What are the treatment options for melasma?

Treatment Options for Melasma

Begin with strict broad-spectrum sunscreen (SPF 50+) combined with topical hydroquinone 4% as the foundation of melasma treatment, and for refractory cases, add intradermal platelet-rich plasma (PRP) injections which demonstrate superior efficacy compared to all other advanced therapies. 1, 2, 3

First-Line Treatment Approach

Sun Protection (Essential Foundation)

• 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

Topical Therapy

• Hydroquinone 4% is FDA-approved for gradual bleaching of melasma and remains the most effective topical agent 3, 4
• Tretinoin can be used alone or combined with hydroquinone 1
• Triple combination cream (hydroquinone + tretinoin + corticosteroid) is the most effective topical treatment available 4, 5
• Counsel patients to avoid smoking, which impairs treatment outcomes 1

Second-Line Treatment for Inadequate Response

When to Escalate

• If inadequate response after 8-12 weeks of first-line therapy, escalate to advanced treatments 2

Intradermal Platelet-Rich Plasma (PRP) Injections

• PRP injections are the most effective treatment for melasma, demonstrating superior efficacy compared to all other advanced therapies including tranexamic acid 1, 2
• Treatment protocol: 3-5 intradermal microinjection sessions (1 cm apart) administered every 2-3 weeks 2
• Follow-up evaluation one month after the last treatment 2
• Mean mMASI score reduction of 45.67% with PRP alone 1
• Patient satisfaction rates exceed 90% 1
• Microneedling delivery may be more effective than direct intradermal injections 1, 6

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 73.68% with tranexamic acid alone 1, 2
• Lower disease recurrence rates with combination therapy 1, 2
• Oral tranexamic acid is more effective than topical formulations 2

Alternative Procedural Options

Radiofrequency Microneedling

• Three treatment sessions spaced at least 21 days apart 1
• Maintenance treatments every 6 months as needed 1

Maintenance Strategy

Long-Term Management

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

Monitoring Treatment Success

• Use modified Melasma Area and Severity Index (mMASI) scores to objectively track improvement 1, 2
• Decreases in MASI >60-90% indicate moderate improvement 1
• Decreases >90% indicate excellent response 1
• Complement objective measurements with patient satisfaction assessment 1

Critical Pitfalls to Avoid

• Forgetting to reapply sunscreen after swimming, sweating, or after 2-3 hours of continuous exposure 1
• Discontinuing treatment too early—maintenance therapy is essential due to high recurrence rates 2
• Using laser therapy without adequate sun protection, which increases risk of post-inflammatory hyperpigmentation 4
• Expecting rapid results—treatment requires 8-12 weeks minimum before assessing efficacy 2