Bottom line
Melasma often becomes more noticeable during periods of hormonal change, including perimenopause. Sun and visible-light exposure can keep it active. Treatment usually starts with daily photoprotection and then adds one or more ingredients based on skin sensitivity, medical history, and how stubborn the pigment is.
The earlier version of this page ranked treatments by the number of findings in our evidence database. That was not a count of all studies, and one paper could contribute several findings. We have removed the ranking because it could create a false impression about the total evidence.
This page reviews selected comparisons. It is not a systematic or comprehensive review of the full melasma literature.
Treatments covered in this review
| Treatment | What the selected evidence suggests | What to consider |
|---|---|---|
| Tranexamic acid | A study of 5% topical tranexamic acid reported benefit in South Asian patients. [1] | Oral use has important clotting precautions. Topical and oral results are not interchangeable. |
| Azelaic acid | One comparison found 20% azelaic acid more effective than 2% hydroquinone. [2] | Strength, formulation, irritation, and the hydroquinone comparator matter. |
| Cysteamine | A placebo-controlled study reported a reduction in Melasma Area and Severity Index score after 16 weeks. [3] | Odor and irritation can affect consistent use. |
| Arbutin | One study reported more skin lightening with arbutin than ellagic acid. [4] | Evidence from one formulation should not be generalized to every product. |
| Niacinamide | One study reported improvement with 4% niacinamide compared with retinoic acid or placebo over eight weeks. [5] | It is often gentler, but the evidence base and product formulations vary. |
These findings answer narrow questions about specific products and study populations. They do not establish a universal order from best to worst.
How treatment choice changes by situation
Someone with sensitive skin may start with a gentler topical option and add stronger treatment gradually. Someone with persistent or deeper pigment may need a dermatologist-directed combination. Acne or redness can make azelaic acid more attractive. A history of blood clots, clotting disorders, estrogen-related clot risk, or certain medicines can make oral tranexamic acid inappropriate.
The best fit is the safest option that addresses the likely pigment pattern and can be used consistently. A dermatologist can help identify a candidate treatment when several products have failed or irritation keeps interrupting the plan.
Pregnancy plans also matter because several pigment treatments have restrictions or limited safety data. A clinician can help separate melasma from post-inflammatory pigmentation or another cause of a changing dark patch.
The evidence is limited by major differences between products, study populations, and outcome measures. Results from one formulation should not be assumed to apply to every product with the same ingredient name.
Sun protection is not optional
Treatment results are harder to maintain without daily broad-spectrum sunscreen. Tinted sunscreen containing iron oxides may add protection from visible light, which can worsen melasma in some skin tones. Hats, shade, and reducing heat and light exposure can also help.
Safety and red flags
Oral tranexamic acid should only be considered after a clinician reviews personal and family clotting history, medicines, smoking, migraine history, and other risk factors. Stop and seek urgent care for sudden chest pain, shortness of breath, coughing blood, or one-sided leg swelling.
A new, changing, irregular, bleeding, or painful pigmented lesion needs an examination. It should not be assumed to be melasma.
What this review includes
We retained selected treatment comparisons with direct citations but removed the unsupported evidence ranking. We did not search every database or formally grade every eligible trial. The page therefore describes the evidence reviewed without claiming to measure the total evidence behind each option.
What to ask your clinician
- Is this clearly melasma, or could it be another pigment condition?
- Which topical treatment best matches my skin sensitivity and other concerns?
- Is oral tranexamic acid unsafe for me because of clotting risk or other factors?
- What sunscreen and visible-light protection should I use every day?
- When should we reassess or change the plan?
Related reading
References
[1] Akhtar N. Assessment of the Efficacy of Tranexamic Acid Solution 5% in the Treatment of Melasma in Patients of South Asian Descent. Cutis. 2023;112(4). doi:10.12788/cutis.0869 https://doi.org/10.12788/cutis.0869
[2] Jimbow K, Minamitsuji Y. Topical therapies for melasma and disorders of hyperpigmentation. Dermatologic Therapy. 2001;14(1):35-45. doi:10.1046/j.1529-8019.2001.014001035.x https://doi.org/10.1046/j.1529-8019.2001.014001035.x
[3] Grimes PE, Ijaz S, Nashawati R, Kwak D. New oral and topical approaches for the treatment of melasma. International Journal of Women's Dermatology. 2019;5(1):30-36. doi:10.1016/j.ijwd.2018.09.004 https://doi.org/10.1016/j.ijwd.2018.09.004
[4] Sarkar R, Handog EB, Das A, et al. Topical and Systemic Therapies in Melasma: A Systematic Review. Indian Dermatology Online Journal. 2023;14(6):769-781. doi:10.4103/idoj.idoj_490_22 https://doi.org/10.4103/idoj.idoj_490_22
[5] Campuzano-García AE, Torres-Alvarez B, Hernández-Blanco D, Fuentes-Ahumada C, Cortés-García JD, Castanedo-Cázares JP. DNA Methyltransferases in Malar Melasma and Their Modification by Sunscreen in Combination with 4% Niacinamide, 0.05% Retinoic Acid, or Placebo. BioMed Research International. 2019;2019:1-7. doi:10.1155/2019/9068314 https://doi.org/10.1155/2019/9068314