What is the recommended treatment approach for a patient diagnosed with Melasma, considering potential hormonal influences and the need for effective management of hyperpigmentation?

Melasma Treatment

Start with triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) applied once daily combined with strict photoprotection using SPF 50+ broad-spectrum sunscreen reapplied every 2-3 hours. 1, 2

First-Line Treatment Protocol

Photoprotection (Essential Foundation)

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

Critical pitfall: Patients commonly forget to reapply sunscreen after swimming, sweating, or after 2-3 hours of continuous exposure—this single failure can undermine all other treatments. 1, 3

Topical Therapy

• Triple combination cream is FDA-approved and most effective: hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01% applied once daily 1, 2, 4
• In clinical trials, 77% of patients were clear or almost clear by week 8, with 81-94% achieving clear/mild status by 12 months 4
• Continue daily application for 12 weeks minimum 5
• If clear or almost clear at 12 weeks, attempt maintenance dosing twice weekly 5
• Important caveat: Most patients (approximately 78%) who switch to maintenance therapy will relapse and require return to daily dosing 5

Addressing Hormonal Influences

• Counsel patients to discontinue oral contraceptives if medically appropriate 6
• Avoid hormone replacement therapy when possible 6
• Counsel patients to avoid smoking, which worsens melasma 1, 3

Second-Line Treatment for Inadequate Response After 12 Weeks

Intradermal Platelet-Rich Plasma (PRP) Injections

If melasma persists despite 12 weeks of triple combination cream and strict photoprotection, add intradermal PRP injections. 1, 3

• Administer 4 treatment sessions spaced every 2-3 weeks 1
• Inject intradermally at 1 cm intervals across affected areas 1
• Evaluate response one month after the last treatment 1
• PRP demonstrates superior efficacy compared to intradermal tranexamic acid injections with similar side effect profiles 3
• Significant improvement occurs within 6 weeks as measured by modified Melasma Area and Severity Index (mMASI) scores 1, 3
• Continue triple combination cream and photoprotection during PRP treatment 1

Adjunctive Oral Tranexamic Acid

• Consider adding oral tranexamic acid 250 mg twice daily, particularly when combined with PRP injections 1, 3
• PRP combined with oral tranexamic acid shows higher total efficacy (90.48%) compared to tranexamic acid alone (73.68%) with lower disease recurrence rates 1, 3

Alternative Procedural Option

• Microneedling may be more effective than intradermal PRP injections in some patients 1, 3, 7
• Consider microneedling as an alternative if PRP is unavailable or ineffective 1
• Radiofrequency microneedling requires three treatment sessions spaced at least 21 days apart 3

Long-Term Management

Maintenance Therapy

Melasma is a chronic condition with high recurrence rates requiring indefinite maintenance. 1, 3

• Maintenance treatments every 6 months are typically required 1, 3
• Continue strict photoprotection indefinitely 1, 3
• Most patients cannot successfully discontinue daily topical therapy without relapse 5

Monitoring Treatment Success

• Use standardized mMASI scores to objectively track improvement 1, 3
• Decreases in MASI >60-90% indicate moderate improvement 1, 3
• Decreases in MASI >90% indicate excellent response 1, 3
• Patient satisfaction assessment should complement objective measurements 3

Critical Pitfalls to Avoid

• Discontinuing treatment too early: Melasma requires long-term maintenance therapy; stopping treatment leads to recurrence 1
• Inadequate photoprotection: Even excellent topical therapy fails without strict sun protection 1, 3
• Failing to address hormonal influences: Oral contraceptives and hormone replacement therapy may limit treatment success 1
• Expecting permanent cure: Patients must understand melasma is chronic and requires ongoing management 1, 3