Beyond the Creams: A Real-World, Stepwise Treatment Strategy Combining Chemical Peels and Oral Tranexamic Acid for Melasma in Skin of Colour

Abstract Background: Melasma is a chronic, relapsing pigmentary disorder with multifactorial aetiology and high psychosocial burden, particularly in individuals with skin of colour. Although oral tranexamic acid (TXA) and chemical peels are individually used, structured protocols integrating both remain underexplored, especially in Fitzpatrick skin types (FST) III–VI. Aims and Objectives: The current study aimed to assess the sustained impact and safety of a standardised regimen combining oral TXA and sequential chemical peels in moderate-to-severe melasma. Materials and Methods: A single-centre retrospective cohort study included 149 patients (mean age: 36.8 ± 7.2 years) with FST III–VI and baseline modified Melasma Area and Severity Index (mMASI) scores ≥10. The protocol involved glycolic acid priming, a multi-agent depigmenting mask, nightly maintenance cream, and oral TXA (500 mg for 6 months, tapered to 250 mg). Outcomes were evaluated at 3, 6, and 12 months using mMASI scores, standardised photographs, and patient satisfaction via a 5-point Likert scale. Subgroup analyses were conducted by age, skin type, and pregnancy history. Results: The mean mMASI scores declined from 13.2 to 3.4 at 12 months ( P < 0.001). At 12 months, 89.2% achieved ≥50% improvement, 57.1% had ≥75% reduction, and 12.1% achieved clearance. High satisfaction (Likert ≥4) was reported by 84.6%. Greater improvement was observed in younger patients, Fitzpatrick type IV, and parous women ( P = 0.04). Adverse effects were mild; hypomenorrhea (6%) resolved with TXA interruption. No serious events occurred. Conclusion: This dual-modality protocol demonstrated high efficacy, durability, and tolerability, warranting further validation in prospective studies.