The patches tend to show up in the same places: across the cheeks, the upper lip, the forehead, sometimes the chin. They're brown or grayish-brown, usually symmetrical, and they tend to darken after a day in the sun or after a month on the wrong birth control. Dermatologists call this melasma. Most people who have it have spent years covering it with foundation and wondering why nothing they try makes it go away for good.
The reason nothing sticks is that melasma isn't just pigmentation. It's a condition where the cells that produce pigment become chronically oversensitive. You can lighten the skin. But unless you address what keeps triggering it, it comes back.
Melasma happens when melanocytes (the skin cells that produce the pigment melanin) become hyperactive and deposit more pigment than normal into the surrounding skin. The patches form in the layers visible on the surface.
Three things reliably trigger this:
Sun exposure. UV light activates melanocytes directly. Even brief sun exposure without protection can worsen melasma dramatically. Infrared heat (the warmth from the sun, even through a window) can also trigger it, which is why physical sun avoidance matters, not just SPF.
Hormones. Estrogen and progesterone increase melanocyte sensitivity. This is why melasma is sometimes called the "mask of pregnancy": it appears or worsens during pregnancy, often fading postpartum. But it also appears in women on combined oral contraceptives, hormonal IUDs, and hormone replacement therapy. Men can develop it too, but it's far less common because the hormonal driver is weaker.
Inflammation and heat. Skin injury, harsh products, and repeated heat exposure can trigger post-inflammatory hyperpigmentation that overlaps with melasma or worsens it.
Most people with melasma have a combination of all three factors operating at once.
The challenge is that the melanocytes involved in melasma don't go back to normal. They stay sensitized. Bleach them back to baseline, then go outside without protection, and they respond aggressively again. This is why patients who do a round of treatment without adjusting sun habits see their melasma return within weeks.
Effective treatment is always dual: lightening the existing pigment while consistently preventing new pigment from forming. Drop either half of that equation and the results won't last.
No topical treatment for melasma is worthwhile without rigorous sun protection, and "rigorous" means more than applying SPF 30 once in the morning. Dermatologists typically recommend:
For some patients, this step alone produces visible improvement because the daily UV trigger is removed.
Hydroquinone is the most studied topical agent for melasma. It works by inhibiting tyrosinase, the enzyme that drives melanin production. At 4% concentration (the standard prescription strength), it reliably lightens melasma over eight to twelve weeks.
A common concern is the idea that hydroquinone causes a permanent darkening called ochronosis. This is real but rare, almost always associated with very long-term use (years, not months) without medical supervision, and more commonly reported with higher concentrations available over the counter in some countries. Used correctly with provider oversight and appropriate breaks in treatment, it's both safe and effective.
Hydroquinone works better when combined with other agents. The original "triple cream" formulation developed by Dr. Albert Kligman combined hydroquinone with tretinoin and a mild corticosteroid. Decades of use in dermatology have validated this combination as one of the most reliable approaches to melasma.
Tretinoin (a retinoid derived from vitamin A) accelerates cellular turnover, meaning the top layers of skin shed more quickly and carry pigmented cells away faster. On its own, it has modest effects on melasma. Paired with hydroquinone, it makes the hydroquinone work faster and more deeply.
It also has independent benefits: tretinoin treats fine lines, refines texture, and improves overall skin clarity, which means patients treating melasma often see broader improvements across the whole face.
The main side effect is initial irritation (redness, dryness, peeling) that usually resolves within four to six weeks as the skin adapts. Starting with a lower concentration and applying every other night can minimize this.
Kojic acid is derived from fungi and works through the same tyrosinase-inhibiting pathway as hydroquinone. It's milder, which makes it a good option for patients with sensitive skin who don't tolerate hydroquinone well, and it's often included in combination formulas alongside other lightening agents. It's less potent when used alone, but meaningful in a well-designed regimen.
Niacinamide (vitamin B3) doesn't inhibit melanin production directly. Instead, it interrupts the transfer of melanin from melanocytes to the surrounding skin cells, targeting a different point in the pigmentation process. It's anti-inflammatory, strengthens the skin barrier, and tends to be very well tolerated. Studies show 5% niacinamide produces meaningful reduction in hyperpigmentation over eight to twelve weeks, making it a useful component in a multi-ingredient approach.
L-ascorbic acid (the active, stable form of vitamin C) is an antioxidant that also inhibits tyrosinase. It's more effective for sun-related spotting and post-inflammatory hyperpigmentation than for deep melasma, but it's a useful adjunct and provides antioxidant protection that complements sunscreen. Formulation stability is important: vitamin C degrades rapidly when exposed to air and light, so packaging matters.
Tranexamic acid works by blocking a pathway (plasmin-mediated prostaglandin synthesis) that connects UV exposure to melanocyte activation. It's been used in Asia for pigmentation for decades and has gained significant research attention in recent years. Studies show it improves melasma both orally (at low doses, typically 250 mg twice daily) and topically. It's well tolerated and doesn't carry the same long-term risks as hydroquinone, which makes it attractive for maintenance after active treatment.
Heat-based treatments are risky. Laser therapies and intense pulsed light (IPL) can worsen melasma in darker skin tones if not performed carefully, because heat activates the same melanocytes the treatment is trying to suppress. When lasers do work for melasma, the benefit often fades without an accompanying maintenance regimen.
Harsh physical exfoliants, fragranced products, and actives that cause significant inflammation can all worsen melasma by triggering post-inflammatory pigmentation on top of the existing condition. Gentleness matters.
Once melasma has responded to treatment, stopping everything and returning to baseline habits usually results in relapse. Maintenance typically involves daily SPF (non-negotiable), a niacinamide or vitamin C serum, and periodic tretinoin use. Some patients cycle back to active hydroquinone for a few months each year if pigmentation starts to creep back.
The goal isn't a single course of treatment. It's building a consistent routine that keeps melanocytes calm.
Over-the-counter options for melasma (most containing niacinamide, vitamin C, or low-dose kojic acid) can produce modest results but rarely address significant or stubborn melasma on their own. Prescription-strength hydroquinone and tretinoin, formulated for your skin's specific needs, are considerably more effective.
A provider can also evaluate whether hormonal factors are driving the melasma and whether changes to contraception or hormone therapy might make treatment easier.
Pomegranate's skincare program offers custom prescription formulas built around ingredients like hydroquinone, tretinoin, niacinamide, kojic acid, and vitamin C, all prescribed by a licensed physician based on your skin's specific needs.
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