Laser Treatment for Melasma: An Update and Literature Review

Background: Melasma is a chronic acquired hyperpigmentation disorder that disproportionately affects women and individuals with darker skin phototypes. Despite numerous topical and procedural treatments, melasma remains therapeutically challenging due to high recurrence rates and risk of post-inflammatory complications. Laser therapy has emerged as a promising treatment modality, though outcomes remain inconsistent and require careful patient selection and parameter optimization. Methods: A comprehensive literature search was conducted in MEDLINE, PubMed, and Ovid databases for studies published between January 2014 and December 2025. Search terms included “melasma,” “laser treatment,” “Q-switched Nd:YAG,” “picosecond laser,” “fractional laser,” “intense pulsed light,” and related terms. Studies were classified according to Oxford Centre for Evidence-Based Medicine levels of evidence. Approximately 39 studies including randomized controlled trials, cohort studies, systematic reviews, and meta-analyses were analyzed. Results: Low-fluence Q-switched 1064 nm Nd:YAG laser demonstrated efficacy with 62–85% improvement in MASI scores, though with high recurrence rates (43–81% at 3 months). Picosecond lasers (755 nm and 1064 nm) showed comparable or slightly superior efficacy (65–75% improvement) with potentially lower complication rates. Fractional non-ablative lasers (1550 nm, 1927 nm thulium) achieved 40–70% improvement with better maintenance. Combination therapies with topical tranexamic acid or triple combination cream significantly enhanced outcomes. Common complications included post-inflammatory hyperpigmentation (15–30% in darker skin), transient hypopigmentation (10–20%), and erythema (>90%). Novel approaches including perfluorodecalin patches, platelet-rich plasma, and laser-assisted drug delivery showed promising results in preliminary studies. Conclusions: Laser treatment for melasma can provide meaningful improvement when appropriate patient selection, conservative parameters, and combination approaches are employed. Low-fluence Q-switched Nd:YAG and picosecond lasers represent first-line laser options, while fractional systems offer safer alternatives for darker skin types. Combination with topical agents, extended treatment intervals, and aggressive photoprotection are essential for optimizing outcomes and minimizing recurrence. Future research should focus on long-term maintenance strategies and standardized treatment protocols for diverse skin phototypes.