What is the recommended treatment plan for melasma using microneedling?

Microneedling Treatment Plan for Melasma

Microneedling combined with topical tranexamic acid or platelet-rich plasma (PRP) is highly effective for melasma, with treatment protocols consisting of 3-4 sessions spaced 2-3 weeks apart, followed by maintenance treatments every 6 months. 1, 2

Treatment Protocol

Initial Treatment Series

• Perform 3-4 microneedling sessions spaced 2-3 weeks apart (every 14-21 days) 1, 2
• Use needle depths between 0.5-2.0 mm depending on facial area and skin thickness 3
• Apply topical compounded anesthesia (pharmacy-based, not over-the-counter) for at least 30 minutes prior to procedure 3
• Ensure complete removal of anesthetic before beginning treatment 3

Adjunctive Topical Agents During Microneedling

The evidence strongly supports combining microneedling with either:

Option 1: Topical Tranexamic Acid (Preferred for cost-effectiveness)

• Apply 10% tranexamic acid solution to skin during microneedling procedure 4
• This achieves 65.92% improvement in modified MASI scores versus 20.75% with microneedling alone 4
• Apply the agent BEFORE microneedling to allow the needles to push it into the skin 3

Option 2: Platelet-Rich Plasma (Most effective but more expensive)

• PRP demonstrates superior efficacy compared to tranexamic acid injections 1, 2
• Apply PRP liberally to keep skin well-lubricated during the procedure to avoid dry tugging sensation 3
• PRP must be applied BEFORE microneedling, not after, for optimal results 3
• If using PRF (platelet-rich fibrin), note it will clot within 20-40 minutes in the syringe 3

Technique Considerations

• Use directional passes across treatment areas with automated microneedling device 3
• Ensure skin remains well-lubricated throughout procedure 3
• Do not microneedle over tattoos or permanent makeup 3
• Downtime is typically 24-48 hours 3

Maintenance Phase

• Schedule maintenance treatments every 6 months indefinitely 3, 1, 2
• Melasma is a chronic condition with high recurrence rates requiring ongoing management 1, 2

Essential Concurrent Photoprotection

Sun protection is non-negotiable and must be implemented from day one:

• Broad-spectrum sunscreen SPF 50+ applied daily 1, 2
• Reapply every 2-3 hours during outdoor exposure 2
• Wear wide-brimmed hats (>3-inch brim) 2
• Seek shade during peak UV hours (10 AM to 4 PM) 2
• Use UV-protective clothing with tight weave fabrics 2
• Avoid tanning beds completely 2

Adjunctive Systemic Therapy

Consider adding oral tranexamic acid 250 mg twice daily for enhanced efficacy, particularly when combined with PRP treatments 2

• PRP combined with oral tranexamic acid shows 90.48% efficacy versus 73.68% with tranexamic acid alone 1, 2
• Lower recurrence rates with combination therapy 1, 2

Measuring Treatment Success

• Use modified Melasma Area and Severity Index (mMASI) scores at each visit 1, 2, 4
• Decreases in MASI >60-90% indicate moderate improvement 2
• Decreases >90% indicate excellent response 2
• Patient satisfaction assessment should complement objective measurements 2

Critical Pitfalls to Avoid

Applying topical agents AFTER microneedling instead of before - One study showed no benefit when PRP was applied after microneedling rather than before, as the needles need to push the agent into the skin 3

Discontinuing treatment after initial improvement - Melasma requires lifelong maintenance; stopping treatment leads to high recurrence rates 1, 2

Inadequate sun protection - Treatment will fail without strict photoprotection measures 1, 2, 5

Using over-the-counter topical anesthesia - Use compounded pharmacy-based anesthesia for adequate pain control 3

Forgetting to remove anesthetic completely - This must be thoroughly removed before beginning treatment 3

Patient Counseling

• Advise patients to avoid sunlight and heavily scented facial creams/products for 24 hours post-procedure 3
• Counsel patients to avoid smoking, as it negatively impacts treatment outcomes 3, 2
• Set realistic expectations that this is a chronic condition requiring ongoing management 1, 2

Evidence Quality Note

While microneedling shows tremendous potential for melasma treatment 6, the evidence base consists primarily of low-quality studies with methodological differences 7. However, the consistent finding across multiple studies is that microneedling combined with topical agents (especially tranexamic acid or PRP) is significantly more effective than microneedling alone 7, 8, 4, with an excellent safety profile and minimal risk of post-inflammatory hyperpigmentation 3, 7.