What's a good treatment for facial melasma, considering options like Cosmelan (depigmenting agent) and laser therapy?

Recommended Treatment for Facial Melasma

Start with triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) plus strict sun protection (SPF 50+ reapplied every 2-3 hours), and if inadequate response after 8-12 weeks, add intradermal platelet-rich plasma (PRP) injections every 2-3 weeks for 4 sessions. 1

Why Not Cosmelan or Laser as First-Line?

While you asked about Cosmelan and laser therapy, current evidence strongly favors a different approach:

• Laser treatments show limited efficacy and should rarely be used for melasma treatment, as they frequently cause post-inflammatory hyperpigmentation, particularly in darker skin types 2, 3
• Cosmelan (a depigmenting peel) falls under chemical peels, which are considered second-line adjunctive therapy rather than primary treatment 4, 5
• The only FDA-approved treatment for melasma is the triple combination cream mentioned above 3, 5

First-Line Treatment Protocol

Topical Therapy

• Apply triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) as directed 1
• This remains the gold standard with demonstrated efficacy across all ethnicities 3

Essential Sun Protection (Non-Negotiable)

• Use broad-spectrum SPF 50+ sunscreen reapplied every 2-3 hours during outdoor exposure 1, 6
• Wear wide-brimmed hats (>3-inch brim) when outdoors 1
• Seek shade during peak UV hours (10 a.m. to 4 p.m.) 1, 6
• Use UV-protective clothing with tight weave fabrics and darker colors 1
• Avoid tanning beds and sunlamps completely 1

Second-Line Treatment for Inadequate Response

If no adequate improvement after 8-12 weeks of first-line therapy:

Intradermal PRP Injections (Most Effective Advanced Treatment)

• PRP injections are the most effective treatment for melasma, showing significantly better results than all other advanced therapies including tranexamic acid injections 7, 1
• Administer 4 intradermal PRP treatment sessions spaced every 2-3 weeks 7, 1
• Inject intradermally at 1 cm intervals across affected areas 1, 6
• Significant improvement visible within 6 weeks as measured by modified Melasma Area and Severity Index (mMASI) scores 7, 1
• Mean mMASI score reduction of 45.67% with PRP alone 6
• Patient satisfaction rates exceed 90% 6

Consider Adding Oral Tranexamic Acid

• Oral tranexamic acid 250 mg twice daily can be added, particularly when combined with PRP 1, 6
• PRP combined with oral tranexamic acid demonstrates higher total efficacy (90.48%) compared to tranexamic acid alone (73.68%) with lower recurrence rates 7, 1

Alternative Procedural Option

Microneedling

• Microneedling may be more effective than intradermal PRP injections in some patients 1, 6
• Consider as an alternative if PRP is unavailable or ineffective 1
• Radiofrequency microneedling protocol: three treatment sessions spaced at least 21 days apart 6

Maintenance Phase (Critical for Long-Term Success)

• Continue strict sun protection indefinitely 1, 6
• Maintenance PRP treatments every 6 months 7, 1, 6
• Consider intermittent use of topical agents 7
• Follow-up evaluation one month after last treatment session 1

Measuring Treatment Success

• Use standardized mMASI scores to objectively track improvement 1, 6
• Decreases in MASI >60-90% indicate moderate improvement 1, 6
• Decreases in MASI >90% indicate excellent response 1, 6
• Patient satisfaction assessment should complement objective measurements 1, 6

Critical Pitfalls to Avoid

• Never discontinue treatment too early—melasma is a chronic condition requiring long-term maintenance therapy 7, 1
• Forgetting to reapply sunscreen after swimming, sweating, or after 2-3 hours of continuous exposure 1, 6
• 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 1, 6
• Avoid laser treatments as they show limited efficacy and frequently cause post-inflammatory hyperpigmentation 2, 3

Why This Algorithm Works

The evidence strongly supports starting conservatively with proven topical therapy and sun protection, then escalating to PRP injections if needed. This approach:

• Uses the only FDA-approved treatment first 3, 5
• Reserves the most effective advanced treatment (PRP) for inadequate responders 7, 1
• Avoids treatments with high risk of complications (lasers) 2, 3
• Addresses the chronic nature of melasma with appropriate maintenance 7, 1