Evidence-Based Management of Melasma: Diagnosis, Topical Therapy, Procedures, and Relapse Prevention

The talk presented an evidence-based overview of melasma as a chronic, multifactorial condition with no true cure and a high relapse rate, emphasizing the need to set realistic patient expectations and maintain treatment long term. Melasma is most common in women and in Fitzpatrick skin types III–V, and is driven by ultraviolet exposure, genetics, hormones, and especially chronic inflammation. Diagnosis and monitoring can use the MASI score, Woods lamp or dermatoscopy, reflectance confocal microscopy, and patient-reported quality of life measures. First-line therapy remains topical treatment, with modified Kligman triple therapy (hydroquinone, retinoid, and topical steroid) as the gold standard, plus adjuncts such as azelaic acid, kojic acid, cysteamine, and sometimes tranexamic acid or niacinamide. Strict photoprotection is non-negotiable: broad-spectrum high-SPF sunscreen, tinted formulations, frequent reapplication, protective clothing, and oral photoprotection were highlighted. For procedures, superficial chemical peels are preferred, especially glycolic, salicylic, and mandelic acids; deeper peels and phenol should generally be avoided in darker skin due to depigmentation and post-inflammatory hyperpigmentation risk. Pre-treatment priming and careful post-peel care are important. Energy-based devices remain controversial, but low-fluence Q-switched Nd:YAG and picosecond lasers have some evidence, though they are costly and can cause rebound or hypopigmentation. Combination approaches, especially oral tranexamic acid plus triple therapy, were presented as stronger than monotherapy. The speaker stressed a stepwise algorithm: photoprotection first, then topical triple therapy, then oral tranexamic acid as an add-on, with procedures reserved for refractory cases and maintenance used to reduce relapse.