What Is Melasma and Why Does It Appear?

Melasma is a form of acquired hyperpigmentation characterised by symmetrical brown or grey-brown patches, most often on the cheeks, forehead, upper lip, and chin. It results from overactive melanocytes — the skin cells responsible for producing pigment — and is far more prevalent in people with Fitzpatrick skin types III–V, which includes most Southeast Asian skin tones.

Three overlapping factors drive melasma:

  • Hormonal influence. Oestrogen and progesterone stimulate melanocyte activity. This is why melasma is frequently associated with pregnancy (sometimes called “the mask of pregnancy”) and with the use of hormonal contraceptives.
  • Ultraviolet and visible light exposure. UV radiation is the single most consistent trigger. Research also indicates that high-energy visible (HEV) light — emitted by both the sun and screens — can worsen pigmentation, particularly in deeper skin types.
  • Genetic predisposition. A positive family history significantly increases susceptibility, suggesting an inherited tendency toward melanocyte reactivity.

Other contributing factors include thyroid dysfunction and certain skincare products or procedures that cause chronic low-grade irritation.

Common Triggers That Worsen Existing Pigmentation

Even when melasma is well-controlled, certain exposures can cause a flare. Understanding these helps patients make informed day-to-day decisions.

Sun exposure without adequate protection remains the most common trigger. In Bali’s year-round high-UV environment, consistent broad-spectrum sunscreen use (SPF 30 or higher, reapplied every two hours outdoors) is considered a clinical standard of care — not optional. Physical blockers containing zinc oxide or titanium dioxide are often preferred because they also deflect visible light.

Heat is an under-recognised trigger. Studies show that thermal radiation independently stimulates melanin production, which means that outdoor activity during peak afternoon heat, saunas, and even very hot showers can contribute to flares.

Hormonal changes from pregnancy, contraceptive adjustments, or perimenopause can destabilise pigmentation that was previously managed. Open communication with both a dermatologist and a gynaecologist is advisable in these situations.

Skin irritation from aggressive exfoliation, fragrance-containing products, or unsuitable active ingredients can provoke post-inflammatory hyperpigmentation that compounds existing melasma.

Evidence-Based Management Approaches

No single treatment eliminates melasma for every individual, and outcomes vary considerably depending on skin type, trigger control, and adherence to a consistent regimen. The following options have meaningful clinical evidence supporting their use.

Topical depigmenting agents. Tranexamic acid, azelaic acid, kojic acid, and niacinamide are widely studied and generally well-tolerated in Asian skin. Hydroquinone remains effective but is typically used in supervised, time-limited courses due to the risk of ochronosis with prolonged use. Combination formulations (for example, a low-dose retinoid with a mild acid and a corticosteroid in the short term) have shown stronger results in clinical trials than single-agent therapy.

Chemical peels. Superficial and medium-depth peels using glycolic acid, lactic acid, or salicylic acid can accelerate the turnover of pigmented epidermal cells. They are most effective when used as part of a broader programme that includes strict photoprotection. Results depend on individual skin response and the skill with which the peel is applied and neutralised.

Laser and light-based therapies. Low-fluence Q-switched Nd:YAG laser treatments have an established evidence base for melasma in darker skin types, with a lower risk of post-inflammatory hyperpigmentation than older high-fluence protocols. Multiple sessions are typically required, and maintenance photoprotection is essential to sustain improvement.

Oral tranexamic acid. Emerging evidence, including several randomised controlled trials, supports low-dose oral tranexamic acid as an adjunct for recalcitrant melasma. It is prescribed under medical supervision due to its systemic mechanism of action.

Taking the Next Step

Melasma is a chronic, relapsing condition — but with the right combination of trigger management, appropriate topical care, and clinically supervised treatment, meaningful improvement is achievable for most patients. Because skin type, hormonal status, and lifestyle all influence which approach is most suitable, a personalised assessment is the most reliable starting point.

If you have questions about your pigmentation or would like to discuss your options, the team at Kirana Skin Clinic in Ubud is available for consultation. You are welcome to reach out via WhatsApp to arrange an appointment at a time that suits you.