Multimodal Approach for Recalcitrant Melasma Using Picosecond Laser and Topical JAK Inhibition: A Case Report

Melasma is a chronic hyperpigmentation disorder with high relapse rates, particularly in Fitzpatrick skin types III-V. Increasing evidence implicates cytokine-driven inflammation and visible light-induced melanogenesis as key contributors to disease persistence. These mechanisms support the rationale for exploring a multimodal therapeutic approach.

A woman in her early 30s with phototype IV presented with a 5-year history of recalcitrant centrofacial melasma. Previous treatments-including hydroquinone, oral tranexamic acid, and superficial chemical peels-produced only transient and incomplete improvement. Baseline Melasma Severity Index (MSI) score was 7.9, consistent with moderate-to-severe disease.

Treatment consisted of low-fluence picosecond 755 nm alexandrite laser, short-term topical corticosteroid post-procedure, initiation of topical tofacitinib 2% cream twice daily for 11 months, and continuous iron oxide-based visible light-blocking photoprotection. Laboratory monitoring during therapy remained normal.

At 11 months, the patient achieved near-total clearance with an MSI reduction from 7.9 to 0.10 (98.7% improvement). No adverse events, post-inflammatory hyperpigmentation, or relapse were observed, including 3 months after treatment cessation.

This case illustrates the potential clinical value of combining pigment-targeted picosecond laser therapy with topical JAK inhibition and visible light-specific photoprotection for recalcitrant melasma. The durable remission achieved supports further investigation into anti-inflammatory and photoreactive pathway modulation as adjunctive strategies in melasma management.