Melasma is a common skin condition that causes pigmented brown marks and uneven skin tone to form, usually on the face. They are harmless and often caused by pregnancy or hormonal birth control pills.

There are three main types of melasma categorized according to the depth of pigment penetration into the skin.

Epidermal melasma is usually dark brown and more likely to fade with treatment.
Dermal melasma is light brown or bluish and is difficult to treat.
Mixed melasma is most common in patients.  It has a combination of epidermal and dermal pigment that results in blue and brown pigmentation.  Some of these respond well to treatment.

There are several ways to prevent melasma or ensure it does not worsen. Doctors recommend avoiding sun exposure and wearing a sunscreen of SPF 30-50 at all times. Other factors like tanning beds, LED screens, irritants in soaps, and hormonal birth control can worsen melasma.

Several treatments can target these pigmented patches. Various topical creams are available on the market that can lighten dark brown spots. Hydroquinone (HQ), which is available in cream, lotion, gel, or liquid formulation, works by inhibiting pigment (melanin) production.  Over-the-counter HQ is available, but prescription strength is more effective.

Other topical options are tretinoin and corticosteroids, which can be combined with HQ to improve the skin lightening process. Azelaic acid, licorice, Vitamin C, and kojic acid creams are also topical options to fade melasma spots. 

If topical creams are not effective, specific clinic procedures offer alternatives. Some doctors may recommend chemical peels, which can remove any old layers of skin and regenerate new skin cells to fade dark spots. Most of the time, superficial or medium-depth peels treat melasma.  Patients with darker skin have a risk of hyperpigmentation with some peels. 

Laser treatments are also popular for fading pigmented spots. Non-ablative fractional laser treatment is most suited for epidermal melasma. A pulsed dye laser can target the blood vessels that affect melasma.

Intense pulsed light (IPL) can treat melasma as melanin cells absorb the light, move into the skin's epidermis and flake off. IPL is not recommended for darker skin tones as it can cause hyperpigmentation. While doctors still use these laser procedures to treat melasma, there is also a risk that it will worsen the condition.