What are the treatment options for managing melasma?

Melasma Management

First-Line Treatment Approach

Start with strict broad-spectrum sunscreen (SPF 30 minimum, preferably SPF 50+) combined with topical hydroquinone 4%, which remains the most effective treatment for melasma. 1, 2, 3

Essential Photoprotection Strategy

• Apply broad-spectrum sunscreen daily and reapply every 2-3 hours during sun exposure 1
• Wear wide-brimmed hats (>3-inch brim) when outdoors 1
• Seek shade during peak UV hours (10 a.m. to 4 p.m.) 1
• Use UV-protective clothing with tight weave fabrics and darker colors 1
• Avoid tanning beds and sunlamps completely 1
• Critical pitfall: Even minimal sunlight sustains melanocytic activity and will cause repigmentation, making photoprotection non-negotiable throughout treatment and maintenance 2

Topical Therapy Regimen

Triple combination cream (hydroquinone 4% + tretinoin + corticosteroid) is the most effective topical treatment, superior to hydroquinone monotherapy. 3, 4

• Hydroquinone 4% works by inhibiting enzymatic oxidation of tyrosine to dopa, producing reversible depigmentation 2
• Tretinoin can be used alone or combined with hydroquinone to enhance efficacy 1, 5
• Corticosteroids in triple combination formulations reduce inflammation and enhance penetration 1
• Test for skin sensitivity before full application by applying to a small unbroken patch of skin and checking within 24 hours 2
• Minor redness is acceptable, but discontinue if itching, vesicle formation, or excessive inflammation occurs 2

Advanced Treatment Options for Refractory Cases

Intradermal Platelet-Rich Plasma (PRP) Injections

For moderate to severe melasma not responding adequately to topicals, intradermal PRP injections demonstrate superior efficacy with mean mMASI score reduction of 45.67%. 1

• PRP shows higher efficacy compared to tranexamic acid injections with similar side effect profiles 1
• Significant improvement occurs within 6 weeks of treatment 1
• Patient satisfaction rates exceed 90% 1
• Microneedling delivery is more effective than intradermal injections alone 1

Radiofrequency Microneedling Protocol

• Perform three treatment sessions spaced at least 21 days apart 1
• Plan for maintenance treatments every 6 months as melasma is a chronic condition with high recurrence rates 1
• Measure efficacy using modified MASI (mMASI) scores: >60-90% reduction indicates moderate improvement, >90% indicates excellent response 1

Adjunctive Oral Tranexamic Acid

Consider oral tranexamic acid 250 mg twice daily as adjunctive therapy, particularly when combined with PRP injections, showing 90.48% total efficacy versus 73.68% with tranexamic acid alone. 1, 3, 4

• Reduces disease recurrence rates when combined with PRP 1
• Maintains normal levels of VEGF and α-MSH 1
• Represents a promising systemic treatment for moderate and severe recurrent melasma 3
• More studies needed to determine long-term safety 3

Alternative Procedural Options

Chemical Peels and Laser Therapy

• Chemical peels and laser/light-based devices show mixed results and are generally equal or inferior to topical treatments 5, 3, 4
• These modalities carry higher risk of adverse effects, particularly post-inflammatory hyperpigmentation 3
• Should be reserved for cases where topical therapy has failed and used with extreme caution 5

Treatment Algorithm

1. Foundation (all patients): Strict photoprotection + topical hydroquinone 4% or triple combination cream 1, 2, 3
2. If inadequate response after 8-12 weeks: Add intradermal PRP with microneedling delivery 1
3. For moderate to severe recurrent cases: Add oral tranexamic acid 250 mg twice daily 1, 3
4. Maintenance phase: Continue photoprotection indefinitely; consider maintenance treatments every 6 months 1
5. Measure progress: Use mMASI scores to objectively track improvement 1

Critical Counseling Points

• Counsel patients to avoid smoking, which damages treatment outcomes 1
• Manage expectations: melasma is a chronic condition requiring long-term treatment and regular follow-ups 1, 6
• Emphasize that treatment without strict photoprotection will fail due to ongoing melanocytic stimulation 2, 6
• Warn about potential for post-inflammatory hyperpigmentation with aggressive procedural treatments 3

Important Safety Considerations

• Hydroquinone has demonstrated mutagenic and clastogenic properties in animal studies; carcinogenic potential in humans is unknown 2
• Avoid hydroquinone contact with eyes and mucous membranes 2
• Safety and effectiveness not established in pediatric patients below age 12 2
• Use in pregnancy only if clearly needed (Category C) 2
• Caution patients about concomitant use of photosensitizing medications 2