Optimizing melasma management

By Emily Margosian, Senior Editor, March 1, 2026

Pigmentary disorders represent some of the most common cutaneous concerns globally. In the U.S. alone, melasma affects more than 5 million people (doi:10.1016/j.jaad.2010.12.046).

While primarily a cosmetic condition, melasma is often a chronic, therapeutically challenging, and psychologically devastating disorder. Six patients interviewed as part of a pilot study on the effect of melasma on self-esteem (doi:10.1016/j.ijwd.2017.11.003) reported decreased self-esteem, restricted sense of freedom, avoidance of social situations, and frustration with treatments.

When it comes to management, pigmentary experts agree: melasma can be controlled, not cured. “It’s important to set expectations from the very first appointment and explain that while we have many options to get to the goal of clear skin, melasma is a chronic condition. It’s not uncommon that a patient improves and then later has flares or recurrences particularly when becoming less compliant with their regimen,” said Nada Elbuluk, MD, MSc, FAAD, professor of clinical dermatology, and founding director of the Skin of Color and Pigmentary Disorders Program at the University of Southern California. “When it comes back, they’re devastated all over again. I explain to patients that compliance and consistency is key, and we’ll work together to create a plan they can stick with.”

Despite its recalcitrant nature, recent insights into melanocyte biology coupled with emerging therapies and new device technology have yielded a growing treatment armamentarium to tackle this challenging condition. “It is an exciting time for melasma in 2026. We have multiple new oral and topical agents that have shown efficacy,” said Pearl Grimes, MD, FAAD, director of the Vitiligo & Pigmentation Institute of Southern California, and clinical professor of dermatology at the University of California, Los Angeles. “The future is pretty darn bright.”

New data on the melasma pathogenesis

Research has offered new insights into dermatologists’ understanding of normal melanocyte biology and abnormal pigment physiology. Experts suggest dermatologists should think about melasma as a photoaging disorder and have an etiological approach based on several risk factors: sun exposure, barrier function, pollution, hormones, microbiome genetics, and a vascular etiology.

“Melasma is a profoundly complex disorder of hyperpigmentation, driven by the trifecta of genetic susceptibility, ultraviolet and visible light radiation, and hormonal dysregulation,” said Dr. Grimes. “It is mediated by the intricate and dysregulated crosstalk between melanocytes, keratinocytes, mast cells, fibroblasts, endothelial cells, and dermal blood vessels. This dysregulation is associated with an increase in melanogenesis, basement membrane damage, solar elastosis, increased dermal vascularity, and senescent dermal fibroblasts. This supports the concept that melasma represents a unique phenotype of photodamage.”

According to Seemal R. Desai, MD, FAAD, founder of Innovative Dermatology and clinical associate professor of dermatology at the University of Texas Southwestern Medical Center, melasma is now understood to be a chronic, multifactorial pigmentary disorder, rather than a condition driven solely by melanocyte hyperactivity. “While melanocytes play a central role, newer research highlights the importance of dermal/epidermal interactions and the skin microenvironment.”

These new insights have shifted treatment strategies toward a multimodal, long-term management approach, experts say. “Treatment should emphasize not only pigment suppression but also photoprotection (including visible light), vascular modulation, inflammation control, and maintenance therapy to prevent relapse,” said Dr. Desai.

Mapping out a treatment strategy

Melasma has traditionally been treated with a combination of photoprotection, avoidance of trigger factors, and topical depigmenting agents with varying degrees of success.

Experts suggest a multimodal approach to treating melasma, tailored to individual patient needs. “Best practices include beginning with rigorous photoprotection, including broad-spectrum sunscreen with iron oxides to protect against visible light. Initial therapy typically includes topical depigmenting agents, with reassessment at 8–12 weeks,” advised Dr. Desai. “Treatment should be escalated thoughtfully for refractory disease, incorporating systemic agents or procedures when appropriate. Cycling active treatments and transitioning to maintenance regimens are critical to long-term success. Setting realistic expectations and emphasizing the chronic, relapsing nature of melasma are essential from the outset.”

“At minimum for melasma, you’re always looking at a topical regimen with sunscreen and good photoprotection,” agreed Dr. Elbuluk. “Then you wait to see how the patient responds. Some respond well and that’s sufficient, but others don’t and that’s when you start to think about trying other ingredients based on what the patient can tolerate. Sometimes we incorporate procedures in combination with their treatment regimen. Lasers may be used as a second or third line as adjuvant therapy but require caution because sometimes the heat from a laser can make melasma worse. Now we have an oral medication, tranexamic acid, which we may use off label in some qualifying patients. There are a lot of options, but the important point with melasma is that it often comes back and flares. Our goal is to clear it as much as possible, but it does require year-round treatment.”

Tried-and-true topical agents

For many dermatologists, the time-honored FDA-approved triple combination cream (4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide) remains a first-line treatment for melasma — with some caveats.

“While triple combination is still a first-line treatment that we consider, nowadays we also use a lot of compounding pharmacies, which sometimes alter the strengths and doses of the three ingredients that are in TCC,” said Dr. Elbuluk. “However, with higher concentrations, something to be aware of is that hydroquinone and retinoids can be irritating for many people. We must keep that in mind and balance it with what they can tolerate to avoid creating an irritant dermatitis that can also result in hyperpigmentation.”

According to Dr. Desai, dermatologists should also be mindful of how long patients stay on TCC. “Fixed-dose triple combination cream should be used strategically and intermittently, rather than continuously, due to the risks associated with prolonged corticosteroid and hydroquinone use. Maintenance therapy with non-hydroquinone agents is essential to sustain results and minimize relapse.”

“First-line therapies for melasma continue to include triple combination therapy, which can be hydroquinone or non-hydroquinone formulations. However, depending on disease severity, other topical therapies can be used first-line, including azelaic acid, arbutin formulations, and kojic acid. New treatments, such as thiamidol and topical formulations containing tranexamic acid have emerged. I no longer have one first-line recommendation.”

“First-line therapies for melasma continue to include triple combination therapy, which can be hydroquinone or non-hydroquinone formulations,” said Dr. Grimes. “However, depending on disease severity, other topical therapies can be used first-line, including azelaic acid, arbutin formulations, and kojic acid. New treatments, such as thiamidol and topical formulations containing tranexamic acid, have emerged. I no longer have one first-line recommendation. It is based on the needs of the patient, and I often combine treatments. Non-hydroquinone formulations are now much more efficacious. Hence, we rely on hydroquinone significantly less to achieve optimal therapeutic outcomes in patients with melasma.”

Resurfacing procedures

Beyond topicals, resurfacing procedures have emerged as helpful adjuvants to treat melasma.

“Microneedling shows significant improvements in MASI scores particularly when used in combination with tranexamic acid, platelet-rich plasma, or chemical peels, such as salicylic acid 30%, glycolic acid 35%, or trichloroacetic acid 15%,” said San Diego dermatologist and chair of the International Peeling Society-USA, Seaver Soon, MD, FAAD, who will discuss best practices for melasma resurfacing procedures at the 2026 AAD Annual Meeting. “Potential risks of microneedling include foreign body granuloma when cosmeceuticals not approved for intradermal use are introduced, and punctate scar risk, particularly when needles greater than a 2mm depth are used. My preference is moderate depth microneedling for melasma with 1.5mm needles.”

Chemical peels have also shown improvement in MASI score and general skin quality when used for the treatment of melasma. Dr. Soon has observed the best results with superficial peels such as salicylic acid 30%, glycolic acid 35%, trichloroacetic acid 15%, and modified Jessner’s solution. “There are also preliminary data that phenol-croton oil peels may induce durable remission in melasma by dermal remodeling/regeneration,” he noted. “Risks include post-inflammatory hyperpigmentation for superficial peels, and infection and scarring for deep peels.”

While use of platelet-rich-plasma (PRP) is still being investigated for many dermatologic conditions, the technique has reportedly shown some improvement in melasma with a more favorable safety profile than chemical peels and microneedling, with transient erythema, edema, and bruising as the main reported adverse events.

“Generally, most melasma patients are good candidates for the above procedures, although patients who are non-compliant with sun protection and topical therapies may be at higher risk for post-inflammatory hyperpigmentation,” said Dr. Soon.

While resurfacing procedures present new options for dermatologists and melasma patients, as always, a multimodal approach to therapy is key according to Dr. Soon. “Microneedling, chemical peels, and PRP are generally not as effective as monotherapy, but more so in combination with iron oxide-containing inorganic sunscreen, triple combination bleaching agents, topical or oral antioxidants, topical retinoids, and tranexamic acid. Phenol-croton oil chemical peeling may be effective as monotherapy, inducing durable remission in melasma, but further confirmatory studies are necessary.”

Laser and light therapies

Like other resurfacing procedures, laser and light therapies are typically not a sole modality for melasma. “I often take a four-fold approach when I treat melasma, and the laser plays maybe 15% of the role,” said Edward Ross, MD, FAAD, director of the Scripps Clinic Laser and Cosmetic Dermatology Center. “Sometimes it’s a last resort after I’ve exhausted other options.”

Dr. Ross has two main approaches to lasers when treating melasma. The first involves fractional lasers. “There are a lot of fractional lasers out there, but the ones that work best for melasma are 1927 nanometers or 1940 nanometers; that wavelength range tends to help when used very conservatively. The key with melasma is using low pulse energies and low density,” he recommended. “If you use low density, say 25% or less of the skin’s cross sectional area coverage percent and five or less millijoules, you usually do okay.”

Dr. Ross also occasionally uses a technique called laser toning to treat melasma. “You take a laser and go quickly back at 5-10 Hz and forth at 1064 nanometers and at very low fluences — 1-2 Jcm² — using a large spot like 8 millimeters and either nanoseconds or picoseconds. It’s popular, but I don’t do it very often. For one, it takes several treatments, usually spaced one to two months apart, and also there is a small risk of guttate hypopigmentation, which is very challenging to correct. Additionally, although you can get some initial clearing, there is a tendency toward rebound. There are now fractional nanosecond and picosecond options which probably work a bit better and are safer.”

As with all melasma treatments, Dr. Ross reiterated that it is important to set patient expectations from the outset. “Typically, 10 days after the fractional treatment, patients’ melasma will be markedly improved. If they have a wedding in 10 days, you’ll be their hero, but if they have a wedding in three weeks, you’ll be the worst doctor that ever treated them because the melasma will start coming back. That’s the real key here — and I tell every patient with melasma — it’s like high blood pressure or diabetes. There’s no cure. It’s all about control and it’s a lifelong journey.”

“I tell every patient with melasma — it’s like high blood pressure or diabetes. There’s no cure. It’s all about control and it’s a lifelong journey.”

Emerging oral therapies

Over the last decade, oral tranexamic acid (TXA) has emerged as a promising systemic therapy for melasma. “The most well-studied and clinically utilized oral therapy for melasma is oral tranexamic acid. Multiple trials and meta-analyses demonstrate significant improvement in melasma severity scores and reduced recurrence rates when TXA is used appropriately. However, this is still considered off-label by the FDA,” noted Dr. Desai.

Oral TXA is typically reserved for patients who have failed conventional therapies as it poses some concern about thromboembolic risk with its use. “We do not use this agent first-line, but I consider it a second- or third-line approach in individuals who have more recalcitrant melasma unresponsive to other modalities,” said Dr. Grimes.

While oral TXA remains the primary systemic agent of interest for the treatment of melasma, emerging research continues to explore optimized dosing regimens, combination systemic antioxidant strategies, and oral photoprotective agents. “Other oral agents with evidence include Polypodium leucotomos extract as a photoprotective adjunct,” observed Dr. Desai. Polypodium leucotomos extract (PLE) is derived from a fern native to Central and South America and has shown some benefit in randomized placebo-controlled studies (Int J Womens Dermatol. 2019; 5:30-36).

According to Dr. Grimes, another emerging oral agent of note for melasma is metformin, a common first-line oral medication for type 2 diabetes. “Metformin blocks multiple pathways, including cyclic adenosine monophosphate (AMP), which drives melanogenesis. Multiple studies are documenting the efficacy of both oral and topical metformin in the treatment of melasma.”

As with many treatment modalities, oral therapy for melasma requires a careful calculation of risks and benefits. “Benefits of systemic therapy include the ability to target vascular, inflammatory, and UV-mediated pathways that are not addressed by topical agents alone, making oral therapies particularly useful for moderate-to-severe, refractory, or recurrent melasma,” said Dr. Desai. “Risks, particularly with oral TXA, include a risk of thromboembolic events, although reported incidence at dermatologic dosing is low. Other potential side effects include gastrointestinal upset, headache, and menstrual irregularities.”

Ideal candidates for oral therapy include patients with refractory melasma who have failed optimized topical therapy, have no personal or family history of thromboembolic disease, are not pregnant or breastfeeding, and can adhere to monitoring and follow-up. Poor candidates include patients with a history of thrombosis, smokers, those with hypercoagulable states, active malignancy, pregnancy, or those taking estrogen-containing hormonal therapies. “As a reminder, this is all off-label,” emphasized Dr. Desai. “Extensive counseling, documentation, and appropriate patient selection and monitoring are critical. Systemic agents are often not used as monotherapy. The strongest and most durable clinical outcomes are seen when oral therapies are incorporated into a combination treatment plan. Melasma is a disease that often requires a polytherapeutic approach.”

New topical agents

While TCC works well against melasma in many patients, new topical agents have emerged in recent years, offering expanded options for patients who cannot tolerate hydroquinone.

“Emerging and increasingly utilized topical therapies include cysteamine, topical tranexamic acid, thiamidol, azelaic acid–based combinations, and topical anti-inflammatory and antioxidant agents,” said Dr. Desai.

“Probably the most significant new topical agent for melasma, which is being used globally in multiple countries, is thiamidol,” emphasized Dr. Grimes. “It blocks human tyrosinase unlike many of the traditional lighteners that we use which are inhibitors of mushroom tyrosinase. Other topical agents that have shown efficacy include lotus sprout extract, malassezin, cysteamine, and 2-Mercaptonicotinoyl Glycine (2MNG).

“There are a lot of botanical and synthetic ingredients that are being created as lightening agents. Many of them have some benefit, but we need more studies for a lot of these that are done in more standardized ways,” said Dr. Elbuluk. “For us to start recommending more botanical ingredients, we would need sufficient data and rigorous studies done with standardized outcome measures.”

Incorporating cosmeceuticals and over-the-counter products

As many dermatologists know, patients often exhaust over-the-counter (OTC) options before seeking professional care for their skin disease. However, melasma experts say cosmeceuticals can play a role when used appropriately with physician guidance.

“Evidence supporting OTC products is variable and generally modest,” according to Dr. Desai. “Dermatologists should counsel patients that OTC products may serve as adjunctive therapy but are unlikely to be effective as stand-alone treatments. Ingredients such as niacinamide, vitamin C, kojic acid, and licorice extract may provide incremental benefits. Patients should be cautioned against unregulated skin-lightening products.”

“Often ingredients like kojic acid, niacinamide, vitamin C, or soy alone don’t really do enough, but in combination with our mainstay ingredients can be helpful,” said Dr. Elbuluk. “Use of cosmeceuticals should be tailored based on an individual’s melasma, the treatments they’ve responded to, and their tolerability. For most people, we’re treating with a combination of prescription and OTC. I want to emphasize that sunscreen, an OTC product, is still a mainstay in treating melasma, and is just as important as the medications that we prescribe. I make sure to talk to patients about mineral sunscreens and ensure they have broad-spectrum protection.”

Considerations for treating melasma in skin of color

Melasma is a common driver for patients with skin of color to seek out a dermatologist for treatment and requires a careful approach as certain treatments may result in additional dyspigmentation and other adverse side effects.

Dermatologists should be mindful of differences in presentation when recognizing and diagnosing melasma in skin of color. “Other conditions can sometimes be confused with melasma. So differential diagnosis is important. Some of the confusions include lichen planus, contact dermatitis, and in some instances post-inflammatory hyperpigmentation. An accurate diagnosis is essential. If in doubt, we will perform a biopsy because the correct diagnosis clearly impacts therapeutic outcomes,” said Dr. Grimes.

According to Dr. Desai, in patients with skin of color, melasma may appear gray-brown or violaceous rather than light brown. “Wood’s lamp examination is often less reliable. It is important to distinguish melasma from other pigmentary disorders such as post-inflammatory hyperpigmentation, exogenous ochronosis, and lichen planus pigmentosus,” he recommended.

“In my experience, most cases of melasma have both an epidermal and dermal component, so traditionally I don’t rely heavily on a Wood’s lamp examination to help me determine my therapeutic regimen,” agreed Dr. Grimes. “It is much easier to treat post-inflammatory hyperpigmentation than melasma. It’s also important to do a thorough skin examination, looking for any clinically evident vascular features. If significant, I will incorporate an agent that addresses the vascular component as well. I always emphasize to the patient that I will take them through a more aggressive phase of treatment followed by a maintenance phase, and it’s important the patient understands they will probably be on treatment long-term if we are going to be effective in managing their melasma.”

In treating melasma, patients with skin of color are at increased risk for post-inflammatory hyperpigmentation, necessitating a cautious and individualized approach. “Dermatologists should use care with aggressive chemical peels, energy-based devices, and prolonged topical corticosteroid use. Emphasis should be placed on gentle regimens, gradual escalation, maintenance therapy, and culturally sensitive counseling,” recommended Dr. Desai.

“When considering resurfacing treatments for melasma patients with skin of color, I advise priming the skin for four weeks with iron oxide-containing zinc oxide sunscreen, topical triple combination bleaching cream, and a gentle retinoid, such as adapalene rather than tretinoin or tazarotene,” said Dr. Soon. “I also have them stop their retinoid one week prior to resurfacing. Immediately after resurfacing, I prescribe a mid-potency topical steroid, such as triamcinolone 0.1% cream, twice daily for two weeks to suppress any inflammation which may progress to post-inflammatory pigmentation, as well as tinted mineral sunscreen daily.”

According to Dr. Ross, while laser therapy is typically not recommended for melasma patients with skin of color, new devices entering the market may show promise. “There’s currently one fractional 755nm laser out there called PicoSure. It has a lens array with 755 nanometers which is ideal for melasma in darker patients. I don’t have this laser, but that might be something that other dermatologists want to know about.”

“The biggest risk is often dyspigmentation; you could create the exact problem you’re trying to treat if your laser or peel is too aggressive,” agreed Dr. Elbuluk. “That can cause irritation to the skin and rev up the melanocytes to produce more pigment. It’s a very delicate balance because there are procedures that can be safely done, but they really must be done at the right settings or right percentages. In skin of color, we stick with more superficial chemical peels. Whereas in melasma patients with lighter skin, you may be able to get away with a medium peel.”

Improving treatment adherence

Despite promising new treatment options, melasma is still often frustrating for patients and physicians. Experts say improving treatment adherence — and outcomes — begins with setting realistic expectations about treatment timelines and relapse risk. “Simplifying treatment regimens, reinforcing the importance of daily sunscreen use, and addressing the psychosocial burden of melasma can significantly improve adherence,” said Dr. Desai.

“It is absolutely key during that initial consultation that dermatologists emphasize that while there is no cure, if the patient adheres to their regimen, we can optimize our therapeutic responses,” said Dr. Grimes. “If a patient is not responding to initial treatment, we certainly have newer and better agents that allow us to continue to pivot for improvement. However, we are always striving for more because of the reality of relapse, which is one of my key frustrations. This is the Holy Grail for new research as we continue to explore factors that drive the pathogenesis of melasma, and open new doors for therapeutic intervention.”

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