What are the recommended first-line treatments for melasma in adults, and how effective are they?

Recommended first-line treatments for melasma in adults primarily include topical agents such as hydroquinone, azelaic acid, kojic acid, and tretinoin, often used in combination to enhance efficacy and reduce side effects. These treatments act by inhibiting melanin synthesis and promoting skin turnover, thereby lightening hyperpigmented areas. Combination therapies, for example, triple combinations of hydroquinone, tretinoin, and corticosteroids, have shown superior effectiveness compared to monotherapy. Additionally, strict photoprotection with broad-spectrum sunscreens is essential to prevent worsening of melasma and to maintain treatment benefits.

Effectiveness of these treatments varies, but topical hydroquinone remains the gold standard with good efficacy in reducing pigmentation. Azelaic acid and kojic acid are effective alternatives, especially for patients who cannot tolerate hydroquinone. Tretinoin enhances the penetration and efficacy of other agents and promotes epidermal turnover. However, treatment response can be slow, often requiring several weeks to months, and relapse is common if photoprotection is inadequate or treatment is discontinued. Adjunctive procedures such as chemical peels or laser therapy may be considered in resistant cases but require specialist input.

While UK clinical guidelines do not provide detailed melasma-specific treatment protocols, the evidence from dermatological literature (Rendon et al., 2006) supports these topical regimens as first-line options, emphasizing the importance of combination therapy and photoprotection for optimal outcomes ¹.