What are the treatment options for melasma?

Melasma Treatment

Begin with strict broad-spectrum sunscreen (SPF 50+) combined with triple combination cream (hydroquinone 4% + tretinoin + corticosteroid), and if inadequate response after 8-12 weeks, add intradermal platelet-rich plasma (PRP) injections as the most effective advanced treatment option. 1, 2

Foundation: Sun Protection (Essential for All Patients)

• Apply broad-spectrum sunscreen with minimum SPF 30, though SPF 50+ is preferable, and reapply every 2-3 hours during outdoor exposure 1, 2
• Combine sunscreen with additional photoprotection measures: wide-brimmed hats (>3-inch brim), seeking shade during peak UV hours (10 AM to 4 PM), UV-protective clothing with tight weave fabrics and darker colors, and complete avoidance of tanning beds 1
• Sunscreen covering both visible and ultraviolet light spectra enhances treatment efficacy compared to UV-only protection 3
• Counsel patients to avoid smoking, which damages treatment outcomes 1

First-Line Topical Therapy

• Triple combination cream (hydroquinone 4% + tretinoin + corticosteroid) remains the most effective treatment for melasma 1, 4
• Hydroquinone 4% is FDA-indicated for gradual bleaching of melasma and can be used alone or in combination 5, 4
• Tretinoin 0.05% to 0.1% can be used alone or combined with hydroquinone 2% 1, 6
• Azelaic acid is an alternative topical agent, though patients should be counseled about temporary skin irritation (pruritus, burning, stinging) that commonly subsides with continued treatment 7

Advanced Treatment: Intradermal PRP Injections (For Inadequate Response)

PRP injections demonstrate superior efficacy compared to all other advanced treatments, including tranexamic acid injections, with mean mMASI score reduction of 45.67% improvement 1, 2

PRP Treatment Protocol:

• Administer 4 intradermal PRP treatment sessions every 2-3 weeks using monthly intradermal microinjections spaced 1 cm apart 2
• Follow-up evaluation one month after the last treatment 2
• Expect significant improvement within 6 weeks as measured by modified Melasma Area and Severity Index (mMASI) scores 1, 2
• Patient satisfaction rates exceed 90% with PRP treatment 1

Adjunctive Systemic Therapy:

• Consider oral tranexamic acid 250 mg twice daily combined with PRP injections for even higher total efficacy (90.48%) compared to tranexamic acid alone (73.68%) 1, 2
• This combination reduces disease recurrence rates and maintains normal levels of VEGF and α-MSH 1
• Intradermal PRP injections are more effective than intradermal tranexamic acid injections with similar side effect profiles 1, 2

Alternative Procedural Options

• Radiofrequency microneedling: three treatment sessions spaced at least 21 days apart, with maintenance treatments every 6 months 1
• Microneedling is more effective than intradermal injections for delivering treatments to melasma-affected skin 1

Measuring Treatment Success

• Use standardized mMASI scores to objectively track improvement: decreases >60-90% indicate moderate improvement, >90% indicate excellent response 1
• Complement objective measurements with patient satisfaction assessment 1

Maintenance Therapy (Critical for Long-Term Success)

• Melasma must be managed as a chronic condition requiring regular follow-ups with maintenance treatments every 6 months 1, 2
• Continue strict sun protection indefinitely 1, 2
• Consider intermittent use of topical agents 2
• Maintenance PRP treatments every 6 months may be required 1, 2

Common Pitfalls to Avoid

• Discontinuing treatment too early—melasma is a chronic condition with high recurrence rates requiring long-term management 2, 8
• Forgetting to reapply sunscreen after swimming, sweating, or after 2-3 hours of continuous exposure 1
• Failing to address genetic factors and hormonal influences (such as oral contraceptives) that may limit treatment success 1, 6
• Using monobenzyl ether of hydroquinone, which should never be used in melasma therapy 6