Efficacy and Safety of Laser-Based Therapies for Melasma: A Systematic Review and Meta-Analysis.

Melasma is a chronic acquired hyperpigmentation disorder that often exerts a psychosocial burden on affected individuals. Although laser- and light-based therapies are pivotal third-line interventions for recalcitrant cases, clinical consensus regarding their comparative efficacy and long-term safety remains inconsistent. This systematic review and meta-analysis aimed to evaluate and synthesize evidence from randomized controlled trials (RCTs) on the efficacy and safety of various laser-based therapies for melasma. A literature search was performed using PubMed, Excerpta Medica Database (EMBASE), Cochrane Library, and Web of Science databases from inception to January 2026. RCTs and split-face comparative studies evaluating laser therapies versus placebo, topical agents, or alternative laser modalities were included. Data synthesis was performed using a random-effects model with Hartung-Knapp adjustment. The primary outcome was the mean difference (MD) in the reduction of the Melasma Area and Severity Index (MASI) score. The certainty of evidence was appraised using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Fifty-two studies, involving 1,058 participants, met the inclusion criteria. The overall pooled analysis showed a trend toward clinical improvement that was not statistically significant (MD: 0.70; 95% CI: -0.55, 1.95; p = 0.2682). Subgroup analysis by laser technology revealed that low-fluence Q-switched Nd:YAG (QSNY) (1064 nm) lasers provided a statistically significant reduction in melasma severity (MD 1.47; 95% CI: 0.08 to 2.85, p < 0.05), while picosecond lasers (MD -0.11; 95% CI: -0.79 to 0.57) and fractional lasers (MD 0.94; 95% CI: -0.84 to 2.71) did not significantly outperform control groups. Statistical heterogeneity was high across the evidence (I² = 96.2%). The overall certainty of evidence for the primary outcome was very low because of the lack of blinding and the high inconsistency. No serious adverse events were reported, although minor complications, such as transient erythema and localized burning, were common. Low-fluence QSNY laser therapy is an effective adjunctive modality for melasma management. However, due to high recurrence rates and variability in outcomes, it should be integrated into a multi-modal approach alongside strict photoprotection and topical depigmenting agents. Future research should prioritize the long-term follow-up and standardization of laser parameters across different skin phenotypes.