In an adult patient with melasma, is laser therapy appropriate as first‑line treatment, and what are the recommendations for its use based on Fitzpatrick skin type and prior trial of topical depigmenting agents?

Laser Therapy for Melasma: Not Recommended as First-Line Treatment

Laser therapy should NOT be used as first-line treatment for melasma and should be reserved only for cases that have failed adequate trials of topical depigmenting agents combined with strict photoprotection. 1, 2, 3, 4

First-Line Treatment Protocol (Must Be Attempted First)

Start all melasma patients with this combination approach for 8-12 weeks before considering any procedural interventions: 1, 2

• Triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) applied nightly 1
• Broad-spectrum sunscreen SPF 50+ reapplied every 2-3 hours during outdoor exposure 1, 2
• Physical sun protection measures: wide-brimmed hats (>3-inch brim), seeking shade during peak UV hours (10 AM-4 PM), UV-protective clothing with tight weave and darker colors 1, 5
• Complete avoidance of tanning beds and sunlamps 1

When Laser May Be Considered (Second-Line or Beyond)

Laser therapy can only be considered after documented failure of first-line topical therapy for at least 8-12 weeks. 3, 4, 6 However, even in refractory cases, intradermal platelet-rich plasma (PRP) injections are superior to laser therapy and should be the preferred second-line treatment. 1, 2, 5

Critical Fitzpatrick Skin Type Considerations

For Fitzpatrick skin types IV-VI (darker skin): Laser therapy carries significantly higher risk and should be used with extreme caution or avoided entirely due to increased melanin content that attracts more light energy, causing burns and pigmentation changes. 7 This is particularly relevant since melasma predominantly affects individuals with darker skin types.

For Fitzpatrick skin types I-III (lighter skin): Laser may be considered in refractory cases, but still carries substantial risk of post-inflammatory hyperpigmentation and high recurrence rates. 3, 6

Preferred Second-Line Treatment Algorithm

If inadequate response after 8-12 weeks of first-line therapy: 1, 2

1. Add intradermal PRP injections: 4 treatment sessions spaced every 2-3 weeks, injected intradermally at 1 cm intervals across affected areas 1, 2
2. Consider oral tranexamic acid 250 mg twice daily as adjunctive therapy, particularly when combined with PRP (total efficacy 90.48% vs 73.68% with tranexamic acid alone) 1, 2, 5
3. Continue strict photoprotection throughout treatment 1, 2
4. Maintenance PRP treatments every 6 months as melasma is chronic with high recurrence rates 1, 2, 5

Why Laser Is Not Preferred

Multiple expert consensus statements emphasize that laser cannot be first-line treatment and should be restricted to cases unresponsive to topical therapy. 3, 4 The evidence shows:

• High recurrence rates with all laser modalities 6
• Significant risk of post-inflammatory hyperpigmentation, especially in darker skin types 3, 6
• Risk of post-inflammatory hypopigmentation with certain laser types 6
• Requires multiple treatment sessions with variable efficacy 6
• PRP injections demonstrate superior efficacy with better safety profiles compared to laser interventions 1, 2, 5

Specific Laser Considerations If Used (Third-Line)

If laser therapy is ultimately pursued after failure of both topical therapy and PRP injections: 6

• Low-fluence Q-switched Nd:YAG lasers have the most evidence but require the greatest number of treatments 6
• Non-ablative fractional lasers may provide slightly longer remission intervals 6
• Avoid ablative fractional lasers due to very high risk of post-inflammatory hypo- and hyperpigmentation 6
• Avoid vascular-specific lasers as they do not appear effective for melasma 6

Critical Pitfalls to Avoid

• Never use laser as first-line therapy without adequate trial of topical depigmenting agents 3, 4
• Never discontinue photoprotection even when using advanced treatments—this is the foundation of all melasma management 1, 2, 8
• Never forget that melasma is chronic requiring long-term maintenance therapy regardless of treatment modality chosen 1, 2, 5
• Never use laser in Fitzpatrick skin types IV-VI without extensive counseling about high risk of pigmentary complications 7
• Never fail to address hormonal influences (pregnancy, oral contraceptives, hormone replacement therapy) that may limit treatment success 5
• Counsel patients to avoid smoking which worsens melasma 1, 5

Measuring Treatment Success

Use standardized modified Melasma Area and Severity Index (mMASI) scores to objectively track improvement: 1, 5

• >60-90% decrease in MASI: moderate improvement 1
• >90% decrease in MASI: excellent response 1
• Patient satisfaction assessment should complement objective measurements 1, 5