The Efficacy and Safety of Radiofrequency Microneedling for Melasma: A Systematic Review and Qualitative Evidence Synthesis

Melasma is a chronic, relapsing hyperpigmentation disorder that is difficult to treat, particularly in Fitzpatrick skin types III-V, where energy-based devices frequently induce postinflammatory hyperpigmentation (PIH). Radiofrequency microneedling (RFMN) has emerged as a promising alternative because it targets dermal pathology while minimizing epidermal injury. Systematically evaluate the efficacy, safety, and mechanistic rationale of RFMN for melasma. A PRISMA 2020 compliant search of PubMed, Embase, Cochrane CENTRAL, and LILACS (2014-2025) identified clinical studies evaluating RFMN alone or in combination therapies. Risk of bias was assessed using Joanna Briggs Institute tools. Owing to clinical and methodological heterogeneity, a qualitative synthesis was performed. Across 12 included studies, RFMN consistently improved Melasma Area and Severity Index (MASI) or modified MASI scores and melanin indices, with effects maintained up to 6 months. Histological evidence demonstrated reductions in dermal senescence markers and partial restoration of basement-membrane integrity. RFMN also showed a favorable safety profile, with a low incidence of PIH in darker phototypes. Combination treatment, particularly with low-fluence Q-switched Nd:YAG laser produced greater pigment reduction than monotherapy. RFMN is an effective and safe modality for melasma, offering advantages over pigment-directed lasers by addressing dermal mechanisms and limiting PIH risk. It may serve as a first-line energy-based therapy. Level of Evidence:3 (Therapeutic) For image description, please refer to the figure legend and surrounding text.