Is laser therapy recommended as a first‑line treatment for melasma, particularly in patients with Fitzpatrick skin types III–VI?

Laser Therapy is NOT Recommended as First-Line Treatment for Melasma

Laser therapy should be avoided as first-line treatment for melasma, particularly in patients with Fitzpatrick skin types III–VI, due to the markedly elevated risk of post-inflammatory hyperpigmentation, burns, and paradoxical worsening of pigmentation. 1

First-Line Treatment Algorithm

Start with the following evidence-based approach before considering any procedural interventions:

Step 1: Triple Combination Cream + Strict Photoprotection

• Apply triple combination cream (hydroquinone 4%, tretinoin 0.05%, fluocinolone acetonide 0.01%) nightly 1
• Use broad-spectrum SPF 50+ sunscreen reapplied every 2-3 hours during outdoor exposure 1
• Wear wide-brimmed hats (>3-inch brim) and seek shade during peak UV hours (10 a.m. to 4 p.m.) 1
• Continue this regimen for at least 8-12 weeks before escalating therapy

Step 2: If Inadequate Response After First-Line Therapy

• Add intradermal PRP injections as second-line therapy: 4 treatment sessions spaced every 2-3 weeks 1
• PRP demonstrates significantly better efficacy than tranexamic acid injections with similar safety profiles 2, 1
• Consider oral tranexamic acid 250 mg twice daily as adjunctive therapy, which when combined with PRP shows 90.48% total efficacy versus 73.68% for tranexamic acid alone 1

Step 3: Alternative to PRP - Microneedling

• Microneedling is safer than laser for Fitzpatrick III–VI skin types with very low risk of post-inflammatory hyperpigmentation 1
• Use needle depth 0.25-2.5 mm with topical anesthetic applied 30 minutes prior 1
• Apply PRP before microneedling (not after) to maximize growth factor penetration 1
• Minimal downtime of 24-48 hours compared to laser therapy 1

Why Laser Should Be Avoided or Used Only as Last Resort

Critical Safety Concerns in Darker Skin Types

• In Fitzpatrick IV-VI skin types, laser therapy carries markedly higher risk of burns, post-inflammatory hyperpigmentation, and hypopigmentation due to increased melanin absorption of laser energy 1
• Multiple expert consensus statements confirm laser cannot be first-line treatment and should be restricted to cases unresponsive to topical therapy 3, 4
• Even when used, low-energy settings are mandatory due to risk of paradoxical melasma stimulation 5

Evidence Hierarchy

• Systematic review of 113 randomized controlled trials (6,897 participants) concluded that chemical peels and laser/light-based devices show mixed results and are equal or inferior to topicals while offering higher risk of adverse effects 6
• The 2017 Indian Pigmentary Expert Group consensus explicitly states: "laser cannot be the first line treatment for melasma" and should only be used as adjuvant therapy in resistant cases with proper patient selection and counseling 4

When Laser Might Be Considered (Third-Line Only)

If you must consider laser after failed topical therapy and PRP/microneedling:

• Q-switched Nd:YAG 1064-nm at low fluence is the safest laser option for darker skin types 3, 5
• Fractional non-ablative lasers may be used cautiously 5
• Always combine with maintenance topical therapy (hydroquinone or triple combination) to prevent relapse 3, 5
• Strict photoprotection is mandatory before, during, and after any laser treatment 5, 7

Critical Pitfalls to Avoid

• Never discontinue photoprotection - UV exposure is the primary cause of recurrence regardless of treatment modality 1, 7
• Do not use laser without extensive patient counseling about high risk of worsening pigmentation in darker skin types 1, 4
• Avoid treating melasma as an acute condition - it requires chronic maintenance therapy with regular follow-ups 2, 1
• Do not forget to address hormonal factors (oral contraceptives, pregnancy, hormone replacement therapy) that may limit treatment success 1

Evidence-Based Treatment Hierarchy

1. First-line (Category 1): Triple combination cream + SPF 50+ photoprotection 1
2. Second-line: Add intradermal PRP (4 sessions every 2-3 weeks) ± oral tranexamic acid 2, 1
3. Alternative second-line: Microneedling with PRP (safer than laser for darker skin) 1
4. Third-line only: Low-fluence Q-switched Nd:YAG laser with extreme caution in selected patients who failed all other therapies 3, 4, 5

The most recent high-quality evidence (2025 guideline in Periodontology 2000) emphasizes that melasma management should prioritize topical therapy and PRP/microneedling over laser, with laser reserved only for refractory cases after thorough risk-benefit discussion. 2, 1