What are the treatment options for Chloasma (melasma)?

Treatment of Chloasma (Melasma)

Start with strict broad-spectrum sunscreen (SPF 50+) combined with triple combination cream (hydroquinone 4%, tretinoin, and corticosteroid), which remains the most effective first-line treatment for melasma. 1, 2, 3

First-Line Treatment Approach

Sun Protection (Foundation of All Treatment)

• Apply broad-spectrum sunscreen with SPF 50+ daily, reapplying every 2-3 hours during outdoor exposure 1, 4
• Use physical blockers (titanium dioxide and zinc oxide) rather than chemical blockers for broader protection 5
• Wear wide-brimmed hats (>3-inch brim), seek shade during peak UV hours (10 AM to 4 PM), and use UV-protective clothing with tight weave fabrics 1
• Avoid tanning beds completely 1
• Critical pitfall: Forgetting to reapply sunscreen after swimming, sweating, or after 2-3 hours negates treatment efficacy 1

Topical Depigmenting Agents

• Hydroquinone 4% is FDA-indicated for gradual bleaching of chloasma and melasma 2
• Triple combination cream (hydroquinone + tretinoin + corticosteroid) is the most effective and well-studied topical treatment 3
• Tretinoin can be used alone or combined with hydroquinone 1
• Continue topical therapy for at least 8-12 weeks before assessing response 4

Second-Line Treatment for Inadequate Response

Intradermal Platelet-Rich Plasma (PRP) Injections

If first-line therapy fails after 8-12 weeks, intradermal PRP injections are the most effective advanced treatment, demonstrating superior efficacy compared to all other procedural options including tranexamic acid injections. 4, 6

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

Adjunctive Oral Tranexamic Acid

• Consider oral tranexamic acid 250 mg twice daily when combined with PRP injections 1
• PRP combined with oral tranexamic acid demonstrates higher total efficacy (90.48%) compared to tranexamic acid alone (73.68%) 1, 4
• This combination reduces disease recurrence rates 1, 4

Alternative Procedural Option

• Microneedling may be more effective than intradermal PRP injections in some cases 1, 6
• For radiofrequency microneedling: three treatment sessions spaced at least 21 days apart 1

Measuring Treatment Success

• Use modified Melasma Area and Severity Index (mMASI) scores to objectively track improvement 1, 4
• Decreases in MASI >60-90% indicate moderate improvement; >90% indicates excellent response 1

Maintenance Therapy (Essential for Long-Term Control)

Melasma is a chronic condition requiring ongoing maintenance—discontinuing treatment prematurely is the most common pitfall leading to recurrence. 1, 4

• Continue strict sun protection indefinitely 1, 4
• Maintenance PRP treatments every 6 months as needed 1, 4
• Consider intermittent use of topical depigmenting agents 4
• Regular follow-ups are mandatory as melasma has high recurrence rates 1

Treatments to Avoid

• Avoid destructive modalities (cryotherapy, medium-depth chemical peels, aggressive lasers) as they yield unpredictable results with potential adverse effects including post-inflammatory hyperpigmentation 5
• Chemical peels and laser-based therapies are equal or inferior to topicals with higher risk of adverse effects 3

Special Considerations for Pregnancy

• During pregnancy, treatment is limited to strict photoprotection only 5, 7
• Broad-spectrum sunscreen (SPF 50+) prevents chloasma development in 97.3% of pregnant women (only 2.7% occurrence vs. 53% without protection) 7
• Avoid photosensitizing products and inappropriate skin care routines 7
• Condition is self-limited but may take months to resolve postpartum 5