Quick answer
A 2023 review gave grade A support to hydroquinone, triple combination creams, kojic acid, azelaic acid and sunscreen for melasma; in Malaysia hydroquinone, tretinoin and medicinal azelaic acid are poisons supplied by a doctor or pharmacist.
- Daily sunscreen: called essential by a 2026 expert consensus, and the one product used all the time.
- Hydroquinone and triple combination creams: the standard in the consensus when supervised, and well documented in trials; Group C poisons in Malaysia.
- Azelaic acid and kojic acid: alternatives in the consensus; azelaic acid is a poison for medicinal use, kojic acid has no Poisons List entry.
- Tranexamic acid: tablets are Group B and need a prescription; topical forms have smaller effects and need larger studies.
- Mercury creams are not a treatment and carry real danger; see a doctor for a patch that does not respond.
What creams are used for melasma, and what do trials report?
A 2023 systematic review of 174 randomised or controlled trials gave a grade A recommendation to hydroquinone, triple combination creams, sunscreens, kojic acid and azelaic acid. It said topical vitamin C, resorcinol and topical tranexamic acid still need larger studies, and that the choice of agent should be individualised and depends on what is available in a country. A 2026 Delphi consensus of 38 dermatologists from 11 countries reached high agreement on 21 of its statements, among them that broad-spectrum sunscreen is essential, that regulated and supervised use of hydroquinone-based triple combination creams is the standard, and that azelaic acid, kojic acid and oral tranexamic acid are alternatives.
The two reviews do not rank every product against every other, and the trials differ in strength, duration and skin type. What they agree on is the order of the foundation: protection from sun first, then a supervised lightening cream, then alternatives or additions when that is not suitable or not enough. The pigmentation page describes the clinic approach to melasma in the same terms: strict sun protection, a prescription topical regime, control of heat and hormonal triggers, and patience, with laser only in selected cases.
Do hydroquinone and triple combination creams work?
Trials report improvement, and they also report side effects. A triple combination cream combines hydroquinone, tretinoin and a mild corticosteroid (fluocinolone acetonide). In a 2025 trial of 53 Chinese patients with moderate to severe melasma, a generic version used once daily for 8 weeks reached 52.2 per cent efficacy, against 57.1 per cent for the brand and none for placebo, and adverse events were reported in 69.6 per cent of the generic group and 90.5 per cent of the brand group, a difference that was not significant. The trial does not separate the two creams on safety, and a doctor decides the duration of use and watches the skin.
Hydroquinone has a harder side too. In a trial of 99 patients, adverse reactions and relapse were seen in the hydroquinone group, and the authors favoured tranexamic acid and niacinamide creams for tolerability. That is one trial, and the consensus panel still calls supervised hydroquinone-based creams the standard, so the fair reading is that a doctor weighs benefit and irritation for the person in front of them.
Do azelaic acid, kojic acid and niacinamide work for melasma?
Azelaic acid and kojic acid have grade A support in the 2023 review and appear as alternatives in the 2026 consensus. They are used when hydroquinone is not suitable, as an addition, or for maintenance, and the reviews place them as alternatives or additions. Niacinamide is not among the agents named in the abstract of the 2023 review, and in the 99-patient trial it was paired with tranexamic acid, so that result belongs to the combination and not to niacinamide alone.
Expect a gradual change, and expect melasma to remain a condition managed over time. A cream that promises to erase it in days is describing something none of these studies reports.
Does tranexamic acid cream or tablet work for melasma?
A 2024 meta-analysis of 22 randomised trials with 1,280 patients found tranexamic acid reduced melasma severity by every route, most by tablets, then by injection, then by topical use, with high heterogeneity between studies. Side effects were stomach upset, skin irritation and menstrual irregularities. The 2023 review gave oral tranexamic acid a strong recommendation provided there are no contraindications, and topical tranexamic acid still needed larger studies.
The tablet carries a clot-risk question that a doctor checks before prescribing, and a tablet is a Group B poison in Malaysia. The article on tranexamic acid for melasma sets out the clot data and the legal position in full.
What does Malaysian law say about melasma creams?
The Poisons List, updated in line with P.U.(A) 125/2024, sorts them into groups, and the Poisons Act sets who may supply each. Group B may be supplied by a registered medical practitioner, or by a licensed pharmacist as a dispensed medicine on a doctor’s prescription. Group C may be supplied as a dispensed medicine, meaning supplied to a particular person for their treatment by a doctor or licensed pharmacist, which is not a shelf sale.
- Hydroquinone: Group C for medicinal preparations. The only exemptions are artificial nail systems at not more than 0.02 per cent and notified cosmetics containing arbutin, so hydroquinone itself in a face cream is not exempted.
- Tretinoin: Group C, all preparations. The retinoid law article explains what that means in a shop and why topical retinoids are avoided in pregnancy.
- Azelaic acid: Group B for medicinal preparations, and Group C for medicinal preparations for external use, so a medicinal azelaic acid cream is dispensed.
- Tranexamic acid: Group B, all preparations unless exempted, with an exemption for a notified cosmetic.
- Kojic acid and niacinamide: no entry in the Poisons List. This article did not check the cosmetic annexes of the National Pharmaceutical Regulatory Agency for them, so a pharmacist is the person to ask about a particular product.
Why are mercury whitening creams dangerous?
Mercury is on the Poisons List with an exemption only for a notified cosmetic containing not more than 1 part per million, and a cream whose lightening comes from mercury carries harm that the label never mentions. A cream sold as a treatment gives no assurance about what it contains. The article on whitening creams and mercury explains how to check a cream against the Ministry of Health list, and the advice is to stop a doubtful cream and see a doctor.
How does sunscreen fit in?
Sunscreen is the one product the 2023 review and the 2026 consensus both treat as basic. The consensus calls broad-spectrum sunscreen essential. Melasma is driven by sun, heat and hormones, so a cream used without daily protection is working against a trigger that is present every day in this climate.
How long do melasma creams take, and what should I expect?
Expect weeks to months, and expect the patch to relapse. The trials above ran for 8 weeks in the triple combination study and three months in the 99-patient study, and the tranexamic acid meta-analysis included treatment durations from 8 weeks to nearly 2 years. The 2026 consensus describes melasma as having a multifactorial cause, high recurrence rates and a need for long-term maintenance, and it keeps lasers for refractory cases. A cream that lightens a patch while it is used does not remove the triggers that brought it on, which is why sun protection carries on after the active cream is stopped.
What should I ask before starting a melasma cream?
Ask what the active ingredient is and at what strength, because one name can cover very different products. Ask how long it is meant to be used and when the skin will be reviewed, since the trials above used fixed courses. Ask what to do if the skin burns, reddens or peels, and whether it is safe to use if a pregnancy is possible. Check that the supplier is a doctor or a licensed pharmacist when the cream is one of the poisons above, and be cautious of any cream sold without an ingredient list. These are questions about safety and supply, and the right answer depends on an examination of the skin.
When should I see a doctor about melasma?
See a doctor when a dark patch is on one side only, has an uneven edge, has changed recently, or does not fit the usual symmetrical cheek pattern, since not every brown patch is melasma. The article on telling melasma, sun spots and horis naevus apart sets out how they differ, and the article on laser and melasma explains why an aggressive treatment can do harm. Also see a doctor before using any prescription cream while pregnant or planning a pregnancy, and for any patch that has not responded after months of sun protection and a supervised regime.
