What is the first line of treatment for melasma?

First-Line Treatment for Melasma

The first-line treatment for melasma is topical therapy with triple combination cream containing 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide, which has shown 77-94% of patients achieving clear or almost clear skin. 1

Treatment Algorithm for Melasma

Step 1: Initial Topical Therapy

• Triple combination cream (4% hydroquinone, 0.05% tretinoin, 0.01% fluocinolone acetonide) applied once daily for 8-12 weeks 1, 2
• If triple combination is unavailable or not tolerated, use:
  • Hydroquinone 4% monotherapy applied twice daily 1, 3
  • Alternative agents with less irritation potential but similar efficacy:
    • Azelaic acid (15-20%)
    • Kojic acid
    • Non-hydroquinone formulations containing tranexamic acid, vitamin C, arbutin, or niacinamide 1

Step 2: Essential Adjunctive Measures

• Broad-spectrum sunscreen SPF 70+ applied every 2 hours when outdoors 1
  • Critical component as inadequate sun protection is the most common reason for treatment failure
• Avoidance of known triggers (hormonal contraceptives, excessive sun exposure)
• Physical sun protection (hats, protective clothing)

Step 3: Monitoring and Follow-up

• Evaluate response every 4-6 weeks using standardized photography and MASI/mMASI scores 1
• Continue treatment for 8-12 weeks before considering alternative approaches
• Limit hydroquinone use to 3-6 months to prevent ochronosis (blue-black discoloration) 1

Second-Line Treatments (If First-Line Fails)

For Moderate to Severe or Resistant Cases:

1. Oral tranexamic acid (250 mg twice daily) with monitoring for thromboembolic risk 1, 3, 4
2. Chemical peels (glycolic acid or salicylic acid) - 3-4 sessions spaced one month apart 1, 5
3. Procedural options (with caution, especially in darker skin types):
   • Microneedling
   • Laser therapy (with high risk of post-inflammatory hyperpigmentation) 1, 2

Important Clinical Considerations

• Treatment expectations: Melasma is chronic and often recurrent; complete clearance may not be achievable 6, 3
• Risk assessment: Higher risk of treatment complications in darker skin types (Fitzpatrick IV-VI) 1
• Depth assessment: Determine if pigmentation is epidermal (responds better to treatment) or dermal (more resistant) 1
• Common pitfalls:
  • Discontinuing treatment too early
  • Inadequate sun protection
  • Ignoring hormonal factors
  • Aggressive treatments causing post-inflammatory hyperpigmentation 1

Evidence Quality Assessment

The recommendation for triple combination cream as first-line therapy is supported by multiple high-quality studies showing superior efficacy compared to monotherapies 1, 3. Hydroquinone monotherapy remains effective but with slightly lower efficacy than triple combination 3, 2. Oral tranexamic acid shows promising results in recent studies but requires more long-term safety data 1, 4. Chemical peels and laser therapies show mixed results and carry higher risks of adverse effects, particularly in darker skin types 1, 5.