What is the best product to treat facial melasma?

Best Product for Facial Melasma (Dark Macular Lesions)

Start with triple combination cream (hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01%) combined with strict broad-spectrum sunscreen (SPF 50+), as this represents the most effective first-line topical treatment for melasma. 1

First-Line Treatment Protocol

Topical Therapy

• Apply triple combination cream once daily to affected areas, which combines three proven mechanisms: melanin synthesis inhibition (hydroquinone), enhanced skin cell turnover (tretinoin), and reduced inflammation with improved penetration (corticosteroid) 1, 2
• Hydroquinone 4% is FDA-approved specifically for melasma and works by inhibiting tyrosine oxidation to prevent melanin production 3
• This combination achieves 77% clear/almost clear rates by week 8, with 29% experiencing complete clearing 2

Essential Photoprotection (Non-Negotiable)

• Use broad-spectrum sunscreen SPF 50+ reapplied every 2-3 hours during any outdoor exposure, as UV light directly reverses treatment gains 1, 3
• Wear wide-brimmed hats (>3-inch brim) 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
• Critically important: Choose sunscreen covering both UV and visible light spectra, as visible light protection enhances hydroquinone efficacy beyond UV-only protection 4

Second-Line Treatment for Inadequate Response After 8-12 Weeks

If topical therapy proves insufficient after 8-12 weeks, add intradermal platelet-rich plasma (PRP) injections, which demonstrate superior efficacy compared to all other advanced treatments 5, 1:

PRP Treatment Protocol

• Administer 4 intradermal PRP sessions spaced every 2-3 weeks 1
• Inject intradermally at 1 cm intervals across affected areas 5
• Expect significant improvement within 6 weeks as measured by modified Melasma Area and Severity Index (mMASI) scores 5, 6
• PRP shows mean mMASI score reduction of 45.67% 6
• Follow-up evaluation one month after the last treatment 1

Adjunctive Oral Therapy

• Consider adding oral tranexamic acid 250 mg twice daily, particularly when combined with PRP injections 1
• PRP combined with oral tranexamic acid achieves 90.48% total efficacy compared to 73.68% with tranexamic acid alone, with lower recurrence rates 5, 6

Treatment Algorithm Decision Points

Week 0-8:

• Triple combination cream daily + strict sun protection 1
• Measure baseline mMASI score 1

Week 8-12 evaluation:

• If clear/almost clear: Continue topical therapy + sun protection 1
• If inadequate response: Add PRP injections every 2-3 weeks for 4 sessions 1
• Consider adding oral tranexamic acid 250 mg twice daily 1

Month 6 onwards:

• Maintenance PRP treatments every 6 months (melasma is chronic with high recurrence rates) 5, 1
• Continue intermittent topical therapy and strict sun protection 5

Measuring Treatment Success

Track improvement objectively using standardized mMASI scores 1:

• >60-90% reduction = moderate improvement 6, 1
• >90% reduction = excellent response 6, 1
• Patient satisfaction assessment should complement objective measurements 6

Critical Pitfalls to Avoid

• Never discontinue treatment prematurely—melasma requires long-term maintenance therapy due to its chronic nature and high recurrence rates 1
• Never forget sunscreen reapplication after swimming, sweating, or after 2-3 hours of continuous exposure 1
• Never use monobenzyl ether of hydroquinone for melasma therapy 7
• Address hormonal influences (pregnancy, oral contraceptives, hormone replacement therapy) that may limit treatment success 6, 1
• Counsel patients to avoid smoking, which worsens melasma 6, 1

Alternative Consideration

Microneedling may be more effective than intradermal PRP injections in some patients and can be considered as an alternative if PRP is unavailable or ineffective 6, 1