Objective To analyze the clinical effect of Q-switched laser+tranexamic acid in the treatment of melasma and its influence on patients' skin physiological parameters. Methods A total of 110 patients with melasma who visited Suzhou Industrial Park Shumei Medical Aesthetics Clinic from June 2023 to June 2024 were selected, and they were divided into the conventional group (n =55) and the treatment group (n =55) by the random number table method. The conventional group received Q-switched laser treatment alone, and the treatment group received tranexamic acid treatment on the basis of the conventional group. The clinical efficacy, skin physiological parameters, Melasma Area and Severity Index (MASI) score, Melasma Quality of Life Scale (MELA-SQOL) score, adverse reaction rate and 1-year recurrence rate were compared between the two groups. Results The total effective rate of treatment in the treatment group (96.36%) was higher than that in the conventional group (81.82%) (P <0.05). After treatment, the TEWL, melanin index, MASI score and MELA-SQOL score of the treatment group were lower than those of the conventional group (P <0.05). There was no statistically significant difference in the incidence of adverse reactions between the two groups (P >0.05). The 1-year recurrence rate of the treatment group was lower than that of the conventional group (P <0.05). Conclusion Q-switched laser+tranexamic acid can effectively improve the symptoms and skin physiological state of patients with melasma, reduce the degree of skin lesions, lower the recurrence rate, help to improve patients' quality of life, and will not increase the risk of adverse reactions.