What is melasma?

Melasma is a pigmentary condition defined by discoloured patches on the skin, often appearing across the face. Some of the common areas include the forehead, cheeks, nose bridge, and upper lips. The discoloured patches can either be plastered across the skin or resemble freckles that develop sporadically across the face. Types of melasma include:

• Dermal: dermal melasma is often light brown, with blurry borders. 
• Epidermal: epidermal melasma are dark brown with well-defined borders. 
• Mixed melasma: mixed melasma is the most common type of melasma and often depicts a mixed pattern of dark and light brown pigmentation. 

Melasma is more prevalent among women than men. Additionally, it is a condition common to Asian skin types due to the higher melanin content in darker skin phenotypes. Whilst harmless, the development of melasma can be a cause of cosmetic concern to patients and may even cause psychological distress.  

What causes melasma?

Melasma is caused by an overproduction of melanin when our skin interacts with UV light from the sun. It usually results from the interplay of genetic, hormonal and UV factors. Worsening is often reported after sun exposure, pregnancy, and the use of oral contraceptives.

Who is at risk of melasma in Singapore?

In Singapore, you are more likely to develop melasma if you have one of the following risk factors:

• Age: people between 30 and 50 are more at risk of developing melasma.
• Complexion: people with darker skin tones are more prone to developing melasma than those with fairer skin tones.
• Drugs and cosmetic products: some medications and cosmetic products, including birth control pills, anti-seizure medications, hormone replacement therapy, and tetracyclines, can stimulate melasma production.
• Family history: genetics plays a role in melasma, as people with relatives with melasma are more likely to develop it in the future.
• Gender: women are more susceptible to developing melasma than men.
• Hormone: an elevated oestrogen level has been linked to an increased risk of melasma.
• Thyroid problems: people diagnosed with thyroid problems, such as hypothyroidism, are at risk of developing melasma, as thyroid problems can affect hormone levels.
• Pregnancy: the increased levels of oestrogen and progesterone can trigger melasma development in pregnant women.
• Sun exposure: UV exposure is a major risk factor for the development and progression of melasma.

How is melasma diagnosed in Singapore?

It can be tricky to distinguish melasma from other forms of hyperpigmentation. However, Dr. Hoe has extensive experience treating melasma and will be able to diagnose your condition accurately. 

Diagnosis is made clinically with a medical consultation and physical examination. The patient’s medical history will be reviewed, including lifestyle, family history, previous treatments, and the outcomes of previous treatments. Melasma can be diagnosed with a physical examination showing grey-brown pigmentation with irregular borders over the cheeks, forehead, nose, and lips. The extent of the melasma is documented with clinical photographs and 3D skin analysis.  

Dr. Hoe’s deep experience treating melasma allows her to pinpoint certain lifestyles or medications that may be worsening the condition. Furthermore, melasma often coexists with other pigmentary disorders such as freckles and lentigo—it takes a trained eye to identify and distinguish these conditions.

How is melasma treated in Singapore?

Treatment  options available for melasma removal are:

• Lifestyle modifications
  • UV avoidance: UV exposure is the major trigger for melasma and needs to be minimised. Patients must minimise or reduce daytime outdoor activities that lead to sun exposure, such as golfing, tennis, or swimming. UV protective clothing such as face masks, visors, and caps are essential. Applying sunblock such as Heliocare AK Fluid SPF 100 (internal link) and oral sunblock such as Heliocare Luminance (internal link) will help reduce the likelihood of melasma.

• Topical treatment 
  • Prescription de-pigmentation cream: such as Hydroquinone 4% Tretinoin 0.05% Triamcinolone Acetonide 0.05% Cream 15g (Compounded) known as Kligman’s formula. The key ingredient is hydroquinone, a tyrosinase inhibitor that blocks the key steps in pigment production. Considered an ideal and effective treatment for melasma by most doctors, this prescription grade treatment often results in adverse effects, including skin irritation, steroid-induced acne, and ochronosis (worsening of pigmentation). The current consensus is to use Hydroquinone for 8-12 weeks (“cycle on”) before converting to non-hydroquinone depigmentation creams such as Cyspera (“cycle off”). Once a day, with application in the evening.  
  • Cyspera Intensive: Cyspera Intensive (internal link) contains Cysteamine 5%. It acts by inhibiting the enzymes tyrosinase and peroxidase, blocking key steps in pigmentation formation. This is the depigmentation cream (non-hydroquinone) of choice for many doctors and can be used for long-term maintenance without significant side effects. Results take time, and a three to four-month treatment period is required. Apply once a day in the morning.

• Oral medication
  •  Tranexamic acid (TXA) tablets: Cyklokapron TXA, an anti-fibrinolytic agent. This prescription medication, is used to prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. In recent years, multiple published clinical studies have shown that oral TXA effectively treats melasma. It works by inhibiting the plasminogen activator pathway in the skin, preventing melanocyte activation due to ultraviolet (UV) light, hormones, and injured keratinocytes. In a Singaporean study held at the National Skin Center involving over 500 patients, 90% saw improvement in their Melasma after taking oral TXA for at least four months. 

• Laser treatments
  • MOXI laser: MOXI laser (link to service page) is a 1927 nm diode fractional non-ablative laser that delivers targeted laser energy to address a wide range of skin concerns, including ageing skin, fine lines, pigmentation, melasma, sun damage, and dull skin. MOXI laser creates numerous microscopic areas of controlled injury in the skin, which triggers a rejuvenating wound-healing process that causes the skin to generate new collagen and shed unwanted pigment. This results in smoother, radiant, and firmer skin. This treatment can be performed in all skin types (including darker skin tones) all year round and is safe and effective for melasma. MOXI laser effectively targets epidermal melasma (superficial layer) with a low risk of melasma flare. Each treatment of MOXI laser typically improves the melasma by 20-30%, with three MOXI laser treatments generally giving a 70-80% improvement in melasma, as well as rejuvenating the skin and improving fine lines, pores and wrinkles. MOXI laser is preferred by patients who can accept some downtime (about five to seven days of redness and mild flaking).
  • PicoSure laser: PicoSure (link to service page) is a US FDA-approved 755 nm Alexandrite picosecond laser developed by Cynosure, USA. It is approved to treat various skin concerns, including melasma, pigmentation, tattoo removal, post-inflammatory hyperpigmentation, acne scars, sun damage, dull skin, and open pores. PicoSure laser is effective for dermal melasma (deeper layer) with a low risk of melasma flare. Each treatment with PicoSure laser typically improves the melasma by 10-20%, with five PicoSure Laser treatments generally giving a 60-70% improvement in melasma and rejuvenating the skin. PicoSure is preferred by patients who cannot take downtime and must return to work/activity immediately.

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  • Skinboosters: Bay Glow Skinbooster (link to service page) involves full face and intradermal injections of hyaluronic acid, antioxidants, amino acids, minerals, polynucleotides (PN), and tranexamic acid, which act to hydrate the skin, reduce inflammation, and suppress pigmentation. Three to four treatments of Skinbooster injections a month apart leave the skin smooth, glowing, and radiant. Skinbooster treatments can be combined with laser treatments.