What Are the Dark Patches on My Face?

They showed up over the summer: two matching brown clouds across your cheekbones and a smudge above your lip, as if you’d had a chocolate milkshake and missed. By November they’ve faded. By next June they’re back.

What melasma is

The AAD¹ describes melasma as patches and spots, usually on the face, that are darker than your natural skin tone. They can be tan, brown, grayish brown or bluish gray. They sit on areas like the cheeks, forehead, chin and above the upper lip, and they’re usually flat and symmetrical, matching on both sides of the face. It isn’t contagious, and it’s different from skin cancer.

Its nickname is “the mask of pregnancy,” because it often appears during pregnancy or when someone starts birth control. That’s a lot to read when you’re 52 and not pregnant, but the hormone link is the point.

The AAD¹ says women with medium to dark skin tones are most likely to develop it, and that many people with darker complexions see a dermatologist for exactly this. In its causes page, melasma is more common in women between 20 and 40. In the one study the AAD cites, 48% said a blood relative also had it.

What sets it off

The AAD² says sunlight is the big one. When sunlight hits your skin, it triggers the body to make more melanin. That’s why many people with melasma say the patches get darker in summer and fade in winter.

Hormones come next. The AAD² says increases in estrogen and progesterone during pregnancy are believed to activate melasma in people who are prone to it. Birth control pills are on its list of triggering medicines, along with anti-seizure medicines and drugs that make skin more sensitive to sun, such as retinoids and certain antibiotics.

The list continues. The AAD² names tanning beds, which give stronger UV than natural sunlight, and thyroid disease, adding that treating an underlying thyroid problem sometimes clears the melasma. Stress is on it too, through cortisol, though the AAD calls that link somewhat controversial.

Start with sun protection

If you do one thing, do this. The AAD² says sunlight makes the skin produce more pigment, which can darken existing melasma and cause new patches.

For melasma, it recommends sunscreen with zinc oxide, titanium dioxide or iron oxide, broad-spectrum with an SPF of 30 or higher, applied throughout the day. If a white cast bothers you, a tinted sunscreen is an option.

The play

Try this: the mirror check

Look at your face in daylight. Are the patches flat, and do they match on both sides?

Take a photo now, and one next month, in the same light.

Check any single spot, on its own, against the ABCDEs below.

What a dermatologist can add

When sunscreen alone isn’t enough, the AAD³ describes prescription creams. Hydroquinone evens out the skin tone. A triple combination cream pairs hydroquinone with tretinoin, a retinoid, and a corticosteroid that reduces inflammation. Gentler options include azelaic acid, kojic acid and vitamin C.

For stubborn cases, dermatologists may add a chemical peel, microneedling, or laser and light treatments, and tranexamic acid, applied to the skin or taken as a pill.

Expect to wait. The AAD³ says it usually takes 3 to 12 months to see results. It also notes that treatment isn’t considered medically necessary, so insurance typically won’t cover it, and that it can be hard to get noticeable results if you’ve had melasma for many years. Which of these fit you is for a dermatologist to decide.

When dark patches aren’t melasma

Not every dark patch is melasma.

Dark spots can follow acne. The AAD⁴ says dark spots after acne clears are a reason to see a dermatologist.

Darkening in the folds of the body is another pattern. The AAD⁵ says acanthosis nigricans darkens and thickens the skin, which feels like velvet, often in folds such as the neck and underarms. It can be a sign of pre-diabetes, and it can also result from medicines. The AAD says to see a dermatologist, because sometimes a small change is an early warning sign. The Office on Women’s Health⁶ lists darkened skin along the neck creases among the symptoms of polycystic ovary syndrome (PCOS), too.

And then the single spot. The AAD¹ says melasma differs from skin cancer and typically shows up symmetrically on both sides of the face. A lone spot is judged differently. The AAD’s ABCDEs of melanoma: Asymmetry, where one half of the spot is unlike the other. Border, irregular, scalloped or poorly defined. Color that varies from one area to the next. Diameter, usually larger than a pencil eraser though it can be smaller. And Evolving, which means the spot looks different from the rest or is changing in size, shape or color.

If a spot has any of those, the AAD⁷ says to see a board-certified dermatologist for a skin exam.

When to get checked

The AAD² says melasma may go away on its own or last for years, and that a dermatologist can help most if you start early.

Book an appointment if any of these fit:

• A single spot has an uneven border, several colors, or is changing
• Dark patches keep coming back or won’t fade after steady sun protection
• You see dark, velvety skin in the neck or underarm folds
• Patches began after you started a new medicine
• You’re pregnant or planning to be, and you want to treat them

Next June, when the clouds come back, you’ll already know the first step.