What are the treatment options for melasma?

Treatment Options for Melasma

Melasma treatment should include a combination of topical therapies, strict sun protection, and potentially advanced procedures like platelet-rich plasma (PRP) injections for optimal outcomes. 1

First-Line Treatments

• Sun protection is the foundation of any melasma treatment regimen and should include broad-spectrum sunscreen (SPF 30 or higher, preferably SPF 50+) that must be reapplied every 2-3 hours during outdoor exposure 1
• Triple combination cream containing 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide is the most effective topical treatment with 77-94% of patients achieving clear or almost clear skin 2, 3
• Hydroquinone 4% cream alone is FDA-approved for gradual bleaching of hyperpigmented skin conditions including melasma 4, 3
• Patients must be counseled that hydroquinone requires careful use as it may produce unwanted cosmetic effects if not used as directed 4

Second-Line and Adjunctive Treatments

• Oral tranexamic acid (250 mg twice daily) is a promising treatment for moderate to severe recurrent melasma 3
• Platelet-rich plasma (PRP) injections have shown significant improvement in melasma within 6 weeks as measured by modified Melasma Area and Severity Index (mMASI) scores 5
• PRP combined with oral tranexamic acid demonstrates higher efficacy (90.48%) compared to tranexamic acid alone (73.68%) with lower recurrence rates 5
• Niacinamide 4% can be an alternative to hydroquinone with fewer side effects (18% vs 29%) while still providing good to excellent improvement in 44% of patients 6

Treatment Protocol for PRP

• Four intradermal PRP treatment sessions administered every 2-3 weeks 5
• Follow-up evaluation one month after the last treatment 5
• Maintenance treatments may be required every 6 months as melasma is a chronic condition 1

Important Considerations and Precautions

• Test for skin sensitivity before using hydroquinone by applying a small amount to an unbroken patch of skin and checking within 24 hours 4
• Pregnancy considerations: Hydroquinone should be given to pregnant women only if clearly needed as animal reproduction studies have not been conducted 4
• Adverse effects of topical treatments are generally mild and include skin irritation, dryness, burning, and erythema 7, 3
• Avoid photosensitizing medications when using hydroquinone or other melasma treatments 4
• Additional sun protection measures should include wearing wide-brimmed hats, seeking shade during peak UV hours (10 am to 4 pm), and using UV-protective clothing 1

Treatment Algorithm

1. Begin with strict sun protection and first-line topical therapy (triple combination cream or hydroquinone) 1, 3
2. If inadequate response after 8-12 weeks, consider adding or switching to:
   • Oral tranexamic acid 3
   • PRP injections 5
   • Chemical peels (though results are mixed and risk of post-inflammatory hyperpigmentation is higher in darker skin types) 7, 3
3. For maintenance: Continue sun protection, consider intermittent use of topical agents, and maintenance PRP treatments every 6 months 5, 1

Common Pitfalls to Avoid

• Inadequate sun protection - even minimal sunlight exposure can sustain melanocytic activity and cause repigmentation 4
• Expecting quick results - melasma treatment is long-term and often requires combination approaches 8
• Discontinuing treatment too early - maintenance therapy is essential as melasma is chronic with high recurrence rates 1, 8
• Overuse of corticosteroid-containing products which may lead to skin atrophy (though this is rare with proper use of triple combination therapy) 2