Modern Approaches to Treating Melasma

Susan C. Taylor, MD, presented a comprehensive update on contemporary melasma management, emphasizing evolving concepts in pathogenesis and evidence-based treatment strategies. Dr Taylor reviewed the growing understanding that melasma is a multifactorial disorder driven by ultraviolet and visible light exposure, epidermal melanocyte activation, and clinically relevant vascular component characterized by increased vessel number, density, and angiogenesis. These mechanisms help explain disease chronicity, relapse, and treatment 

A central focus of the presentation was the international Delphi consensus on melasma management, developed by 38 experts from 11 countries to standardize diagnosis, monitoring, and treatment. The consensus identified Wood’s lamp examination as a favored method for assessing extent and severity, with dermoscopy accepted for differential diagnosis. Photoprotection was emphasized as foundational therapy, with the “ideal” sunscreen providing protection against UVA, UVB, and visible light, and optional inclusion of antioxidants or depigmenting agents to enhance efficacy. For treatment, triple-combination therapy with hydroquinone, tretinoin, and fluocinolone acetonide was reaffirmed as the gold-standard first-line option for moderate-to-severe melasma, while azelaic acid, antioxidants, and non-hydroquinone agents were highlighted as alternatives or maintenance options. Oral tranexamic acid, chemical peels, microneedling, and energy-based devices were reserved for refractory disease within a stepwise algorithm. 

Dr Taylor also reviewed comparative clinical trial data for newer non-hydroquinone therapies. A randomized non-inferiority trial demonstrated that a 2-Mercaptonicotinoyl Glycine–containing serum achieved similar improvements in mMASI compared with hydroquinone 4%, with fewer local reactions. Additional studies showed that thiamidol and topical metformin produced MASI reductions comparable to hydroquinone-based regimens, supporting their role as effective alternatives in select patients. Collectively, the data reinforce a modern treatment framework that combines standardized photoprotection, targeted topical therapy, and vascular-directed interventions to address both pigment production and relapse risk in melasma.