Q: I have blotchy brown patches on both cheeks and on my nose. What could they be?
A: It sounds like melasma, caused by overproduction of melanin (skin pigment). This hyperpigmentation typically occurs on sun-exposed parts of the body—the face (cheeks, bridge of nose, forehead, chin, upper lip), but also sometimes the neck and chest—and in people with darker complexions. Melasma is a cosmetic issue, but it’s best to consult a dermatologist to make sure you don’t have something more serious.
Though anyone can develop melasma, the patchy discolorations are far more common among women, suggesting that hormones are involved. Women who are on oral contraceptives or hormone therapy are more susceptible, and the condition is associated with pregnancy (called the “mask of pregnancy”). There may also be a genetic predisposition.
Often melasma fades on its own—such as when hormones are discontinued and especially after a pregnancy. The marks also tend to lighten in winter, when there is generally less sun exposure.
Otherwise, if the spots bother you, you can try topical creams with skin-lightening ingredients, such as hydroquinone, kojic acid, azelaic acid, glycolic acid (an alpha-hydroxy acid), and retinoids like tretinoin (but not if you’re pregnant).
Prescription preparations are stronger and usually more effective than over-the-counter products. Some ingredients can cause skin reddening, itching, and other side effects.
If creams don’t help enough—in some cases the hyperpigmentation is deeper in the skin and appears more blue-gray in color—a dermatologist can do a chemical peel, dermabrasion, laser treatment, or pulsed light therapy. In some people, laser and pulsed light may darken skin, especially in darker-skinned people. These treatments are not likely to be covered by insurance.
To help manage or prevent melasma—or keep it from returning after treatment—use sunscreen (SPF of at least 30) and wear a hat when outside. Sunscreen is especially important if you are using skin-lightening creams or undergoing other treatments for melasma, since these increase sun sensitivity. Sunlight also greatly contributes to melasma during pregnancy. Anything that irritates the skin can worsen it, so use skin-care products made for sensitive skin and avoid waxing in melasma-prone areas such as the upper lip.
Also see How to Perform a Skin Exam.