Melasma Treatment Advances, With George Martin, MD

Hydroquinone has anchored melasma treatment for 75 years, but George Martin, MD, told HCPLive that the field is entering a period of meaningful change. During his session on disorders of pigmentation at Maui Derm NP+PA Summer 2026 in Colorado Springs, Martin walked through where hydroquinone still fits, which newer agents are gaining traction, and why he considers oral tranexamic acid the most underutilized tool in the melasma armamentarium.¹

Hydroquinone Remains a Mainstay, but Alternatives Are Expanding

Martin noted that hydroquinone is most effective when combined with fluocinolone and tretinoin in a triple combination cream, a regimen he continues to consider the mainstay of melasma treatment. For patients who cannot tolerate hydroquinone or wish to avoid it, he pointed to over-the-counter topical cysteamine as an established option. He also highlighted topical thiamidol as a newer bleaching agent that he described as more powerful than hydroquinone.

Additional options entering the space include compounded and commercially available topical metformin and topical tranexamic acid-containing serums. Martin said these additions to the melasma toolkit are an encouraging sign for patients who have not responded to conventional therapy.

Oral Tranexamic Acid: An Underused Option

Martin identified oral tranexamic acid as the most powerful and underutilized therapy currently available for melasma. Originally used to inhibit bleeding, the plasmin inhibitor and antifibrinolytic agent is effective at reducing hyperpigmentation and melanin production, a mechanism Martin tied to its antifibrinolytic activity. The drug is also used in operating rooms to control hemorrhage during procedures such as those in obstetrics and gynecology.

Because of its association with clotting risk, Martin emphasized the need for careful patient selection before initiating therapy. He said the effective dose range identified over time is 500 mg per day, typically divided into 250 mg twice daily, and noted that oral tranexamic acid can be used alongside topical bleaching agents. This dosing aligns with published literature, in which a network meta-analysis found 250 mg 3 times daily for 12 weeks to be the optimal dose, though 250 mg twice daily may be an acceptable alternative for patients with adherence concerns.²

Procedural Therapy: When to Escalate

Martin discussed chemical peels, microneedling, and energy-based devices as adjuncts for patients who do not respond to topical and oral therapy. He cautioned that deeper peels carry greater risk of worsening hyperpigmentation, calling the practice “more art than science” and one that requires experience.

Before escalating to procedures, Martin said he evaluates whether patients are practicing effective photoprotection. He noted that visible light, which current sunscreens do not block, is a significant driver of hyperpigmentation, and adequate visible light protection is not yet available but is anticipated soon. Patients who are already using effective photoprotection and oral tranexamic acid without improvement are the ones he considers candidates for procedural intervention.

Acquired Dermal Macular Hyperpigmentation

Martin also addressed acquired dermal macular hyperpigmentation, a unifying term he described for a group of conditions that includes lichen planus pigmentosus, Riehl melanosis, and erythema dyschromicum perstans. He noted that although these conditions have traditionally been treated as distinct entities, they share overlapping histopathology and a common underlying pathogenesis, prompting efforts to consolidate them under one diagnostic framework.

“I think that the introduction of new bleaching agents, such as thiamidal and others, are really exciting to add to our armamentarium, which includes the mainstay of hydroquinone in the form of a triple therapy,” Martin concluded. “Our topical and peeling agents are fantastic adjuncts to the therapy and can help move the needle, but the biggest problem we face in hyperpigmentation of the skin is photoprotection, and hopefully in the next year or so we're going to see effective visible light blockers.”

Watch part 1 of the interview with Martin, where he discusses vitiligo and the JAK inhibitor pipeline.³

Editor’s note: Reported disclosures for Martin include AbbVie, Pfizer, Novartis Pharmaceuticals, Janssen Biotech, ER Squibb & Sons, Incyte Corporation, Organon, Galderma Laboratories, Genzyme Corporation, Amgen, LEO Pharma, UCB, Arcutis Biotherapeutics, Almirall, Biofrontera, Sun Pharmaceutical Industries, Lilly USA, and more.

References

1. Martin G. Disorders of Pigmentation. Session presented at Maui Derm NP+PA Summer 2026 in Colorado Springs.

2. Wang WJ, Wu TY, Tu YK, et al. The optimal dose of oral tranexamic acid in melasma: a network meta-analysis. Indian J Dermatol Venereol Leprol. 2023;89:189-194. https://pubmed.ncbi.nlm.nih.gov/36332095/

3. Pigmentation pipeline: vitiligo and melasma treatment advances. HCPLive. Published July 10, 2026. https://www.hcplive.com/view/pigmentation-pipeline-vitiligo-melasma-treatment