What is the recommended management for melasma in an adult woman with darker skin type, considering hormonal influences and sun exposure?

Melasma Treatment in Adult Women with Darker Skin

For an adult woman with darker skin type and melasma, begin with triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) combined with rigorous broad-spectrum sunscreen (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

Foundation: Strict Photoprotection (Essential for All Patients)

Sun protection is the cornerstone of melasma management and must be maintained throughout treatment and indefinitely to prevent recurrence. 1, 2

• Apply broad-spectrum sunscreen 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
• 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
• Avoid tanning beds and sunlamps completely 1
• Even minimal sunlight sustains melanocytic activity and can trigger repigmentation 2

First-Line Treatment: Triple Combination Cream

Triple combination therapy remains the most effective and well-studied topical treatment for melasma. 1, 4

• Apply triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) nightly to affected areas 1
• The corticosteroid component reduces irritation and enhances penetration of other active ingredients 1
• Hydroquinone monotherapy is also highly effective if triple combination is unavailable 4
• Test for skin sensitivity before full application by applying a small amount to an unbroken patch of skin and checking within 24 hours 2
• Minor redness is acceptable, but discontinue if itching, vesicle formation, or excessive inflammation occurs 2
• Continue treatment for 8-12 weeks before assessing response 1

Important Safety Considerations for Hydroquinone

• Avoid contact with eyes and mucous membranes 2
• Caution patients on concomitant use of photosensitizing medications 2
• Hydroquinone has demonstrated some evidence of carcinogenicity in animal studies and is a mutagen/clastogen, though human carcinogenic potential is unknown 2
• Not recommended during pregnancy (Category C) or in children under 12 years 2
• Counsel patients to avoid smoking, which can worsen melasma 5, 1

Second-Line Treatment: Intradermal PRP Injections

If first-line therapy shows inadequate response after 8-12 weeks, intradermal PRP is the most effective advanced treatment option. 1, 3

Why PRP is Preferred for Darker Skin Types

• PRP demonstrates superior efficacy compared to all other advanced treatments, including tranexamic acid injections, with mean mMASI score reduction of 45.67% 5
• PRP carries very low risk of post-inflammatory hyperpigmentation in Fitzpatrick skin types III-VI, markedly lower than laser therapy 1
• Minimal downtime (24-48 hours) and can be safely applied to all skin types without increasing adverse events 1
• No serious adverse events reported, with minimal risk of hyperpigmentation or bruising when needle depth does not exceed 2.5 mm 1

PRP Treatment Protocol

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

Adjunctive Oral Tranexamic Acid

• Consider adding oral tranexamic acid 250 mg twice daily, particularly when combined with PRP injections 1
• PRP combined with oral tranexamic acid demonstrates higher total efficacy (90.48%) compared to tranexamic acid alone (73.68%) with lower disease recurrence rates 5, 1
• Oral tranexamic acid is more effective than topical formulations for hyperpigmentation disorders 3

Alternative Procedural Option: Microneedling

If PRP is unavailable or ineffective, microneedling is a safe alternative for darker skin types. 1

• Microneedling may be more effective than intradermal PRP injections in some patients 5, 1
• Very low risk of post-inflammatory hyperpigmentation in Fitzpatrick skin types III-VI 1
• Set needle depth between 0.25 mm and 2.5 mm depending on treatment area 1
• Apply compounded topical anesthetic at least 30 minutes before procedure 1
• Ensure skin is well lubricated with topical agent or PRP to prevent pulling sensation 1
• Avoid microneedling over tattoos or permanent makeup 1
• Sun avoidance for 24 hours post-procedure and refrain from fragranced products for 24 hours 1

Critical Pitfall: Avoid Laser Therapy in Darker Skin

In individuals with Fitzpatrick skin types IV-VI, laser therapy is associated with markedly higher risk of burns, post-inflammatory hyperpigmentation, and hypopigmentation due to increased melanin absorption of laser energy; therefore it should be avoided or employed only with extreme caution. 1

• Laser therapy carries significantly higher risk than microneedling or PRP for darker skin types 1
• Chemical peels should also be used with caution in darker-complexioned patients 6

Maintenance Therapy (Essential for Long-Term Success)

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

• Continue strict sun protection indefinitely 1, 2
• Consider intermittent use of topical depigmenting agents 3
• Maintenance PRP treatments every 6 months as needed 1, 3
• Do not discontinue treatment too early—maintenance therapy is essential 1, 3

Measuring Treatment Success

• Use standardized modified Melasma Area and Severity Index (mMASI) scores to objectively track improvement 5, 1
• Decreases in MASI >60-90% indicate moderate improvement 5
• Decreases in MASI >90% indicate excellent response 5
• Patient satisfaction assessment should complement objective measurements 5

Additional Considerations for Hormonal Influences

• Address hormonal factors (pregnancy, oral contraceptives, hormone replacement therapy) that may limit treatment success 1, 7
• Genetic factors may also limit treatment efficacy in some patients 5
• Melasma during pregnancy often improves postpartum, but hydroquinone should be avoided during pregnancy 2