Evidence and a proposed algorithm for periprocedural treatment sequencing in melasma

Abstract

Melasma treatment often combines photoprotection, topical depigmenting agents, oral tranexamic acid and procedures. Evidence for individual treatments is more developed than evidence for their order, spacing and periprocedural care. This narrative review examines the clinical literature relevant to a proposed sequence of tinted photoprotection, azelaic acid, and selected use of oral tranexamic acid, intradermal NCTF 135 HA and fractional 1064-nm picosecond laser. An existing reference collection was supplemented by targeted searches and source verification. Randomized trials support several medical components, whereas laser studies differ substantially in wavelength, optics and treatment schedules. A split-face trial found no additional clinical benefit from adding 755-nm picosecond laser to azelaic acid. Small studies of hyaluronic acid formulations use different products and delivery schedules, and do not establish the proposed pre-laser interval. We specify a candidate protocol, including a six-week medical lead-in, intradermal treatment fourteen days before laser, temporary interruption of azelaic acid and continued maintenance. The exact timing, laser settings and aftercare choices are identified as proposals for evaluation. No original patient observations or clinical outcomes are reported. The principal research questions are whether procedures add worthwhile benefit to medical treatment, whether intradermal NCTF adds further benefit, and whether any improvement persists after oral treatment stops. Controlled evaluation with standardized photographs, severity scores and complete adverse-event reporting is needed before the full sequence can be recommended as an established regimen.