What are the treatment options for melasma?

Treatment of Melasma

Recommended Treatment Approach

Begin with strict sun protection (SPF 50+ broad-spectrum sunscreen reapplied every 2-3 hours) combined with triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%), and if inadequate response after 8-12 weeks, add intradermal platelet-rich plasma (PRP) injections for optimal outcomes. 1, 2, 3

First-Line Treatment Protocol

Sun Protection (Essential Foundation)

• Apply broad-spectrum sunscreen with SPF 50+ daily, reapplying every 2-3 hours during outdoor exposure 1, 2
• Wear wide-brimmed hats (>3-inch brim) when outdoors 2
• Seek shade during peak UV hours (10 AM to 4 PM) 2
• Use UV-protective clothing with tight weave fabrics and darker colors 2
• Avoid tanning beds and sunlamps completely 2

Topical Therapy

• Triple combination cream remains the gold standard and only FDA-approved treatment for melasma 3, 4, 5
• This formulation contains hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% 3, 5
• Hydroquinone monotherapy (4%) is also highly effective if triple combination is not tolerated 5, 6
• Alternative topical agents include tretinoin alone, azelaic acid, or kojic acid, though these are less effective than combination therapy 2, 7, 8

Second-Line Treatment: Intradermal PRP Injections

If first-line therapy fails after 8-12 weeks, intradermal PRP injections demonstrate superior efficacy compared to all other advanced treatments, including tranexamic acid injections. 9, 1, 2

PRP Treatment Protocol

• Administer four intradermal PRP treatment sessions spaced every 2-3 weeks 1, 2
• Inject intradermally with microinjections spaced 1 cm apart 1
• Evaluate response one month after the last treatment 9, 1
• PRP shows significant improvement in modified Melasma Area and Severity Index (mMASI) scores within 6 weeks 9, 1
• Patient satisfaction rates exceed 90% with PRP treatment 9, 1

Evidence for PRP Superiority

• Intradermal PRP injections demonstrate higher efficacy than intradermal tranexamic acid (TXA) injections with similar side effect profiles 9, 2, 3
• Mean mMASI score reduction is significantly greater with PRP (45.67% improvement) compared to TXA 9
• PRP combined with oral tranexamic acid shows even higher total efficacy (90.48%) compared to tranexamic acid alone (73.68%) 9, 1
• Disease recurrence rates are lower with PRP combination therapy 9, 1

Adjunctive Systemic Therapy

Oral Tranexamic Acid

• Consider oral tranexamic acid 250 mg twice daily as adjunctive therapy, particularly when combined with PRP injections 9, 1
• Oral TXA is more effective than topical TXA for hyperpigmentation disorders 1
• This combination maintains normal levels of VEGF and α-MSH while reducing disease recurrence 9

Alternative Procedural Options

Microneedling

• Microneedling may be more effective than intradermal PRP injections alone for some patients 2, 3
• Consider this modality if PRP injections are not available or not tolerated 2

Chemical Peels and Laser Therapy

• Chemical peels and laser/light-based devices show mixed results and are generally equal or inferior to topical therapies 5, 6
• These modalities carry higher risk of post-inflammatory hyperpigmentation, particularly in darker skin types (Fitzpatrick III-V) 4, 6
• Reserve these treatments for refractory cases only, and use with extreme caution 5, 6

Maintenance Therapy

Melasma is a chronic condition requiring long-term maintenance to prevent recurrence. 1, 2

• Continue strict sun protection indefinitely 1, 2
• Maintain intermittent use of topical depigmenting agents 1
• Schedule maintenance PRP treatments every 6 months 1, 2
• Regular follow-ups are essential to monitor for recurrence 2

Treatment Algorithm

1. Initiate immediately: Strict sun protection + triple combination cream 1, 3
2. Assess at 8-12 weeks: If inadequate response, add intradermal PRP injections (4 sessions every 2-3 weeks) 1
3. Consider adding: Oral tranexamic acid 250 mg twice daily for enhanced efficacy 9, 1
4. Evaluate at 6 weeks post-PRP: Measure improvement using mMASI scores 9, 1
5. Long-term maintenance: Continue sun protection, intermittent topicals, and PRP every 6 months 1, 2

Critical Pitfalls to Avoid

• Never discontinue treatment prematurely—melasma has extremely high recurrence rates and requires lifelong maintenance 1, 2
• Avoid laser/light therapies as first-line treatment—these carry higher risk of post-inflammatory hyperpigmentation with inferior efficacy compared to topicals 5, 6
• Do not forget sunscreen reapplication—failure to reapply every 2-3 hours or after swimming/sweating undermines all other treatments 2
• Counsel patients on realistic expectations—genetic and hormonal factors may limit treatment success in some individuals 2
• Avoid smoking—this damaging habit should be eliminated to optimize treatment outcomes 2

Measuring Treatment Success

• Use standardized mMASI scores to objectively track improvement 9, 1, 2
• Decreases in MASI >60-90% indicate moderate improvement; >90% indicates excellent response 9
• Patient satisfaction assessment should complement objective measurements 9, 1