ANSWERED: Your most burning questions about Melasma & Hyperpigmentation.
If I had a dollar for every time someone asked me… “What can I do to get rid of this unwanted pigmentation?”, I’d be a rich bi***!
Seriously… I get a lot of questions about hyperpigmentation. Just recently, I had someone email me with a recommendation for a Vit C and retinol product that I could recommend.
To be honest, I don't have one 🤷♀️
I have learned that over the years, you can do ALL the topicals and treatments, but if you aren't getting to the root cause of what is causing the hyperpigmentation, it will be a vicious cycle of products and inflammation. Many topicals cause inflammation and are photosensitizing. And inflammation, whether internal or external, is what causes hyperpigmentation.
Now, I'm not saying that those don't have a place, but where the ingredients are sourced and how the product is produced is HUGE... and... if you don't get the root cause, you are just making yourself more susceptible to sun damage. Because... dun, dun, dun... that's what those ingredients can do if not used properly.
And HOW they are made, well, maybe an email for another time. But Vit C is one of the most unstable ingredients and HOW the product is made is ALL the difference. Aaannnd depending on how it's made and which type of Vit C is being used, it can be a skin disruptor and cause irritation or sensitivity, so can retinol.
All I am saying is proceed with caution, do your research and find the root cause of the hyperpigmentation BEFORE slapping on product after product.
What’s crazy is that your diet might actually be what’s triggering the dark patches or preventing it from fading.
I believe that hyperpigmentation is caused by INFLAMMATION. Whether that be external or internal. It could be the sun, but typically there is a much deeper cause. It could be damage from overuse of products or treatments, or it usually stems from something internal - imbalance or inflammation.
ANSWERED:
Your most burning questions about Melasma & Hyperpigmentation
To be clear from the get-go, when talking about hyperpigmentation and Melasma, we will treat them pretty much in the same way and find the root cause.
Something to note is that each case of hyperpigmentation or Melasma and each individual will have different circumstances and will need to be treated as such. There is NO one size fits all here!
In short, hyperpigmentation is caused by a combination of diet, hormones, inflammation, sun damage, and other factors.
Let’s get deeper!
WHAT IS MELASMA?
The condition causes dark, discolored patches on your skin, sometimes also called chloasma or the “mask of pregnancy,” when it occurs in pregnant women. The condition is much more common in women than in men, though men can get it too.
Symptoms of melasma:
Melasma causes patches of discoloration. The patches are darker than your usual skin color. It typically occurs on the face and is symmetrical, with matching marks on both sides of the face. Other areas of your body that are often exposed to the sun can also develop melasma.
Brownish colored patches usually appear on the:
Cheeks, jaw
Forehead
Bridge of the nose
Chin
It can also occur on the neck and forearms.
Causes + Risk Factors
It isn’t totally clear what causes melasma. Darker-skinned individuals seem to be more at risk than those with fair skin. What IS known is that melasma happens as part of the skin’s defense system.
According to Rachael Pontillo, “The cells that produce melanin pigment in the body are called melanocytes, and they are located in the deepest layer of the epidermis (outermost layer of skin), commonly referred to as the basal layer. The primary purpose of melanin pigment in the body is protection from UV radiation. UV radiation creates free radicals in the skin; thus, the melanocytes jump into action, producing more melanin pigment to fight them off. It is a fact that excessive sun exposure causes hyperpigmentation in general, and that it can exacerbate melasma, but most experts do not believe the sun alone is responsible for melasma.”
“Melanocytes are tricky cells. They are easily triggered as part of the body’s inflammatory response process if they feel the skin or body is unbalanced. Drastic changes in the levels of estrogen and progesterone can trigger these cells and cause them to produce more melanin pigment.”
According to research, melasma is triggered by internal and external conditions, such as:
hormone imbalances
hormone changes from pregnancy and/or breastfeeding
birth control pills, injections, patches
HRT (hormone replacement therapy including natural HRT like progesterone creams and supplements, etc.)
IUD
high blood sugar
thyroid issues
sun exposure
sun damage
heat (internal and external)
trauma to the skin
If you are someone who is prone to melasma from these conditions and other people are not, it has to do with underlying inflammation in the skin. Studies have shown that melasma skin has increased vascularity and defective barrier function, making your skin less resistant and reactive.
All the more reason to be gentle and cautious if you ask me😉
If you want to rid your stubborn melasma or hyperpigmentation, you MUST target the underlying issue, and that is INFLAMMATION.
Since inflammatory signals trigger melasma, adjustments to your diet can be made to eliminate inflammation in your body. Inflammation isn’t difficult to get rid of, you just need to know how (and commit to doing it consistently).
In addition to getting rid of the hyperpigmentation, not only will your skin be much healthier, but it will heal quicker, have less redness and texture, and improve the signs of aging.
It’s really common for women with melasma to want to scrub or peel it off with exfoliants–and certain aestheticians use harsh skin lightening ingredients like hydroquinone to address it – but what I’ve found is that this can actually have the opposite effect on the skin.
The American Academy of Dermatology also suggests that the use of irritant cosmetic products or treatments may also cause melasma and hyperpigmentation.”
What I do know is that somehow there IS inflammation or an imbalance happening causing the melasma. The same can be said for all hyperpigmentation.
“From a holistic perspective, there may be some dietary issues that either mimic or trigger hormonal activity.” These foods also feed and breed Candida, causing an overgrowth of this fungus which leads to more inflammation, free radical production, and degradation of the immune system." - Rachael Pontillo
Many foods that are high in sugar, gluten, soy, and yeast can have an estrogenic effect on the body. As can synthetic fragrances.
OTHER IMBALANCES
Look into liver, adrenal, thyroid health AND mineral deficiencies. These imbalances are a huge cause of melasma, and regulation of the ovarian-adrenals-thyroid axis may be necessary.
Liver
A sluggish liver and the older a person is when pregnant can cause an already overworked liver to show up as melasma.
Adrenal Fatigue
Stress of any kind causes an adaptive response from the body. ACTH stimulates the adrenal glands to release cortisol. The adrenals convert cholesterol into pregnenolone, which is the building block for both sex hormones and cortisol.
When the body is under chronic stress, such as during adrenal fatigue, the body uses pregnenolone to produce more cortisol, limiting what's available for producing sex hormones.
Estrogen and progesterone sensitivity
Certain medications and chemical ingredients can also produce an estrogenic effect on the body. This means birth control pills, pregnancy, and hormone therapy can all trigger melasma. Stress and thyroid disease are also thought to be causes of melasma. “While it is not possible to fully control hormone levels in the body, there are some dietary and lifestyle changes, as well as relaxation and stress reduction techniques. You can try to even them out a bit.” - Rachael Pontillo
Lymphatic Health
I also know that the lymphatic system plays a huge role in removing used-up hormones and lots of other debris. And this has a connection with melasma because the lymph system is stagnant in most people to some degree. When there is stagnancy, stuff accumulates under the skin and can cause disruption.
Sun Exposure
Additionally, sun exposure can worsen melasma because ultraviolet rays affect the cells that control pigment (melanocytes) and causes excess
melanin production.
Topicals and procedures
Topicals or procedures that cause an inflammatory response, can also exasperate the issue by creating dermal inflammation. Inflammation caused by hormonal imbalances or acne is also a major trigger for excess melanin production.
WHERE TO START?
My approach includes Facial Reflexology, Gua Gha, Lymphatic Drainage, or acupressure to release areas of lymphatic or energetic stagnation, addressing mineral imbalances, diet, and lifestyle changes, along with skincare counseling.
Diet and lifestyle changes are very important as melasma does have a few possible contributing factors and triggers--but honestly, the mindset issue is the biggest challenge.
Depending on the severity, additional support may be needed for testing through a Functional Medicine Practitioner or a Naturopathic Doctor. Acupuncture may also be helpful.
HOW LONG WILL IT TAKE TO GO AWAY?
If minor and an easy fix, you can see results in 3 months. 6 to 9 months is more realistic for noticeable improvement -- and that's also typically the amount of time it takes for the client to achieve sustainable overall lifestyle changes.
For some patients, cessation of hormone-altering medications and the normal rebalancing of hormones after pregnancy can cause melasma to fade on its own. This is known as transient melasma.
For others, unfortunately, their melasma is persistent and can stay pronounced indefinitely.
WHAT YOU CAN DO NOW
Find a holistic esthetician and a Functional Medicine Practitioner or Naturopathic Doctor, whether virtual or local.
DIET
You can do the obvious things, like focusing on removing inflammatory foods including processed foods, refined anything, canola oil and vegetable oils. This includes asking and knowing what you can eat when you go to a restaurant.
In regard to diet, I find fructose to be most detrimental for hyperpigmentation. Even fruit for some individuals can cause hyperpigmentation.
Wait! What???
Why? Well, it does affect your hormones and spikes blood sugar, but fructose can also do damage to your liver, which is also connected to your skin’s health.
If you have some sticky hyperpigmentation, it’s worth looking into more and removing it from your diet, at least for a while.
How to begin?
Eliminating foods and drinks containing high fructose corn syrup (colas, sodas, energy drinks, packaged juices, chocolate bars, candy, chips/crisps, bottled salad dressings, pre-made pasta sauces, fast food, ketchup, condiments, etc.).
Cut high fructose corn syrup out of your diet. I also recommend you take agave nectar and honey out of your diet too. Sadly, companies have become sneaking and have renamed this to sneak it in. Check out the new names that companies are using to fool you, HERE.
If you’re already eating a super healthy diet without high fructose corn syrup or added sweeteners and you have hyperpigmentation, I recommend trying to cut down on fruit. Yes, fruit is healthy, but for those of you with hyperpigmentation, the fruit in your diet could be making it worse. Experiment by cutting it down on for a month to see if that helps your skin (you may be pleasantly surprised;). You can continue eating berries and pomegranates, but take a break from the rest. For more information on foods high in Fructose, check out this article.
Eat Real Food
Junk food, processed food, artificial sweeteners, flavor enhancers, food coloring, and chemical additives are not supposed to be in our natural diet and are causing irritation and inflammation. We are NOT meant to eat this shit*!!!
In order to heal your body and rid it of inflammation, you’ve got to start eating foods that contain the nutrients your body needs, so it can start working properly again.
Whole foods… so simple and an obvious solution, but so many people are hooked and addicted to processed foods and ingredients, mostly because of convenience, but also these types of ingredients are addicting, and the body begins to crave them. This is why it’s easy to be in denial of what it’s doing to your health, and how it could affect your skin.
Your food needs to be fresh; you need to prepare it yourself, using quality ingredients. Did you know that once a fruit or vegetable is chopped up (like pre-cut items), it begins to oxidize and lose its potency? Therefore, not having as many readily available nutrients when consumed. Furthermore, if you are using a microwave to prepare these, you are literally ‘nooking’ away ANY nutrients that would have been available otherwise!
Avoid inflammatory drinks
Drinks can be inflammatory too, not just foods.
Removing soda, packaged fruit juices, energy drinks, sugary teas, and also avoiding alcohol and coffee can go a long way in lowering inflammation. OK, so coffee, may be one of those things that I can’t seem to ditch, but I am crazy picky about where it is sourced, and I keep it to a minimum. I am addicted to Purity Coffee and the quality of this coffee is undeniable and unmatchable. Do yourself a favor… choose this coffee! It's pesticide-free, OGANIC green coffee - only defect-free specialty grade beans are chosen. ZERO CONTAMINANTS - and tested to ensure the coffee is free of mold and mycotoxins - ROASTED FOR HEALTH - roast beans to achieve maximum health benefits ANTIOXIDANT RICH - Purity has up to 2x the antioxidants of other leading brands DELIVERED FRESH - Ships within 48 hours of roasting for optimal freshness. Click here for free shipping on orders over $50.
Back to the point…
To drink for your health, drink water, plain herbal tea, infused water, or a freshly pressed vegetable juice😊
Stop Eating Foods you are Sensitive to
Obvious? Yeah, but we are all so guilty and may need a reminder😉 This is also where testing from a holistic practitioner can come in handy… your general practitioner will most likely not do a full panel to get the results you need.
We know it’s easy to keep eating the foods we love, but if we are allergic or sensitive to them, every time you eat them it may cause digestive distress, but undoubtedly will cause inflammation and may be contributing to your hyperpigmentation.
Common allergenic and food sensitives:
Eggs
Milk and dairy products
Soybeans and soy products
Wheat gluten
Fish
Shellfish
Tree nuts
Peanuts
Decrease Carbs in Your Diet
For many of you, the hyperpigmentation and inflammation is being triggered by your hormones.
Too many carbs in your diet may be causing hormone fluctuations and imbalances by throwing off your blood sugar.
If you’ve developed melasma or hyperpigmentation while pregnant, breastfeeding, taking birth control pills, hormone replacement therapy, or the pigmentation appears worse at different times of your menstrual cycle – your hormones are connected to the pigmentation.
Decreasing carbohydrates, especially refined carbohydrates, helps balance your hormones and keeps your blood sugar balanced, which in turn will keep that melasma-causing inflammation down.
For some of you, reducing the carbohydrates can possibly get rid of the melasma completely.
For some of you, just taking out sugar and processed food will be enough to help fade the melasma.
Just remember, carbohydrates are not just sugar, they are also starches too. Eliminate as many processed and refined carbs as possible.
Examples of processed foods high in carbs:
sugar and syrups (all forms)
flour
baked goods (breads, cakes, crackers, bagels, muffins, cookies, etc.)
pastas and noodles
chips and crisps
candy
desserts
rice cakes and puffed grains
cereals
soda or pop
alcohol
fruit drinks
sweet drinks (energy drinks, sweetened teas, sweet coffee drinks, etc.)
It may take a few weeks to start seeing improvements, but it is sooo… worth it.
Even if you are eating fairly healthy and still dealing with the hyperpigmentation, check out even the healthy carbs you are eating, and begin decreasing them.
Examples of health foods high in carbohydrates:
fruit (mango, papaya, banana, grapes, pineapple, etc.)
grains (corn, rice, millet, buckwheat, quinoa, couscous, wheat, etc.)
flour (wheat flour, rice flour, potato flour, cassava flour, corn flour, buckwheat flour, etc.)
beans/legumes (chickpeas, lentils, black beans, pinto beans, etc.)
root vegetables (potatoes, beets, carrots, pumpkin, squash, yams, etc.)
sweeteners (honey, maple syrup, palm sugar)
If you are struggling at knowing what you are eating on the regular and not sure where to begin, think about maybe starting a food journal for 3-5 days, and at the end, circle all the foods that ARE high in carbohydrates. Then the most frequently eaten foods (like every day or a few times a day), you can take a break from for a month to see how your skin responds.
Something to note: If you are pregnant or exclusively breastfeeding, don’t decrease the carbohydrates in your diet. Remove the processed food and eat healthy whole foods which will be better for you and your baby. Once you give birth and your baby is no longer exclusively breastfeeding (after 6 months of age), you can then experiment with decreasing the carbs in your diet to see if this can help fade the melasma (if you continue breastfeeding but not exclusively, you’ll still need a good amount of carbohydrates in your diet to maintain your milk supply, so make sure not to take too much out). Often, you’ll have to wait until after you’ve completely stopped breastfeeding and your postpartum hormones have normalized to see improvements in the melasma anyway, because your hormones will naturally be all over the place.
Take a look at your diet and lifestyle and make the necessary changes in order to reduce the risk of Candida overgrowth, liver toxicity, and estrogenic activity in the body. There’s a lot you can do with your diet and supplementation to address the causes of melasma from within, but in the meantime, focus on strengthening your skin on the outside.
Look into your liver health and possibly incorporate teas/infusions, tinctures, etc. that help the liver get back to functioning optimally.
You can look into the keto diet. Once the body is in ketosis, it can start to heal itself. Also, a diet rich in sun-protective nutrients like beta carotene, omega-3s, and lycopene can help increase your skin’s resilience to sun damage going forward.
What to Add to Your Diet:
In short… Antioxidants.
Antioxidants helps reduce inflammation, strengthens cellular repair, and can protect you skin cells from free radical damage. These days we are constantly exposed to pollution and strong UV rays. We need as much internal and external protection we can get. Antioxidants are key and getting them from your diet can protect your body from the inside out.
As you probably know, sun damage and UV exposure can make melasma worse. Along with protecting your skin from the sun by wearing protective clothing, sunscreen, and staying indoors during strong sun hours; but eating foods containing an abundance of antioxidants can actually boost your body’s ability to protect itself from the sun.
Antioxidants you want in your food:
Vitamin C
Vitamin E
Vitamin A
Resveratrol
Flavonoids
Beta-carotene
Lycopene
Lutein
Selenium
Examples of foods high in antioxidants:
Berries (blueberries, cranberries, blackberries, raspberries, pomegranate, dragon fruit, kiwis, etc.)
Beans (kidney beans, black beans, pinto beans, cacao beans, etc.)
Vegetables (tomatoes, onion, artichokes, broccoli, red cabbage, beets, etc.)
Green Leafy Vegetables & Herbs (kale, spinach, chard, artichokes, cilantro, thyme, basil, etc.)
Spices (turmeric, cinnamon, clove, cumin, ginger, etc.)
Nuts (pecans, Brazil nuts, walnuts, hazelnuts, etc.)
The deeper the color (like wild blueberries, spinach, or turmeric), the more antioxidants it will have. You may have heard the saying “Eat the rainbow”, and yeah, that pretty much covers it.
Now... this may be where this all gets a little confusing. The easiest way around this confusion is by eating antioxidant-rich foods that are also low glycemic. That means eating more green vegetables, colorful vegetables, spices, herbs, berries, and some nuts and beans.
But be cautious because, even though they are healthy, vegetables like carrots and beets are high in natural sugars (OK in small quantities). If you like having a freshly pressed vegetable juice, I don’t recommend carrot, beet, apple juice; instead have a kale, cucumber, and celery juice (big difference!).
What about a supplement? A lot goes into finding the best sourced and manufactured supplements. There are so many out there and they are definitely NOT created equal. Most supplements can actually be toxic to your health… this is a whole other story to get into. But getting the bulk of your nutrition from your food is the way to go!!!
There is no way to know how much of the nutrients in supplements are actually absorbed. Plus, we don’t know what kind of stress supplements put on your kidneys and liver to break them down. Fresh, real food is always the safest and best option. If you must and feel you need a viable option, I love Mary Ruth’s - Created by a Certified Health Educator, Nutritional Consultant, and Culinary Chef, non-GMO, plant-based, vegan ingredients, with the fewest number of allergens possible. And many of them are liquid, which means better absorption. Use code MARYRUTH for 15% Off Your First Order.
Some foods other foods you can try adding to your diet to relax over-productive melanocytes from the inside are watercress, raw apple cider vinegar, and Vitamin C containing foods.
Tissue Salts (minerals) also called Cell Salts
This is not diet per-say, but these days, so many of us are mineral deficient!
I have been doing a deep dive over here into Tissue Salts. Eventually, there will be an email talking about Facial diagnosis of Tissue Salt Deficiencies. That said, I am finding such cool correlations in certain mineral deficiencies and skin conditions. I have seriously geeked out on this and you WILL see more to come! But for now, regarding hyperpigmentation, here are a few that come up:
Kali Sulph - is an anti-inflammatory and cleanses the skin. Deficiency in this mineral can be hyperpigmentation.
Calc Sulph - not for pigmentation directly but helps the liver by removing waste from the blood.
Nat Sulph - Called the liver salt, Controls the healthy function of the liver, and is used to cleanse the cellular wastes from the cells and the intercellular fluid. Also useful in the later stages of digestion, it is also involved in carbohydrate breakdown.
These are homeopathic remedies and can be found on the following sites.
try https://abchomeopathy.com/r.php/Nat-s
https://abchomeopathy.com/r.php/Kali-s
https://abchomeopathy.com/r.php/Calc-s
ENVIRONMENT
Eliminating skin, body, housecleaning products, candles, anything that has synthetic fragrance or perfumes, so much with lifestyle. But for a lot of people, there are hormonal imbalances (not just menopause, so many other things) to consider as well - and these practitioners can help a lot with that.
Reducing stress is also a MUST.
EXTERNAL HELPERS
Keep the skin hydrated, and load up on antioxidant-rich serums/oils and balms, in addition to the loads of antioxidant-rich foods. You can check out some nourishing and balancing product helpers here that will feed your skin in its needy state.
At home and in-person, Gua Sha, Facial Reflexology, and Lymphatic Drainage CAN ALSO BE A BIG HELP in getting things balanced and flowing and help to 'break'up the most superficial hyperpigmentation. I do have Virtual Services available in addition to in-person and can teach you HOW to use modalities these on yourself properly for full benefit.
SUN PROTECTION
It is also necessary to use proper sun protection on a regular basis. Topically, definitely zinc sunblock. You can also use a mineral makeup to cover areas of discoloration and wear a wide-brimmed hat that shields or provides shade for your face. Wearing protective clothing is especially important if you're in the sun for an extended period of time.
Ultimately, you want to protect your skin as much as possible from environmental aggressors. Using plants that are known for their anti-inflammatory and/or lightening properties (licorice, calendula, turmeric, etc.) can help!
What to Steer Clear of:
Stay away from medications & skin care products that cause photosensitivity. Certain ingredients in your skin care products or medications can make your skin extremely sensitive to the sun (photosensitive), which can make you prone to hyperpigmentation.
Also, check in with your pharmacist/chemist to make sure any medications you’re taking (including birth control pills and antibiotics) may cause photosensitivity.
Ingredients in skin care products can cause photosensitivity which may lead to hyperpigmentation:
Retinol/Retin A
Alpha Hydroxy Acids / AHAs (glycolic acid, lactic acid, citric acid, etc.)
Benzoyl Peroxide
Perfume and fragrance
Vitamin C (products containing high amounts of L-Absorbic Acid, 20% or higher)
What’s crazy is that many of these ingredients are used to exfoliate your skin and fade hyperpigmentation, but unfortunately, they can make you prone to hyperpigmentation as well!
If you want to get rid of hyperpigmentation and prevent it from coming back, I highly recommend staying away from these ingredients, or, at least only using them during a time of year when the sun isn’t strong and you will be out of the sun.
That being said, if you do choose to use these ingredients, ONLY use them at night (never during the day). And make sure to use zinc-based sunscreen to protect your skin during the day. Re-applying sunscreen is also important because sun protection wears off after a few hours (for re-applying sunscreen on the go and over makeup, I like using a mineral sunscreen powder).
Using skincare products with strong active ingredients in hot climates or when the sun is strong, can damage your skin. Not only can these ingredients cause hyperpigmentation, but sun damage, wrinkles, and premature aging too.
For more information on Sun Helpers, stay tuned for another Blog Post soon, I got some great info coming your way!!!
To wrap up, I know there is a lot to think about here. That’s why finding a qualified practitioner to help and guide you in the right direction can be the healthiest and most cost-effective way to combat your hyperpigmentation and melasma.
If I can leave you with ONE thing, it is that you should take the guesswork out of it and find someone who can help you find the root cause of your hyperpigmentation.
I can be that person, and there are so many wonderful practitioners out there who can help too. Click the button below to book a Complementary Holistic Skin Wellness Consult.
References to this article:
Kang, H. Y., & Ortonne, J. P. (2010). What should be considered in treatment of melasma. Annals of dermatology, 22(4), 373–378. https://pubmed.ncbi.nlm.nih.gov/21165205/
Lee, D., Lee, J., Ha, J., Park, K.‐C., Ortonne, J.‐P. and Kang, H. (2012), Defective barrier function in melasma skin. Journal of the European Academy of Dermatology and Venereology, 26: 1533-1537. https://pubmed.ncbi.nlm.nih.gov/22077137/
Kim, E., Kim, Y.C., Lee, E.-S., Kang, H.Y., (2007), The vascular characteristics of melasma. Vol. 46, Issue 2, p111-116. https://pubmed.ncbi.nlm.nih.gov/17363223/
Costin, G. E., & Hearing, V. J. (2007). Human skin pigmentation: melanocytes modulate skin color in response to stress. FASEB journal : official publication of the Federation of American Societies for Experimental Biology, 21(4), https://faseb.onlinelibrary.wiley.com/doi/full/10.1096/fj.06-6649rev
Costin, G. and Hearing, V.J. (2007), Human skin pigmentation: melanocytes modulate skin color in response to stress. https://faseb.onlinelibrary.wiley.com/doi/10.1096/fj.06-6649rev
Foods that fight inflammation, Harvard Health Publishing (2014). https://www.health.harvard.edu/staying-healthy/foods-that-fight-inflammation
The perfect storm: How PMS and candida affect your hormones, https://bodyecology.com/articles/pms-and-candida-overgrowth-the-dangers-of-estrogen-dominance/
Treatment of melasma with Pycnogenol. https://pubmed.ncbi.nlm.nih.gov/12237816/
Adrenal Fatigue: How I Reversed Melasma. https://healthylivinghowto.com/adrenal-fatigue-melasma/
How to Fix Hyperpigmentation; Internal & External Treatment Part 1. Dr. Lia Andrews Nov. 17, 2013. https://liaandrews.wordpress.com/2013/11/17/how-to-fix-hyperpigmentation-internal-external-treatment/
Melasma: When Hormones Attack. Rachael Pontillo. May 3, 2011. https://createyourskincare.com/?s=melasma