A New Hope for Melasma: Long‐Term Clearance With 755‐nm Picosecond Alexandrite Laser and Topical JAK Inhibition

Melasma is a chronic, relapsing hyperpigmentary disorder with multifactorial pathogenesis, including melanocyte hyperactivity, inflammatory cytokine signaling, and photoinduction [1]. In Fitzpatrick skin types III–V, visible light (VL)–driven melanogenesis and post-inflammatory hyperpigmentation make long-term clearance difficult [2]. Conventional therapies such as hydroquinone, peels, and oral tranexamic acid often provide only transient improvement, with high relapse rates and PIH risk in darker phototypes. Novel strategies are needed. We report a Fitzpatrick type IV woman, aged 31, with a 4-year history of symmetrical malar-type melasma refractory to hydroquinone, oral tranexamic acid, and superficial chemical peels. Examination revealed dense, patchy hyperpigmentation over the malar and zygomatic regions. Wood's lamp demonstrated a mixed epidermal–dermal pattern. A single session of 755-nm picosecond alexandrite laser (PicoSure Pro; Cynosure, Westford, MA, USA) was performed (flat 10 mm, 0.25 J/cm2, 5 Hz; focus 6 mm, 0.7 J/cm2, 2.5 Hz, multiple passes) [3]. Post-procedure care included fusidic acid + betamethasone cream (Fucicort, LEO Pharma, Ballerup, Denmark) twice daily for 3 days, followed by topical tofacitinib 2% cream twice daily for maintenance. She also applied an iron oxide–tinted sunscreen (Heliocare 360° Color Gel Oil-Free; Cantabria Labs, Madrid, Spain) twice daily to protect against VL [2, 4] No bleaching agents were used. Marked pigment clearance and homogeneous skin tone were observed (Figure 1A,B). Results were maintained for 9 months before gradual relapse. No adverse effects, post-inflammatory hyperpigmentation, or rebound were reported. This strategy directly targets pigment overload, inflammatory signaling, and light-induced oxidative stress simultaneously, offering a more comprehensive pathway to disease control. Importantly, clearance was achieved without hydroquinone or other bleaching agents, underscoring its potential relevance for darker skin phototypes where irritation and rebound are common. This case provides early evidence that combining a 755-nm picosecond alexandrite laser with topical JAK inhibition and visible-light protection may offer a safe and durable approach for refractory melasma in darker phototypes. These findings warrant further investigation in larger controlled studies to validate efficacy and safety. The authors have nothing to report. Ethical approval was not required for this case report, as it describes the clinical course of a single patient without experimental intervention. Written informed consent was obtained from the patient's legal guardians for the publication of this case report, including clinical details and imaging findings, while ensuring confidentiality and anonymity. The authors declare no conflicts of interest. All data generated or analyzed during this study are included in this published article. No additional datasets are available.