What is the best treatment for melasma?

Best Treatment for Melasma

The most effective treatment for melasma is triple combination cream (hydroquinone 4%, tretinoin, and corticosteroid) combined with strict broad-spectrum sun protection (SPF 50+), with intradermal platelet-rich plasma (PRP) injections reserved for refractory cases. 1, 2, 3

Foundation: Mandatory Sun Protection

• Apply broad-spectrum sunscreen with SPF 50+ and reapply every 2-3 hours during outdoor exposure 1, 2
• Wear wide-brimmed hats (>3-inch brim), seek shade during peak UV hours (10 AM to 4 PM), and use UV-protective clothing with tight weave fabrics 1
• Avoid tanning beds completely and discontinue phototoxic medications when possible 1, 4
• Sun protection is non-negotiable and must continue indefinitely, as melasma is a chronic condition with high recurrence rates 1, 2

First-Line Topical Therapy

• Start with triple combination cream containing hydroquinone 4%, tretinoin, and a corticosteroid—this remains the most effective and well-studied treatment 1, 3, 5
• Hydroquinone 4% monotherapy is FDA-approved for gradual bleaching of melasma and can be used if triple combination is not tolerated 6, 3
• Alternative topical agents include azelaic acid or tretinoin alone, though these are less effective than combination therapy 2, 4
• Expect approximately 40% of patients to develop mild erythema and peeling with triple combination therapy 5

Treatment Timeline and Expectations

• Continue first-line topical therapy for 8-12 weeks before assessing response 1
• Measure treatment success using modified Melasma Area and Severity Index (mMASI) scores, with >60-90% reduction indicating moderate improvement and >90% indicating excellent response 2
• Discontinuing treatment too early is a common pitfall—maintenance therapy is essential for this chronic condition 1

Advanced Treatment for Inadequate Response

If inadequate response after 8-12 weeks of topical therapy, add intradermal PRP injections:

• Administer four intradermal PRP treatment sessions every 2-3 weeks, with injections spaced 1 cm apart 1
• PRP demonstrates superior efficacy compared to intradermal tranexamic acid injections (mean mMASI score reduction of 45.67% with PRP vs. lower with tranexamic acid) 1, 2
• Evaluate response one month after the last treatment 1
• PRP combined with oral tranexamic acid 250 mg twice daily shows the highest total efficacy (90.48%) compared to tranexamic acid alone (73.68%) with lower recurrence rates 1, 2

Alternative Advanced Procedures

• Microneedling may be more effective than intradermal PRP injections in some patients 2, 7
• Radiofrequency microneedling requires three treatment sessions spaced at least 21 days apart 2
• Chemical peels show mixed results and carry higher risk of post-inflammatory hyperpigmentation, particularly in darker skin types (Fitzpatrick IV-VI) 3, 5
• Laser treatments show limited efficacy and should rarely be used due to increased risk of adverse effects and hyperpigmentation 4, 3, 5

Long-Term Maintenance Strategy

• Continue strict sun protection indefinitely 1, 2
• Use intermittent topical agents for maintenance 1
• Schedule maintenance PRP treatments every 6 months if this modality was effective 1, 2
• Regular follow-ups are mandatory as melasma is a chronic condition requiring ongoing management 2

Critical Pitfalls to Avoid

• Never forget sunscreen reapplication after swimming, sweating, or after 2-3 hours of continuous exposure 1
• Avoid laser treatments in darker skin types (Fitzpatrick IV-VI) due to high risk of post-inflammatory hyperpigmentation 5
• Do not discontinue treatment prematurely—recurrence rates are high without maintenance therapy 1, 2
• Counsel patients to stop smoking, as this is a damaging habit that can worsen outcomes 2

Patient Counseling Points

• Set realistic expectations: melasma is chronic and requires lifelong management 2
• Discontinue oral contraceptives if possible, as hormonal factors contribute to melasma 4
• Avoid scented cosmetic products that may contain phototoxic agents 4
• Patient satisfaction rates exceed 90% with PRP treatment when combined with appropriate topical therapy and sun protection 1