Melasma is a physically disconcerting condition that results in dark, irregular patches on sun-exposed areas of the face, including the cheeks, upper lip, and forehead.  Its etiology is multifactorial and, as such, can be challenging to treat.  Moreover, it is a chronic, inflammatory skin condition and requires ongoing prevention and management.  The most current understanding of its etiology is a combination of internal and external drivers, including hormones, inflammation, vascular reactivity, heat, and sun exposure. The mainstay of treatment is a combination of topical lightening agents, which is hydroquinone.  Standard prescriptions contain 4% hydroquinone with over-the-counter formulations of 2%.  Higher concentrations up to 12% can be compounded for greater effectiveness and more rapid clearance, although these come with potential side effects of irritation and unknown long-term sequelae of systemic absorption. Typically, amounts between 4% and 8% are combined with agents that increase the permeability of the products resulting in improved absorption and effectiveness and other potentially less toxic lightening agents.  The latter include vitamin C, vitamin A (prescription retinoid or nonprescription retinol), kojic acid, and niacinamide. Regular peels with combinations of alpha-hydroxy acids and retinoids may also be effective for maintaining effect. Lasers, mainly thulium-based technology, can be effective as well.  IPL and devices generating more heat may initially improve the condition, but there is a significant risk of a rebound effect, and therefore, these are not recommended. Sun exposure and ambient visible light, mainly blue light exposure, are also contributing factors. Therefore, relentless sun and heat avoidance should be practiced with a combination of avoidance, covering up, and the use of a broad-spectrum sunscreen. Sunscreens containing iron oxide pigments (tinted sunscreens) allow for visible and blue light protection. 

Recently, off-label use of oral tranexamic acid has been used with excellent remission in doses of 325 to 650 mg per day, provided that the medication is continually used.  Tranexamic acid targets the vascular driver of melasma and can be used in appropriately screened patients.  The patient should have no coronary artery disease history or history of thromboembolic disease. In these low doses, current evidence suggests high tolerance and safety. Oral antioxidants such as polypodium leucomotos have been used to supplement UV protection, and there is a contemporary understanding that oral supplements containing pycnogenol, licorice and glutathione may further improve melasma.  

As always a healthy, Mediterranean diet is preferred, high in Omega 3 fatty acids and rich orange, yellow, and red and green vegetables, high in flavonoids and astaxanthin, have been shown in small case series to benefit patients with melasma. 

Management of melasma requires a multifactorial approach and changes in behavior and lifestyle which will likely facilitate sustained improvement.