Melasma: What are the best treatments?

close-up photo of a middle-aged woman with spots on her face indicative of melasma, looking concerned and holding her hand to her cheek

Melasma is a pigmentation disorder of the skin mostly affecting women, especially those with darker skin. It is commonly seen on the face, and appears as dark spots and patches with irregular borders. Melasma is not physically harmful, but studies have shown that it can lead to psychological problems and poorer quality of life due to the changes it causes in a person’s appearance.

Melasma is a common disorder, with a prevalence of 1% that can increase to 50% in higher-risk groups, including those with darker skin. Melasma is known as the “mask of pregnancy” since hormonal changes caused by pregnancy, as well as hormonal medications such as birth control pills, are major triggers for excessive skin pigment production in melasma. Sun exposure is another important contributor to melasma.

Can melasma be prevented?

Currently, melasma cannot be fully prevented in people who are likely to develop this condition due to their genetics, skin color type, hormones, or sun exposure level. Avoiding direct sun exposure during peak hours (10 a.m. to 4 p.m.), diligently using high-SPF sunscreens, and avoiding hormonal medications when possible may help protect against melasma flares and reduce their recurrence after treatment. Strict sun protection is the mainstay of any melasma treatment regimen.

What sunscreen should melasma patients use?

Choosing an appropriate sunscreen is critical if you develop melasma, and studies have shown that broad-spectrum tinted sunscreens, especially ones containing iron oxide, can lower pigment production in the skin in melasma patients, as they block visible light as well as UVA/UVB rays. Non-tinted sunscreens, on the other hand, do not block visible light.

For some people, it might be more convenient to use cosmetic products such as foundations that contain both UVA/UVB blockers and visible light blockers such as iron oxide. These products can conceal dark spots and therefore alleviate the psychosocial impact of melasma, and at the same time act as a sunscreen to protect against darkening of the lesions.

It is important for people with melasma to know that visible light can go through windows, and therefore even if they are not out in the sun, they can still get melasma flares by exposing themselves to visible light while driving or sitting by a window.

Can melasma be treated?

Currently there is no cure for melasma; however, there are several medications and procedures available to manage this condition. It is important to know that these treatment options may result in an incomplete response, meaning that some of the discolorations become lighter or disappear while some remain unchanged. In addition, frequent relapses are common.

It is also important to be aware of possible side effects of treatment, including darkening of the skin caused by inflammation induced by the treatment, or extra lightening of the skin in a treated area. Using the appropriate medications under the supervision of a dermatologist can help achieve treatment goals and maintain them with fewer relapses.

Common melasma treatments

The most commonly used treatments for melasma are skin lightening medications that are applied topically. These include medications such as hydroquinone, azelaic acid, kojic acid, niacinamide, cysteamine, rucinol, and tranexamic acid. These medications work by reducing pigment production and inflammation, and by reducing excess blood vessels in the skin that contribute to melasma.

Pregnant women (who constitute a big proportion of melasma patients) should avoid most of these medications except for azelaic acid, which is a safe choice during pregnancy. Hydroquinone is a commonly used skin lightener that should only be used for a limited time due to side effects that may happen with prolonged use. It can be used for up to six months for initial treatment and then occasionally if needed.

In most patients a combination therapy is needed for treatment for melasma. A common choice is the combination of hydroquinone with a retinoid that increases skin cell turnover and a steroid that decreases skin inflammation. Oral medications, including tranexamic acid, are usually considered in more severe melasma cases. This medication is thought to help melasma by reducing pigment production and by reducing excess blood vessels in the skin.

Additional treatment procedures may help

If your melasma does not improve with topical or oral medications, adding procedures such as chemical peels and laser therapies to a treatment regimen could be beneficial.

Chemical peels use substances like glycolic acid, alpha-hydroxy acids, and salicylic acid to remove the superficial layer of the skin that contains excess pigment in melasma patients. The effects of a chemical peel are temporary, since this procedure removes a layer of skin without reducing the production of pigment in regenerating deeper layers.

Laser therapies can destroy pigment cells in skin and therefore lighten the dark spots in melasma. However, as with any other treatment option for melasma, there is considerable risk of relapse post-treatment.

Maintenance therapy and prevention

After achieving improvement of melasma lesions, strict sun protection and maintenance therapy need to be continued. Skin lighteners other than hydroquinone can be used in combination with retinoids to maintain the results, and hydroquinone therapy may be used intermittently if needed.

Takeaway message about melasma

The key point in management of melasma is to use sun protection all the time, and to avoid other triggers such as hormonal medications when possible. Since none of the available treatments are a cure, prevention is the best option. People with melasma should see a board-certified dermatologist for evaluation and appropriate treatment regimens to manage melasma and maintain the treatment results.

About the Authors

photo of Lilit Garibyan, MD, PhD

Lilit Garibyan, MD, PhD, Contributor

Dr. Lilit Garibyan is an assistant professor of dermatology at Harvard Medical School, and a physician-scientist at the Wellman Center for Photomedicine at Massachusetts General Hospital. Her research focuses on innovative biomedical discoveries aimed at identifying … See Full Bio View all posts by Lilit Garibyan, MD, PhD photo of Sara Moradi Tuchayi, MD, MPH

Sara Moradi Tuchayi, MD, MPH, Contributor

Dr. Sara Moradi Tuchayi is a dermatology research fellow at Massachusetts General Hospital. Her research at the Wellman Center for Photomedicine at MGH is focused on the development of novel therapies for skin disorders. See Full Bio View all posts by Sara Moradi Tuchayi, MD, MPH


Can an implanted tongue-stimulating device curb your sleep apnea?

Man asleep in bed, snoring, on his side; woman awake and looking at him with one hand cupped over her ear to block noise

Loud snoring, grunts, and gasps can be a sign of obstructive sleep apnea, a serious disorder that causes repeated, brief pauses in breathing (apneas) throughout the night. It can leave people drowsy and depressed, and put them at risk for high blood pressure, heart disease, and other health problems.

If this sounds like you or a bed partner, a recent spate of advertisements for a mask-free treatment for the disorder may catch your attention. Known medically as a hypoglossal nerve stimulator, the pacemaker-like device moves the tongue forward during sleep. That helps reopen a collapsed airway — the root cause of obstructive sleep apnea. But how does it compare with other treatments, and who might be a good candidate?

A second-choice therapy for sleep apnea

Marketed under the name Inspire, the device was approved by the FDA in 2014. It’s a second-choice therapy intended only for people who can’t tolerate positive airway pressure (known as PAP or CPAP), according to Dr. Rohit Budhiraja, a pulmonary and sleep specialist at Harvard-affiliated Brigham and Women’s Hospital.

“Sleep apnea causes the muscles in the back of the throat to collapse, which leads to pauses in breathing that wake you up again and again,” he says. PAP, the gold standard therapy for sleep apnea, prevents airway collapse by using a small bedside machine attached to tubing that blows air through a face mask.

This can improve a measurement called the apnea-hypoxia index (AHI) by approximately 90%, lowering it below 5 in most people. The AHI is a score that gauges the severity of sleep apnea. An AHI between 5 and 14 is considered mild; between 15 and 29 is moderate; 30 and higher is severe.

Targeting tongue muscles is less effective

Inspire targets only the muscles of the tongue rather than the entire airway, so it isn’t as effective as PAP. In fact, the company’s stated treatment goal is to lower a person’s AHI by just 50% (or below 20), although some people may do better.

Because PAP is more effective, sleep specialists encourage people to stick with it by trying different strategies. But research suggests a quarter to a third of people have a hard time using PAP (see here and here). When that’s the case, Inspire may be an alternative, says Dr. Budhiraja.

Who might consider hypoglossal nerve stimulation?

In addition to trying PAP without success, you also must

  • have moderate to severe sleep apnea (an AHI score of 15 to 65)
  • have a body mass index (BMI) of 32 or lower (although some centers allow BMI values as high as 35), which means the device is not right for people in some weight ranges.

If you meet these criteria, you can ask your doctor for a referral to a sleep specialist or an ear, nose, and throat surgeon. The next step is sleep endoscopy. While you are sedated, a doctor passes a small tube with a light and a tiny video camera on one end through a nostril to examine your upper airway. Up to a quarter of people have an airway collapse pattern that can’t be remedied with Inspire, Dr. Budhiraja notes. And, as noted, others have too high an AHI score to try it.

A surgical procedure requiring general anesthesia

The device is implanted during a short, same-day procedure done under general anesthesia. A generator is placed just below the collarbone, a breathing sensor at the side of the chest by the ribs, and a stimulation electrode around the hypoglossal nerve under the tongue.

As with all surgery, possible risks include bleeding and infection. Some people experience tongue weakness, which can cause slightly slurred speech and minor swallowing problems. But this usually resolves within a few days, or for most people, within a few weeks.

The device must be activated a month after surgery at a sleep laboratory. The breathing sensor monitors your breathing and, when necessary, it tells the generator to send a small electrical pulse to the electrode to make the tongue muscles contract. The stimulation moves your tongue forward so you can breathe normally.

How does it feel?

“Some people describe a mild tingling sensation, but most say the feeling is hard to describe,” says Dr. Budhiraja.

At home, you use a small remote control to turn the device on at night and off in the morning. The remote is set to gradually increase the level of stimulation once or twice a week as tolerated until you reach the highest level. You then return to the sleep lab for a study to determine your optimal range. The remote is then programmed to that range.

Some people start noticing a difference in their sleep quality even at the lowest levels of stimulation. Yearly checks are recommended thereafter, and the replaceable battery lasts about 11 years. Medicare and most major insurance plans cover Inspire.

Once it’s working, hypoglossal nerve stimulation is definitely convenient: no maintenance, cleaning, or buying supplies as required with a PAP machine. “But because Inspire is less effective, it’s not considered a replacement for PAP,” says Dr. Budhiraja.

About the Author

photo of Julie Corliss

Julie Corliss, Executive Editor, Harvard Heart Letter

Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss


An emerging treatment option for men on active surveillance

tightly cropped photo of a sheet of paper showing prostate cancer test results with a blood sample tube, stethoscope, and a pen all resting on top of it

Active surveillance for prostate cancer has its tradeoffs. Available to men with low- and intermediate-risk prostate cancer, the process entails monitoring a man’s tumor with periodic biopsies and prostate-specific antigen (PSA) tests, and treating only when — or if — the disease shows signs of progression.

Active surveillance allows men to avoid (at least for a while) the side effects of invasive therapies such as surgery or radiation, but men often feel anxious wondering about the state of their cancer as they spend more time untreated. Is there a middle path between not treating the cancer at all and aggressive therapies that might have lasting side effects? Emerging evidence suggests the answer might be yes.

During a newly-published phase 2 clinical trial, researchers evaluated whether a drug called enzalutamide might delay cancer progression among men on active surveillance. Enzalutamide interferes with testosterone, a hormone that drives prostate tumors to grow and spread. Unlike other therapies that block synthesis of the hormone, enzalutamide prevents testosterone from interacting with its cellular receptor.

A total of 227 men were enrolled in the study. The investigators randomized half of them to a year of daily enzalutamide treatment plus active surveillance, and the other half to active surveillance only. After approximately two years of follow-up, the investigators compared findings from the two groups.

The results showed benefits from enzalutamide treatment. Specifically, tumor biopsies revealed evidence of cancer progression in 32 of the treated men, compared to 42 men who did not get the drug. The odds of finding no cancer in at least some biopsy samples were 3.5 times higher in the enzalutamide-treated men. And it took six months longer for PSA levels to rise (suggesting the cancer is growing) in the treated men, compared to men who stayed on active surveillance only.

Enzalutamide was generally well tolerated. The most common side effects were fatigue and breast enlargement, both of which are reversible when men go off treatment.

In an accompanying editorial, Susan Halabi, a statistician who specializes in prostate cancer at Duke University, described the data as encouraging. But Halabi also sounded a cautionary note. Importantly, differences between the two groups were evident only during the first year of follow-up. By the end of the second year, signs of progression in the treated and untreated groups “tended to be very similar,” she wrote, suggesting that enzalutamide is beneficial only for as long as men stay on the drug. Longer studies lasting a decade or more, Halabi added, may be necessary to determine if early enzalutamide therapy changes the course of the disease, such that the need for more invasive treatments among some men can be delayed or prevented.

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, editor of the Harvard Health Publishing Annual Report on Prostate Diseases, and editor in chief of, said the study points to a new way of approaching active surveillance, either with enzalutamide or perhaps other drugs. “An option that further decreases the likelihood that men on active surveillance will need radiation or surgery is important to consider,” he says. “This was a pilot study, and now we need longer-term research.”

About the Author

photo of Charlie Schmidt

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt