What are the treatment options for melasma?

Melasma Treatment

Begin with strict broad-spectrum sunscreen (SPF 50+) combined with topical hydroquinone 4% (with or without tretinoin 0.05-0.1%), and for refractory cases, add intradermal platelet-rich plasma (PRP) injections which demonstrate superior efficacy over all other advanced treatments. 1, 2, 3

Foundation: Sun Protection (Essential for All Patients)

• Apply broad-spectrum sunscreen with minimum SPF 30, though SPF 50+ is preferable 1, 2
• Reapply every 2-3 hours during outdoor exposure 1, 2
• Wear wide-brimmed hats (>3-inch brim) when outdoors 1
• Seek shade during peak UV hours (10 a.m. to 4 p.m.) 1, 2
• Use UV-protective clothing with tight weave fabrics and darker colors 1
• Avoid tanning beds and sunlamps completely 1
• Counsel patients to avoid smoking, which impairs treatment outcomes 1, 2

Critical pitfall: Forgetting to reapply sunscreen after swimming, sweating, or after 2-3 hours of continuous exposure will undermine all other treatments 1

First-Line Topical Therapy

• Hydroquinone 4% is FDA-approved and indicated for gradual bleaching of melasma 3
• Hydroquinone works by inhibiting enzymatic oxidation of tyrosine to dopa, producing reversible depigmentation 3
• Tretinoin 0.05-0.1% can be used alone or combined with hydroquinone 1, 4
• Triple combination cream (hydroquinone + tretinoin + corticosteroid) remains the most effective topical treatment 1, 5
• Continue topical therapy for 8-12 weeks before assessing response 2

Advanced Treatment for Inadequate Response

If first-line therapy fails after 8-12 weeks, intradermal PRP injections are the most effective next step 2, 6

PRP Treatment Protocol

• Administer 4 intradermal PRP treatment sessions every 2-3 weeks 2
• Use intradermal microinjections spaced 1 cm apart 2
• Follow-up evaluation one month after the last treatment 2
• PRP demonstrates mean mMASI score reduction of 45.67% improvement 1
• Patient satisfaction rates exceed 90% with PRP treatment 1

PRP Superiority Over Alternatives

• Intradermal PRP injections show higher efficacy than intradermal tranexamic acid (TXA) injections with similar side effect profiles 1, 2, 6
• Microneedling may be more effective than intradermal PRP injections in some patients 1, 6

Adjunctive Systemic Therapy

• Consider oral tranexamic acid 250 mg twice daily when combined with PRP injections 1
• PRP combined with oral tranexamic acid shows 90.48% total efficacy compared to tranexamic acid alone at 73.68% 1, 2
• This combination reduces disease recurrence rates 1, 2

Measuring Treatment Success

• Use modified Melasma Area and Severity Index (mMASI) scores to objectively track improvement 1, 2
• Decreases in MASI >60-90% indicate moderate improvement 1
• Decreases >90% indicate excellent response 1
• Patient satisfaction assessment should complement objective measurements 1

Long-Term Management

• Melasma must be managed as a chronic condition requiring regular follow-ups 1, 2
• Maintenance treatments every 6 months are required to prevent recurrence 1, 2
• Continue sun protection indefinitely, as UV exposure causes repigmentation of bleached areas 3
• Consider intermittent use of topical agents during maintenance phase 2

Critical pitfall: Discontinuing treatment too early leads to recurrence, as melasma has high recurrence rates without maintenance therapy 2