What is the recommended treatment plan for melasma, including photoprotection and topical therapy?

Treatment for Melasma

Begin treatment with triple combination cream (hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01%) combined with strict photoprotection using SPF 50+ broad-spectrum sunscreen reapplied every 2-3 hours, as this remains the only FDA-approved and most effective treatment for melasma across all ethnicities. 1, 2, 3

Foundation: Photoprotection (Non-Negotiable for All Patients)

Photoprotection is the cornerstone of melasma management and must be implemented before any other therapy, as UV exposure directly triggers melanogenesis and causes treatment failure. 1, 4, 5

• Apply broad-spectrum sunscreen with minimum SPF 50+ every morning and reapply every 2-3 hours during any outdoor exposure 1, 6
• Wear wide-brimmed hats (>3-inch brim) when outdoors 1, 6
• 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, 6
• Avoid tanning beds and sunlamps completely 1, 6
• Reapply sunscreen after swimming or sweating—this is the most common pitfall leading to treatment failure 1, 6

First-Line Topical Therapy

Triple combination cream is the gold standard and should be prescribed as initial therapy for all melasma patients. 1, 2, 3

• Hydroquinone 4% blocks melanin synthesis by inhibiting tyrosinase 5, 2
• Tretinoin 0.05% increases melanin elimination and enhances penetration of other agents 1, 5, 2
• Fluocinolone acetonide 0.01% reduces irritation from the other components and enhances their penetration 1, 2

This combination demonstrates superior efficacy compared to any single agent alone and is effective across all skin types. 2, 3

Second-Line Treatment: Intradermal Platelet-Rich Plasma (PRP)

If triple combination cream fails to achieve adequate improvement after 8-12 weeks, add intradermal PRP injections as second-line therapy. 1, 6

PRP Treatment Protocol

• Administer 4 intradermal PRP treatment sessions spaced every 2-3 weeks 1
• Inject intradermally at 1 cm intervals across all affected areas 1
• Follow-up evaluation one month after the last treatment session 1
• Maintenance treatments every 6 months are required due to melasma's chronic nature and high recurrence rates 1, 6

Evidence Supporting PRP

PRP demonstrates significantly superior efficacy compared to intradermal tranexamic acid injections with similar safety profiles. 1, 6 Patients show significant improvement in modified Melasma Area and Severity Index (mMASI) scores within 6 weeks, with mean mMASI score reductions of 45.67%. 1, 6

Adjunctive Systemic Therapy: Oral Tranexamic Acid

Consider adding oral tranexamic acid 250 mg twice daily, particularly when combined with PRP injections, for enhanced efficacy. 1, 6

• PRP combined with oral tranexamic acid demonstrates higher total efficacy (90.48%) compared to tranexamic acid alone (73.68%) 1, 6
• Lower disease recurrence rates are observed with combination therapy 1, 6
• Oral tranexamic acid shows the greatest improvement among all tranexamic acid formulations, though effects are temporary 7
• This combination is particularly effective for moderate to severe recurrent melasma 3

Alternative Procedural Option: Microneedling

Microneedling may be more effective than intradermal PRP injections and should be considered as an alternative if PRP is unavailable or ineffective. 1, 6

Microneedling Protocol

• Set needle depth between 0.25 mm and 2.5 mm based on treatment area 1
• Apply topical anesthetic at least 30 minutes before the procedure 1
• Ensure adequate skin lubrication with topical agent or PRP to prevent pulling sensation 1
• Avoid microneedling over tattoos or permanent makeup 1

Safety Advantages of Microneedling

• Very low risk of post-inflammatory hyperpigmentation in Fitzpatrick skin types III-VI, markedly lower than laser therapy 1
• Minimal downtime (24-48 hours) compared to other modalities 1
• Safe for all skin types, including thin, sensitive, and ethnic skin 1
• No serious adverse events reported when needle depth does not exceed 2.5 mm 1

Post-Procedure Care

• Avoid sun exposure for 24 hours after treatment 1
• Refrain from facial creams or fragranced products for 24 hours post-procedure 1

Radiofrequency Microneedling Option

For patients seeking advanced procedural treatment, radiofrequency (RF) microneedling offers another option. 6

• Three treatment sessions spaced at least 21 days apart 6
• Maintenance treatments every 6 months as needed 6

Critical Pitfalls to Avoid

Discontinuing treatment too early is the most common cause of treatment failure—melasma is a chronic condition requiring long-term maintenance therapy even after clearance. 1, 4, 5

Inadequate sunscreen reapplication after swimming, sweating, or after 2-3 hours of continuous exposure leads to treatment failure and rapid recurrence. 1, 6

Failing to address hormonal influences such as pregnancy, oral contraceptives, or hormone replacement therapy may limit treatment success, though women may continue these medications when medically necessary. 1, 6, 4

Smoking worsens melasma and should be addressed through counseling. 1, 6

Important Safety Consideration: Avoid Laser Therapy in Darker Skin

In individuals with Fitzpatrick skin types IV-VI, laser therapy carries a markedly higher risk of burns, post-inflammatory hyperpigmentation, and hypopigmentation due to increased melanin absorption of laser energy and should be avoided. 1 Chemical peels and laser therapies show mixed results and offer higher risk of adverse effects compared to topical treatments. 3

Measuring Treatment Success

Use standardized mMASI scores to objectively track improvement at each visit. 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 6

Treatment Algorithm Summary

1. Initiate strict photoprotection (SPF 50+ reapplied every 2-3 hours) + triple combination cream 1, 2, 3
2. If inadequate response after 8-12 weeks, add intradermal PRP injections (4 sessions every 2-3 weeks) 1, 6
3. Consider adding oral tranexamic acid 250 mg twice daily for enhanced efficacy, particularly with PRP 1, 6
4. Alternative: Use microneedling instead of PRP if unavailable or ineffective 1, 6
5. Maintenance therapy every 6 months is essential to prevent recurrence 1, 6