What are the treatment options for melasma?

Melasma Treatment

Begin with strict broad-spectrum sunscreen (SPF 50+) combined with triple combination cream (hydroquinone, tretinoin, and corticosteroid), and if inadequate response after 8-12 weeks, add intradermal platelet-rich plasma (PRP) injections which demonstrate superior efficacy to all other advanced treatments. 1, 2

Foundation: Sun Protection (Essential for All Patients)

• Apply broad-spectrum sunscreen with minimum SPF 30, though SPF 50+ is preferable 1, 2
• Reapply every 2-3 hours during outdoor exposure 1, 2
• 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
• Counsel patients to avoid smoking, which impairs treatment outcomes 1

Common pitfall: Forgetting to reapply sunscreen after swimming, sweating, or after 2-3 hours of continuous exposure leads to treatment failure 1

First-Line Topical Therapy

• Triple combination cream (hydroquinone + tretinoin + corticosteroid) is the most effective topical treatment 3, 4, 5
• Hydroquinone monotherapy (2% concentration) can be used alone or combined with tretinoin (0.05% to 0.1%) 1, 6
• Continue first-line therapy for 8-12 weeks before escalating treatment 2

The evidence strongly supports combination therapy over monotherapy, with triple combination showing approximately 40% of patients achieving significant improvement, though erythema and peeling occur in similar proportions 4, 5

Advanced Treatment: Intradermal PRP Injections

For inadequate response to topical therapy, intradermal PRP injections are the most effective advanced treatment option 2, 3

PRP Protocol:

• Administer 4 treatment sessions every 2-3 weeks 2
• Use 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

PRP Efficacy Data:

• Mean mMASI score reduction of 45.67% with PRP alone 1
• PRP demonstrates superior efficacy compared to intradermal tranexamic acid injections with similar side effect profiles 1, 2, 3
• Patient satisfaction rates exceed 90% 1

Adjunctive Systemic Therapy

• Consider oral tranexamic acid 250 mg twice daily when combined with PRP injections 1
• PRP combined with oral tranexamic acid shows 90.48% total efficacy compared to tranexamic acid alone (73.68%) 1, 2
• This combination reduces disease recurrence rates 1, 2

Important consideration: Oral tranexamic acid is more effective than topical tranexamic acid for hyperpigmentation disorders 2

Alternative Procedural Options

• Microneedling may be more effective than intradermal PRP injections in some patients 1, 3
• Radiofrequency microneedling requires three treatment sessions spaced at least 21 days apart 1
• Chemical peels and laser therapies show mixed results with increased risk of post-inflammatory hyperpigmentation, particularly in darker-skinned individuals 4, 5

Critical caveat: Laser and light-based therapies are equal or inferior to topical treatments but carry higher risk of adverse effects 5

Maintenance Strategy

• Melasma is a chronic condition requiring long-term management 1, 2
• Continue strict sun protection indefinitely 2, 3
• Maintenance PRP treatments every 6 months as needed 1, 2
• Consider intermittent use of topical agents for maintenance 2

Common pitfall: Discontinuing treatment too early leads to high recurrence rates, as melasma requires ongoing maintenance therapy 2

Measuring Treatment Success

• Use standardized mMASI scores to objectively track improvement 1
• Decreases in MASI >60-90% indicate moderate improvement 1
• Decreases >90% indicate excellent response 1
• Patient satisfaction assessment should complement objective measurements 1

Treatment Algorithm Summary

1. Initiate immediately: Strict sun protection + triple combination cream 1, 2, 3
2. At 8-12 weeks: If inadequate response, add intradermal PRP injections (4 sessions every 2-3 weeks) 2
3. Consider adding: Oral tranexamic acid 250 mg twice daily with PRP for enhanced efficacy 1, 2
4. Long-term: Maintenance PRP every 6 months + continued sun protection 1, 2