Melasma is a common acquired disorder of pigmentation. To compare the efficacy of oral tranexamic acid (TA) versus oral TA and Q-switched Nd: YAG laser (1064-nm wavelength) in the treatment of melasma. Sixty patients were divided into two groups. Group A: oral TA only and group B: oral TA plus Qs-Nd: YAG laser (1064 nm) sessions. Evaluations were performed on the clinical basis including the use of Modified Melasma Area and Severity Index (m MASI) and dermoscopy. Dermoscopic examinations were performed before and after the treatment sessions as well as at the 3-month follow up visit. There were statistically significant differences between the two studied groups regarding the change of m MASI after treatment and at the end of follow-up ( = .036) by using dermoscopy. Epidermal type of melasma showed the best response (0.048) and telangiectasias significantly improved in both groups of patients. Low-fluence 1064-nm Qs-Nd:Yag laser is effective and safe line of melasma treatment. Adding oral TA may enhance its clinical efficacy and decrease its side effects or complications. Dermoscopy is an important tool in pigment detection and vascular components in melasma, as well as their response to treatment.