Comparison of The efficacy and safety of fractional erbium: YAG laser in combination with Tranexamic acid delivery by different methods versus Tranexamic acid alone: A systematic review and meta-analysis.

Melasma is a chronic hyperpigmentary disorder characterized by light-brown to bluish-gray patches. No single treatment is universally efficacious. Thus, a combination treatment should be applied. This Systematic review and meta-analysis aims to evaluate the efficacy of fractional erbium: YAG laser combined with tranexamic acid (TXA) delivery methods compared to TXA alone for melasma treatment. A comprehensive search was conducted across PubMed, Google Scholar, and Web of Science, including Randomized controlled trials (RCTs), cohort studies, and case series of patients diagnosed with melasma, excluding studies with high bias risk or low quality, studies involved patients with active skin infections, inflammatory skin conditions, or systemic diseases affecting healing, patients with keloid history or with concurrent anticoagulant or steroid use, and non-compliance with protocols. Studies should report at least one of the following outcomes such as improvement in melasma, incidence/severity of adverse events, objective pigment reduction, or treatment effect duration and relapse time. The risk of bias was assessed using the Newcastle-Ottawa Scale and the meta-analysis was conducted using a random-effects model (restricted maximum-likelihood estimator) to account for study variability. We included 13 studies involving a total of 585 participants. Most studies involved between 30 and 60 participants. Subgroup analysis of the modified Melasma Area and severity index showed no overall effect (standardized mean differences (SMDs) = -0.0802, p = 0.8685), with high heterogeneity (I² = 92.5%, p < 0.0001). A large positive effect was observed at 3 months (SMD = 1.9802) and a negative effect at 6 months (SMD = -0.7190) with significant differences. The overall effect of interventions on the Melasma Area and severity index was minimal (SMD = 0.0039, p = 0.9877), with moderate heterogeneity (I² = 50.3%, p = 0.1337). A small negative effect at 6 months was observed (SMD = -0.4234) and no significant effects at 3 months. There is no consistent or significant long-term impact on melasma severity. While some short-term improvements were observed, they often declined over time. Future studies are needed to better define the long-term effectiveness and safety.