Evidence-Based Best Practices for Melasma Care

A clinician can look at a case of melasma and see something cosmetically minor. The patient living with it often sees something else entirely.¹ That disconnect is at the heart of why melasma remains one of dermatology's most frustrating conditions to manage—and why, for July's Hyperpigmentation and Melasma Awareness Month, Dermatology Times sat down with Skin of Color Society member Jane Yoo, MD, MPP, FAAD, to talk through what effective, equitable care actually looks like. "The burden is real and frequently underestimated by clinicians who see a cosmetically mild presentation and miss a profoundly affected patient underneath it," Yoo said.

Melasma is stubborn and recurrent and disproportionately affects patients with skin of color—the same patients for whom an aggressive intervention can backfire into postinflammatory hyperpigmentation (PIH) or paradoxical darkening.² Yoo's answers walk that tightrope: how she gets patients to actually wear tinted sunscreen, when she cycles off hydroquinone, how she risk-stratifies candidacy for lasers and peels, where she lands on oral vs topical tranexamic acid (TXA), and why the upstream targets generating buzz are not yet ready for the examination room.

She closed on the problem that the field has been slowest to fix: The patients carrying the heaviest melasma burden are still the least represented in the trials meant to treat them. As Yoo put it, "We still reach for data generated in populations that don't fully reflect the patients in our exam rooms."

Dermatology Times: Tinted sunscreens with iron oxides are the standard recommendation for melasma, but adherence is a persistent challenge. What barriers do you hear most from patients, and how do you address them?

Yoo: The barrier I hear most with tinted sunscreens is cosmetic elegance. Patients with deeper skin tones have often tried a tinted sunscreen that left an ashy, gray, or darkened complexion. Sometimes patients have a great foundation match, and then adding a separate tinted SPF [sun protection factor] on top makes it feel over the top. So finding a tinted sunscreen that can have great skin tone match and finish is key. I encourage patients to experiment with a wide variety of diverse tinted shades until they find one that works. However, the message remains the same. They must protect themselves against visible light. This is because light in the 400- to 700-nm range drives melanocyte stimulation independently of UV, and iron oxides are the only widely available filter that blocks it. Once they understand this, they are more willing to adhere.

Dermatology Times: Melasma carries a well-documented psychosocial burden that often goes unaddressed in clinical visits. How do you assess QOL [quality-of-life] impact, and does it influence your treatment sequencing?

Yoo: I use the MELASQoL, the Melasma Quality of Life scale, as a conversational framework during patient visits. Asking a patient to rate how much their melasma affects their confidence opens up a very different kind of clinical conversation from just asking, "How long have you had this?" Just like many other dermatological conditions, the burden is real and frequently underestimated by clinicians who see a cosmetically mild presentation and miss a profoundly affected patient underneath it. A patient with high psychosocial burden and moderate melasma may be a better candidate for a more aggressive approach than their clinical severity alone would suggest. Conversely, a patient who is relatively unbothered may be better served by a simpler maintenance regimen that reduces the risk of irritation-induced PIH. It is always a good idea to get a sense of how the patient views his or her disease before initiating treatment.

Dermatology Times: Procedural interventions in skin of color carry real risks: PIH, rebound, paradoxical darkening. What's your framework for determining candidacy for laser or chemical peel?

Yoo: It is good to assess and risk-stratify before we even discuss device parameters. It is important to get as much of a patient’s history as you can, and initially, patients may not disclose everything that they have had or what has happened to them in the past. Has the patient had PIH in the past from laser procedures or acne, or do they scar easily or [have a] keloid after surgery? Is their melasma triggered by hormones? I will start with topicals before I go to lasers and chemical peels, and I first use dermoscopy and Wood light to determine if their melasma is predominantly epidermal or dermal. Once the patient is consistent with sun protection and stabilized with topical treatment, I will introduce lasers or chemical peels.

Appropriate patients for chemical peels are those who have more of an epidermal component of melasma along with heterogeneous pigment. Also, focal melasma yields better results than extensive pan-facial patterns. It is important to prime the patient before performing the peel with topicals such as hydroquinone, retinoic acid, or azelaic acid. A variety of peels can be utilized for melasma, including glycolic acid, TCA [trichloroacetic acid], salicylic acid, retinoic acid, and combinations thereof. However, it is important to be realistic with the patient about treatment results and emphasize the importance of sunscreen post procedure to prevent any postinflammatory hyperpigmentation.

Lasers can also be utilized for adjunctive treatment for melasma, as melanin has a broad absorption spectrum. Various lasers have been utilized for the management of melasma, including Q-switched lasers, thulium, fractional, and IPL [intense pulsed light]. In my office, I tend to utilize picosecond—works photomechanically and does not create thermal damage—and pulsed dye lasers—for the vascular component—for my melasma patients. Like chemical peels, lasers are not a first line of treatment for melasma, and again, photoprotection is essential afterward. I explain to patients that procedures in melasma are adjunctive, not curative, and that the risk of worsening is real and that it can happen at any time.

Dermatology Times: Long-term hydroquinone use raises legitimate concerns despite triple combination therapy remaining an anchor. What does your cycling protocol look like, and what do you use during hydroquinone holidays?

Yoo: My standard approach in utilizing hydroquinone is a 3- to 4-month cycle, then a break. During this period, I will transition to alternative treatments that target different steps in the melanogenesis pathway, such as tranexamic acid, azelaic acid, kojic acid, alpha arbutin, thiamidol, and cysteamine. What I tell patients is that we are still treating the melasma, but with a different mechanism, and sun protection is still nonnegotiable.

Dermatology Times: Oral tranexamic acid has gained significant traction. How do you approach patient selection, dosing, and the safety conversation before initiating?

Yoo: Oral TXA is a great drug and works well, in my experience. In terms of patient selection, I normally use it for those who have been refractory to topical monotherapy and who do not have a history of hypercoagulability—DVT/PE [deep vein thrombosis/pulmonary embolism]—or active cardiovascular or cerebrovascular disease. Patients who [use] oral contraceptives or hormonal therapy I warn about potential risks, and with all patients, I obtain [laboratory test results] prior to initiating treatment. In terms of dosing, the literature is variable, anywhere from 250 mg to 500 mg [twice daily], but I dose it as 325 [mg] daily—half of a 650-mg pill—because that is easiest and what is dispensed at most pharmacies. The safety conversation, aside from thromboembolic risk, includes GI [gastrointestinal] adverse effects. I tell patients to expect to see benefits in 2 to 3 months, and just like hydroquinone, I cycle this medication for 4 to 6 months and take any patient off the medication who does not appear to be benefiting from treatment.

Dermatology Times: Topical tranexamic acid spans prescription and OTC [over-the-counter] formulations with variable evidence. How do you evaluate efficacy, and when do you favor topical over oral?

Yoo: Topical TXA is great for patients who are not a candidate for oral treatment, do not want the systemic form, or have more of an epidermal component of melasma. The dosage ranges in clinical trials can vary from 0.5% to 5% with cream and solution formulations stating 32% to 52% reduction in MASI [melasma area and severity index] scores. The concentration and vehicle matter tremendously, and we know that not all topical TXA products are clinically equivalent. In some cases, topical formulations are combined with other actives such as niacinamide or alpha arbutin. When disease is more severe or there is a dermal component, I lean toward oral TXA.

Key PMIDs: 40923777, PMC5574746, PMC6247725, PMC5428632, 22506692.

Dermatology Times: Melasma treatment involves real trade-offs: efficacy, tolerability, cost, procedural risk. How do you structure that shared decision-making conversation when patient priorities don't align with your first-line recommendation?

Yoo: This frequently comes up when patients have a specific treatment in mind, whether it is HQ [hydroquinone], laser, or chemical peel. I acknowledge their frustration with other treatments and try to have the patient understand why I come up with my recommendations based on the clinical evidence and work with them to come up with a mutual plan so the patient will adhere and feel that they had a voice in the decision-making process. If the patient is unhappy about the regimen, then she or he will not be willing to see the treatment through.

Dermatology Times: There's growing interest in upstream targets: MCR1, JAK-STAT signaling. How close is the field to a mechanism-based therapy rather than downstream melanin suppression?

Yoo: We are closer than we were but not yet at clinical translation. The MCR1 axis is interesting because it positions α-MSH/ACTH signaling as an upstream target. If you can interrupt the keratinocyte-to-melanocyte paracrine signaling loop rather than just blocking tyrosinase downstream, you're targeting the disease more fundamentally. JAK-STAT pathway involvement is relevant because of the inflammatory and UV-response components of melasma pathogenesis. However, the problem is that the pathway is not melasma specific. I am also looking at work being done on stem cell factor/c-KIT signaling, PAR2 pathway modulation, and fibroblast-derived factors, with the understanding that dermal fibroblasts actively participate in melasma pathogenesis through paracrine mechanisms. I expect the next generation of meaningful therapeutics to be combination approaches targeting melanocyte activation upstream and melanin transfer downstream simultaneously.

Dermatology Times: Patients with skin of color bear a disproportionate burden of melasma but remain underrepresented in trials. Is that changing, and what does meaningful enrollment representation look like to you?

Yoo: Melasma disproportionately affects Fitzpatrick III to VI skin—South Asian, East Asian, Latina, Middle Eastern, and Black patients—but the trials that established the evidence for many of our standard interventions were conducted in predominantly lighter-skinned populations or in Asian populations in ways that weren't always disaggregated. Meaningful enrollment representation means disaggregated reporting by skin phototype, ancestry, and hormonal context, powered to detect differential response and adverse event rates across subgroups. The tendency to enroll patients with Fitzpatrick III to IV, without adequate Fitzpatrick V to VI representation, remains a gap. It also means primary end points that include PIH rates as safety outcomes, not just efficacy metrics. The field is moving in this direction, partly driven by FDA guidance on diversity in clinical trials and partly by advocacy from dermatologists of color who have made this a visibility issue. But we still reach for data generated in populations that don't fully reflect the patients in our exam rooms, and that's a clinical and ethical problem we haven't fully solved.

References

1. Hizli P, Kiliç FA, İçöz Aytaç S. Melasma revisited: national survey reveals how dermatologists diagnose and treat this complex skin condition. J Cosmet Dermatol. 2025;24(1):e16630. doi:10.1111/jocd.16630
2. Huerth KA, Hassan S, Callender VD. Therapeutic insights in melasma and hyperpigmentation management. J Drugs Dermatol. 2019;18(8):718-729.