Transforming melasma care
International leaders provide fresh perspectives and tailored approaches.
U035 – Melasma in Skin of Colour: 2025 Update
7:30-8:30 a.m. | Saturday, March 8
Location: W308A
People of all ages, races, ethnicities, and skin types can be born with or develop dermatologic diseases. But certain conditions impact populations with primarily darker skin pigmentation in significantly different ways.
This morning’s session, U035 – Melasma in Skin of Colour: 2025 Update, returns with important, timely developments on the diagnosis, treatment, and management of the multifaceted ailment.
Session director Mukta Sachdev, MD, IFAAD, will lead the discussion alongside Andrew F. Alexis, MD, MPH, FAAD, and Kavita Mariwalla, MD, FAAD, providing a comprehensive overview and in-depth assessment of key updates, recent trends, and new strategies.
“Melasma is disproportionately common in individuals with skin of color, often leading to significant psychosocial and quality-of-life impacts,” said Dr. Sachdev, who heads the department of dermatology at Manipal Hospital Bangalore and is medical director of MS Skin Centre and MS Clinical Research in Bangalore, India. She is a skin of color expert and global key opinion leader.
This enhanced burden on patients with higher melanin levels requires sensitivity and swift action on the part of dermatologists.
A progressing methodology
As scientific discoveries produce emerging clinical options for patients with melasma, dermatologists should remain open to new lines of thinking and bespoke strategies, said Dr. Sachdev.
“Over time, the dermatologic approach to melasma has shifted from one-size-fits-all treatments to a more tailored approach, emphasizing certain considerations,” she said.
Contemplate Dr. Sachdev’s suggestions to help formulate or adapt your own treatment plan.
- Recognize triggers and disease chronicity, including hormonal, genetic, and environmental factors, as well as the likelihood of relapse.
- Focus on skin barrier function, and understand the importance of reducing irritation and inflammation, especially in patients with skin of color.
- Combine therapies or choose multimodal treatments, ranging from topical agents and oral medications to non-invasive procedures like microneedling and lasers.
- Employ cultural and psychosocial empathy, paying greater attention to patients’ individual needs, lifestyle practices, and aesthetic goals.
Putting it into practice
Once a personalized treatment plan is established, it’s ready to be deployed and used when treating patients with melasma. Dermatologists should be ready to fine-tune their comprehensive approach as new evidence-based research and best practices are announced.
Dr. Sachdev said doctors should apply ongoing analysis to integrate medications and procedures to achieve synergistic outcomes. It’s also important to remember that upon diagnoses, patients need to be educated or counseled on their disorder, such as how to achieve adherence, protect their skin from the sun, and avoid lifestyle and environmental triggers.
“Managing melasma in these populations requires nuanced approaches to avoid exacerbating pigmentation or triggering post-inflammatory hyperpigmentation,” Dr. Sachdev said. “New research and treatments are continually evolving, requiring dermatologists to stay updated on the latest evidence-based practices.”
Etiology of melasma
Dr. Sachdev said recent advancements have helped doctors better understand the pathophysiology of melasma and be able to recognize its contributing factors, common triggers, and preventable approaches. These dermatology-focused recommendations emphasize the importance of prevention, patient education, and a customized approach for managing melasma triggers.
Leading causations and risk factors:
- Hormonal influences: Elevated levels of estrogen and progesterone, such as during pregnancy or with oral contraceptive use, can stimulate melanocytes, leading to increased melanin production.
- Vascular abnormalities: Increased dermal blood vessels and elevated expression of vascular endothelial growth factor (VEGF) have been observed in affected skin, suggesting that vascular changes may promote melanogenesis. This is one of the factors that is gaining a lot of focus from an etiological and management perspective.
- Genetic predisposition: A significant number of individuals with melasma report a family history of the condition, indicating a genetic component.
- Illumination damage: Researchers are examining the relationship among UV radiation, visible light, and infrared radiation to determine any correlation responsible for exacerbating melasma.
- Skin type: Melasma is more prevalent in individuals with Fitzpatrick skin types III, IV, and V, which are common among people of African, Asian, and Hispanic descent.
Avoidances include:
- UV radiation/sun exposure
- Heat exposure and infrared radiation
- Oral contraceptives and hormone therapy
- Photosensitizing agents, like certain medications and topical ointments
- Cosmetic or dermatologic irritants
- Skin barrier disruption
- Hair removal methods
Determination of diagnosis
Dermatologists should perform appropriate assessments for facial melanosis differential diagnoses and eliminate related hyperpigmentary disorders that are prevalent in patients with skin of color. Tools, such as dermoscopy, Wood’s lamp, and digital imaging, help determine depth, severity, and chronicity of the condition.
Examine patients for the presence of concerning physical signs, such as:
- Symmetrical hyperpigmented patches: Melasma typically presents as brown to gray-brown patches on sun-exposed areas of the face, such as the cheeks, forehead, upper lip, and nose. These patches are usually symmetrical, appearing on both sides of the face.
- Color variations: The pigmentation can vary from light to dark brown and may sometimes appear bluish gray, especially in individuals with darker skin tones.
- Histological features: This includes 1) epidermal type, characterized by increased melanin in the basal and suprabasal layers of the epidermis; 2) dermal type, identified by the presence of melanophages (melanin-laden macrophages) in the dermis; and 3) mixed type, combination of both epidermal and dermal types. Studies have reported that mixed-type melasma is more common among individuals with skin of color, with prevalence rates around 50–60%.
Medical management
Triple combination therapies are proven, including the trifecta of hydroquinone, retinoids, and corticosteroids. According to Dr. Sachdev, combination drug strategies reduce relapse rates by up to 30%. For melasma maintenance, she suggests a non-hydroquinone alternative, such as cysteamine, azelaic acid, or tranexamic acid (TXA).
Recent studies have found that off-label oral treatments of TXA can improve refractory melasma by roughly 50%.
Procedural management
Further evidence shows that Melasma Area and Severity Index (MASI) scores improve by 60-70% with combined medical and procedural interventions.
Patients with stubborn and/or chronic melasma may also benefit from laser treatments and chemical peels with agents like glycolic acid or mandelic acid. Several laser and light-based therapies have been customized for skin of color, including low-influence Q-switched Nd:YAG lasers and pico lasers. These options deliver less energy and gently target deep pigmentation without causing major surface damage.
Dr. Sachdev also stresses the importance of proper post-procedural care to minimize post-inflammatory hyperpigmentation or other complications, like persistent erythema, hypertrophic scarring, and keloid formation, which is more prevalent in darker skins.
