Melasma Management Protocol
Foundation: Strict Photoprotection (All Patients, All Skin Types)
Broad-spectrum sunscreen with SPF 50+ is mandatory and must be reapplied every 2-3 hours during outdoor exposure. 1, 2
- Apply sunscreen daily regardless of weather or season 1
- Wear wide-brimmed hats (>3-inch brim) when outdoors 1
- Seek shade during peak UV hours (10 AM to 4 PM) 1
- Use UV-protective clothing with tight weave fabrics and darker colors 1
- Avoid tanning beds and sunlamps completely 1
- Counsel patients that even minimal sunlight sustains melanocytic activity and can reverse treatment gains 3
First-Line Topical Therapy
Triple combination cream (hydroquinone 4% + tretinoin 0.05-0.1% + corticosteroid) is the most effective first-line treatment for melasma. 4
- Apply nightly to affected areas for 8-12 weeks 4, 5
- Test for skin sensitivity before full application by applying to a small unbroken patch of skin and checking within 24 hours 3
- Minor redness is acceptable, but discontinue if itching, vesicle formation, or excessive inflammation occurs 3
- Avoid contact with eyes and mucous membranes 3
- Hydroquinone monotherapy (2-4%) is an alternative if triple combination is not tolerated 4, 5
- Patients must discontinue oral contraceptives and other agents that promote pigmentation 5
Second-Line Treatment for Inadequate Response
If inadequate response after 8-12 weeks of topical therapy, add intradermal platelet-rich plasma (PRP) injections. 1, 2
PRP Treatment Protocol:
- Administer 4 intradermal PRP treatment sessions spaced every 2-3 weeks 2
- Use microinjection technique with injections spaced 1 cm apart 2
- Evaluate response one month after the last treatment using modified Melasma Area and Severity Index (mMASI) scores 1, 2
- PRP demonstrates mean mMASI score reduction of 45.67% with patient satisfaction rates exceeding 90% 1
- PRP is superior to intradermal tranexamic acid injections with similar side effect profiles 1, 2
Consider Adjunctive Oral Tranexamic Acid:
- Add oral tranexamic acid 250 mg twice daily when combining with PRP injections 1
- PRP combined with oral tranexamic acid shows 90.48% total efficacy compared to 73.68% with tranexamic acid alone 1, 2
- This combination reduces disease recurrence rates 1
- Oral tranexamic acid is more effective than topical formulations for hyperpigmentation 2
Alternative Procedural Options
Microneedling may be more effective than intradermal PRP injections in some patients. 1, 6
- Consider microneedling as an alternative to PRP for treatment delivery 1
- Radiofrequency microneedling requires three treatment sessions spaced at least 21 days apart 1
Maintenance Therapy (Essential for All Patients)
Melasma is a chronic condition requiring lifelong maintenance to prevent recurrence. 1, 2
- Continue strict sun protection indefinitely 1, 2
- Maintenance PRP treatments every 6 months as needed 1, 2
- Radiofrequency microneedling maintenance every 6 months if used as primary treatment 1
- Regular follow-ups to monitor for recurrence 1
Measuring Treatment Success
- Use standardized mMASI scores to objectively track improvement 1, 2
- Decreases in MASI >60-90% indicate moderate improvement 1
- Decreases >90% indicate excellent response 1
- Complement objective measurements with patient satisfaction assessment 1
Common Pitfalls to Avoid
- Never discontinue treatment prematurely - melasma has high recurrence rates without maintenance therapy 2
- Never forget sunscreen reapplication after swimming, sweating, or after 2-3 hours of continuous exposure 1
- Never use monobenzyl ether of hydroquinone in melasma therapy 5
- Never rely on topical therapy alone for moderate to severe cases - combination approaches are superior 4, 7
- Adverse events from treatments are typically mild (skin irritation, dryness, burning, erythema) but post-inflammatory hyperpigmentation can occur with aggressive procedures 4