A mask that's hard to shed

Since the start of the pandemic, many of us have contemplated the pros and cons of masks. Yet there's another type of mask that's been around for a long time but isn't as easy to peel off. It's called melasma, and 90% of its sufferers are women, according to the American Academy of Dermatology.

Melasma is often dubbed the "mask of pregnancy" because its characteristic dark patches — which tend to cluster on the nose, cheekbones, and jaw — are even more prevalent in expectant mothers. But hormonal fluctuations related to birth control pills, menopause, and hormone therapy are also triggers, says Dr. Arianne Shadi Kourosh, director of the Pigmentary Disorder and Multiethnic Skin Clinic at Harvard-affiliated Massachusetts General Hospital.

Melasma isn't harmful, but its stubborn splotches (known formally as hyperpigmentation) can certainly lead to emotional distress, Dr. Kourosh says. And some melasma is so severe it can't be covered with makeup. "Patients have told me their melasma is ruining their life," she says. "Some isolate themselves and don't want to go out in public because they feel so disfigured."

Insight into triggers

Hormonal ups and downs work hand in hand with other factors, including genetics and darker skin tones, to make melasma more likely. But the chief co-conspirator is sun exposure. In recent years, scientists have also learned that ultraviolet (UV) light from the sun isn't the only offender, with blue light from screens and devices also contributing to melasma development. Even prolonged heat exposure (say, from standing near an oven) or air pollution (such as smog and car exhaust) can play a part.

"These harmful chemicals and pollution can corrode the skin's protective barrier and cause irritation that worsens hyperpigmentation," Dr. Kourosh says.

Certain medications, including some antibiotics and pain remedies, can also make us more sensitive to light exposure and aggravate melasma. That's why Dr. Kourosh thoroughly reviews a patient's medical history when she diagnoses melasma, a process sometimes aided by devices that measure how deeply pigment is deposited within the skin.

"It's really a holistic picture," she says. "I need to rule out other problems that can cause hyperpigmentation, including hormonal imbalances, medication reactions, or endocrine disorders."

Mainstays and new approaches

Melasma can fade or disappear on its own, especially when the trigger causing it — such as a sunshine-filled vacation, pregnancy, or oral contraceptive use — ends. But you shouldn't try to self-diagnose or treat melasma without a dermatologist's input, Dr. Kourosh says. If you're tempted to use a nonprescription product that claims to lighten dark patches, you need a doctor's expertise on its safety and effectiveness.

That said, various mainstay treatments and newer remedies are available. Options your doctor may recommend include the following:

Hydroquinone. This skin-lightening substance comes in cream, lotion, gel, or liquid form. It works by destroying overly pigmented skin cells.

Tretinoin and corticosteroids. Tretinoin is a retinol derived from vitamin A that boosts cell turnover in skin, enhancing skin lightening when added to hydroquinone. Steroids can lower skin inflammation. A "triple cream" (Tri-Luma) may contain all three substances.

Acid-based lighteners. Incorporating azelaic acid, kojic acid, or other acids, these topical products gently slough off top skin layers to reduce dark patches.

Tranexamic acid. Traditionally used to treat heavy bleeding, this medication has also proven effective in recent years against stubborn melasma, Dr. Kourosh says. But the pandemic dialed back its use somewhat, because one possible side effect — blood clots — is also a complication of COVID-19.

Dr. Kourosh also red-flags chemical peels or laser procedures to treat melasma. Many "medical spas" advertise these techniques to lighten splotchy skin, but they're often staffed by workers without medical training who can't ensure results. "These procedures can do more harm than good by heating and inflaming the skin," she says.

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