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BACKGROUND Tranexamic acid can prevent melanocyte activation by various stimuli. Combining tranexamic acid with either hydroquinone 4% or Q-switched Nd:YAG laser may be associated with greater improvement of melasma. OBJECTIVES We aimed to evaluate the efficacy and safety of oral tranexamic acid alone and combined with either topical hydroquinone 4% or low-fluence 1064nm Q-switched Nd:YAG laser in treatment of mixed melasma. PATIENTS & METHODS Patients were randomly divided into three groups of 20 patients each. Group A were treated with oral tranexamic acid 250 mg twice daily for 3 months; group B were treated with tranexamic acid similarly combined with topical hydroquinone 4% cream; group C were treated with tranexamic acid combined with 2 sessions of 1064nm low fluence Q-switched ND:YAG laser (850-1200 mJ/cm2, 4-5Hz,spot size 4 mm) spaced 4 weeks apart. Patients were followed monthly for 9 months. RESULTS After cessation of therapy, the mean mMASI score was lowest in group B(2.34± 2.37) followed by groups A (6.38±4.04) and C (7.24 ± 4.95).Mean percentage of mMASI score improvement was 35.91 ± 24.13, 77.47 ± 19.07 and 24.94 ± 27.79 in groups A, B and C (p<0.001). There was a significant reduction of telangiectasia in the three groups. Reported side effects were itching & irritation, post-inflammatory hyperpigmentation and gastritis. CONCLUSION Oral tranexamic acid is a tolerable effective treatment modality for melasma. Combining hydroquinone 4% with oral tranexamic acid is associated with a relatively earlier and better cosmetic outcome.