hair loss, most of which settle with time.

Hormonal contraception is a well-recognised trigger. If you have melasma and take combined (oestrogen-containing) pills, discuss with your gynaecologist whether a progestin-only pill or a non-hormonal method such as the copper IUD or a hormonal IUD might suit you better, balancing your contraceptive needs against the melasma. Menopausal hormone therapy can similarly trigger or worsen it, and is worth raising if it concerns you.

The framing that matters: melasma is more common in deeper skin because more reactive melanocytes respond strongly to triggers. That is biology, not a flaw. Treating the patches when they bother you is reasonable medicine. The patches can be managed; your underlying skin tone was never a problem to fix.

Costs vary widely depending on whether you use the public system, a private dermatologist with pharmacy products, or a chain-clinic package.

Public dermatology at government medical colleges and AIIMS offers free or very-low-cost consultations and basic treatment, often with topicals like hydroquinone, tretinoin and azelaic acid available cheaply at the hospital pharmacy. Wait times can be long and procedures limited, but for the medical management of melasma the public system is excellent and underused.

Private consultations typically run 500 to 2,000 rupees for a first visit (more with senior consultants in metros), with follow-ups cheaper. Chain skin clinics often give free first consultations and then sell packages, which can be predictable in cost but may push procedures you do not need; go in with realistic expectations.

The Indian market is full of melasma "treatments" that are useless or actively harmful.

Mercury-containing fairness creams (often imported, sold informally and online) cause rapid visible lightening but lead to mercury toxicity, including kidney and neurological damage. They are illegal in India. Never use any cream that lightens unusually fast.

Over-the-counter steroid creams such as clobetasol and betamethasone (sold for "fairness" under brand names like Betnovate, Quadriderm, Panderm) thin the skin to fake a lightening effect, then cause skin thinning, visible red veins, perioral dermatitis, steroid acne, rebound darkening and worse melasma over time. Indian dermatology bodies have campaigned against their cosmetic sale for good reason.

DIY acid peels from online videos can cause severe burns, scarring and post-inflammatory hyperpigmentation that is worse than the original patches. Lemon juice, baking soda, toothpaste and undiluted turmeric range from useless to harmful (lemon juice is photosensitising and can cause severe reactions in the sun). Aggressive scrubs (apricot, walnut shell) cause micro-tears that trigger more pigment.

Finally, be sceptical of any product or clinic promising complete, permanent clearance in a few weeks, anything with "secret" ingredients, injectable glutathione "skin lightening" at non-medical spas, or any approach that targets your overall skin tone rather than the specific patches. If makeup helps you feel better day to day, apply sunscreen first, then a colour-correcting concealer; it covers temporarily without treating, and without leaving skin unprotected.

The melasma conversation in India is tangled up with the much larger, more harmful pressure on women to be "fairer" than they naturally are. The distinction matters: treating melasma when you want to is medicine; fairness-cream marketing is not. You should be able to seek treatment without absorbing the idea that lighter skin overall is better.

A useful test for any clinic or product: the goal of melasma treatment is to reduce the patches, evening out the difference between affected and unaffected skin. It is not to make your whole face lighter than it naturally is. If something is selling "whole-face whitening" or "glowing fair skin" rather than reduction of pigmented patches, that is fairness marketing, not melasma medicine.

The choice is genuinely yours. If the patches bother you, dermatologist-guided topicals, peels and procedures are reasonable, with safe options at every life stage. If they do not bother you enough to commit to lifelong sun protection and treatment, that is equally valid. Decide based on what you want, not on the assumption that any visible pigment is a defect. The pressure around fairness, often felt most acutely as part of wider conversations about hormones, mood and self-image, is a separate issue that does not need to drive your medical decisions.

Melasma itself is not dangerous, but a dermatologist visit is worth it in several situations. See a doctor if the patches are bothering you and you want a treatment plan, if they are spreading or changing despite good sun protection, or if you started a cream from a pharmacy and developed redness, thinning, visible veins or new breakouts, which can signal a steroid or mercury product.

Get medical advice promptly if a pigmented spot is asymmetrical, has irregular or changing borders, is multi-coloured, is growing, or is a single new dark patch rather than symmetrical facial patches, since these features can suggest something other than melasma and need assessment. Also seek review if the pigmentation appears alongside unexplained tiredness, weight change or other symptoms that might point to a thyroid or hormonal cause worth investigating.

• American Academy of Dermatology — Melasma: Diagnosis and Treatment
• British Association of Dermatologists — Melasma patient information leaflet
• DermNet (NZ) — Melasma
• Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) — Standard guidelines of care for melasma
• Indian Journal of Dermatology — Melasma in Indian skin (review of epidemiology and management)