Best Online Prescription Skincare for Melasma

The standard prescription cream for melasma is the triple cream: hydroquinone 4%, tretinoin 0.05% and fluocinolone 0.01% (a mild steroid) in one tube. In the FDA trials, people applied it once a night for 8 weeks, and it cleared melasma more often than any two-ingredient version. It is approved only for short-term treatment, though, and melasma usually comes back after you stop, so you need a plan for what comes next.

If hydroquinone isn't right for you, there are other options. In a pooled analysis of melasma creams, non-hydroquinone creams such as tranexamic acid and azelaic acid improved melasma about as much as hydroquinone creams. Pregnancy plans, easily irritated skin and a deep skin tone are all good reasons to talk through this choice with your clinical team. Whichever cream you use, daily sun protection is part of the treatment.

Which prescription cream works best for melasma?

The triple cream (brand name Tri-Luma) combines fluocinolone acetonide 0.01% (a mild steroid), hydroquinone 4% (a pigment blocker) and tretinoin 0.05% (a retinoid). The FDA approves it for short-term treatment of moderate to severe melasma of the face, alongside sun avoidance and sunscreen, according to the Tri-Luma label.

In two FDA trials with 641 people aged 21 to 75, the full three-ingredient cream worked better than any two-ingredient version. In the first trial, 38% of people on the triple cream had their melasma fully cleared at 8 weeks. The rates for the two-ingredient versions were 15% for hydroquinone plus tretinoin, 4% for steroid plus hydroquinone and 0% for steroid plus tretinoin.

How long does melasma cream take to work, and how will my skin feel?

Expect to give it about two months. The FDA trials measured the triple cream after 8 weeks of nightly use. The label says to apply a thin film once a day, at least 30 minutes before bed. During the day, wear SPF 30 and protective clothing. The tranexamic acid cream trial measured results at 12 weeks.

Your skin will probably react at first. In the FDA trials of the triple cream, 41% of people had redness, 38% had peeling, 18% had burning, 14% had dryness and 11% had itching. If you know your skin gets cranky with active ingredients, raise that before you start. In the tranexamic acid trial, irritation was much less common than with hydroquinone.

Which melasma treatment fits me?

• If you are pregnant or planning a pregnancy: Tell your clinical team before you start. The triple cream's label warns it may cause birth defects or death of the baby if used during pregnancy, and the risk may be greater in the first trimester. The pooled analysis notes that hydroquinone creams are not used in pregnant or breastfeeding women because the evidence is lacking.
• If you use hormonal birth control: The triple cream label advises patients to switch to a non-hormonal method. Bring this up with your clinical team.
• If you have deep brown or Black skin: The triple cream was studied only in skin types I to IV, not in types V and VI, and its label says too much lightening can't be ruled out. Hydroquinone can also cause ochronosis, a gradual blue-black darkening of the skin. Most cases have been in Black patients, but it has also happened in white and Hispanic patients. Ochronosis has been linked to using hydroquinone products for more than 6 months, so ask your clinical team how long you should stay on one.
• If you have had a blood clot: Tell your clinical team before you consider tranexamic acid pills. The review of 28 trials left out people with a history of clots or bleeding problems, so its results don't cover you.
• If your skin gets irritated easily: Ask about a non-hydroquinone option. In the tranexamic acid trial, 3 of 50 people had irritation on tranexamic acid, compared with 19 of 50 on hydroquinone, and satisfaction was higher with tranexamic acid.
• If you want tretinoin in your routine: Tretinoin is one of the three ingredients in the FDA-approved triple cream. Our clinical team can prescribe tretinoin if it fits your goal and can tell you how it works with the rest of your melasma plan.

Why does melasma come back, and how do I keep it away?

The triple cream is meant to clear melasma, not to keep it away. Its label says it is not for maintenance and that melasma usually comes back after you stop. Once melasma is under control, some patients can move to other treatments. Ask your clinical team what you should switch to before you finish your course, so you aren't caught off guard when the tube runs out.

Recurrence isn't unique to the triple cream. The review of 28 trials notes that melasma commonly returns during or after any treatment, including lasers and tranexamic acid pills. Before you book a laser for dark spots, ask your clinical team whether your spots are melasma.

Sun protection is part of every plan. The label says even a small amount of sunlight keeps pigment cells active. Use sunscreen every day and cover treated areas with a hat or other protective covering when you're outside.

You want an even face, without dark patches on your cheeks and upper lip. Take the quiz so our clinical team can review your skin, your pregnancy plans and what you've tried, then build a skin plan that fits, including tretinoin if it suits your goal.