What are the recommended treatment options for a patient with melasma, considering their potential medical history and need for effective management?

Melasma Management and Advances

Start with triple combination cream (hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01%) combined with strict broad-spectrum sunscreen (SPF 50+), and if inadequate response after 8-12 weeks, add intradermal platelet-rich plasma (PRP) injections as the most effective advanced treatment for melasma. 1

Foundation: Sun Protection (Essential for All Patients)

Sun protection is the absolute foundation of melasma treatment and must be maintained throughout all treatment phases 2, 1:

• Apply broad-spectrum sunscreen with minimum SPF 30, preferably SPF 50+, reapplied every 2-3 hours during outdoor exposure 2, 1
• Wear wide-brimmed hats (>3-inch brim) when outdoors 2, 1
• Seek shade during peak UV hours (10 a.m. to 4 p.m.) 2, 1
• Use UV-protective clothing with tight weave fabrics and darker colors 2, 1
• Avoid tanning beds and sunlamps completely 2, 1

First-Line Treatment: Triple Combination Therapy

Triple combination cream remains the most effective topical treatment for melasma 1, 3:

• Hydroquinone 4% inhibits enzymatic oxidation of tyrosine to dopa and suppresses melanocyte metabolic processes 4
• Tretinoin 0.05% can be used alone or combined with hydroquinone for enhanced efficacy 1
• Fluocinolone acetonide 0.01% (corticosteroid) reduces irritation and enhances penetration 1
• Continue for 8-12 weeks before assessing response 5

Important caveat: Exposure to sunlight or UV light will cause repigmentation of bleached areas, making sun protection non-negotiable 4

Second-Line Treatment: Intradermal PRP Injections

If inadequate response to first-line therapy after 8-12 weeks, intradermal PRP injections are the most effective advanced treatment, showing superior results compared to all other modalities including tranexamic acid injections 2, 5, 1:

PRP Treatment Protocol:

• Administer 4 intradermal PRP treatment sessions spaced every 2-3 weeks 5, 1
• Inject intradermally at 1 cm intervals across affected areas 5, 1
• Follow-up evaluation one month after the last treatment 5, 1
• Significant improvement visible within 6 weeks as measured by modified Melasma Area and Severity Index (mMASI) scores 2, 5

Evidence Supporting PRP:

• Mean mMASI score reduction of 45.67% improvement with PRP 2
• PRP demonstrates superior efficacy compared to intradermal tranexamic acid with similar side effect profiles 2, 5, 1
• Patient satisfaction rates exceed 90% 2

Alternative consideration: Microneedling may be more effective than intradermal PRP injections in some patients and should be considered if PRP is unavailable or ineffective 2, 1

Adjunctive Systemic Therapy: Oral Tranexamic Acid

Consider oral tranexamic acid 250 mg twice daily, particularly when combined with PRP injections 2, 1:

• PRP combined with oral tranexamic acid demonstrates higher total efficacy (90.48%) compared to tranexamic acid alone (73.68%) 2, 1
• Lower disease recurrence rates with combination therapy 2, 1
• Maintains normal levels of VEGF and α-MSH 2
• Oral tranexamic acid is more effective than topical tranexamic acid for hyperpigmentation 5

Maintenance Phase (Critical for Long-Term Success)

Melasma is a chronic condition requiring long-term maintenance therapy 2, 5, 1:

• Continue strict sun protection indefinitely 5, 1
• Consider intermittent use of topical agents 5
• Maintenance PRP treatments every 6 months 2, 5, 1
• Regular follow-ups to monitor for recurrence 2

Measuring Treatment Success

Use standardized mMASI scores to objectively track improvement 2, 1:

• Decreases in MASI >60-90% indicate moderate improvement 2, 1
• Decreases in MASI >90% indicate excellent response 2, 1
• Patient satisfaction assessment should complement objective measurements 2, 1

Critical Pitfalls to Avoid

Discontinuing treatment too early is the most common mistake—melasma requires long-term maintenance therapy with high recurrence rates without it 5, 1:

• Forgetting to reapply sunscreen after swimming, sweating, or after 2-3 hours of continuous exposure 2, 1
• Failing to address hormonal influences (pregnancy, oral contraceptives, hormone replacement therapy) that may limit treatment success 1
• Counsel patients to avoid smoking, which can worsen melasma 2, 1
• Never use monobenzyl ether of hydroquinone in melasma therapy 6
• Patients should suspend use of oral contraceptives and other agents that promote skin pigmentation 6

Treatment Algorithm Summary

Step 1 (Weeks 0-12):

• Initiate strict sun protection (SPF 50+, reapply every 2-3 hours) 1
• Apply triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) 1
• Counsel on avoiding smoking and hormonal triggers 2, 1

Step 2 (If inadequate response after 8-12 weeks):

• Continue sun protection and topical therapy 1
• Add intradermal PRP injections every 2-3 weeks for 4 sessions 5, 1
• Consider adding oral tranexamic acid 250 mg twice daily for enhanced efficacy 2, 1

Step 3 (Maintenance):

• Continue sun protection indefinitely 5, 1
• Maintenance PRP treatments every 6 months 2, 5, 1
• Consider intermittent topical therapy 5