Objective To analyze the effect of tranexamic acid combined with 1064 nm Q-switched Nd:YAG laser therapy on skin symptoms and skin barrier function in patients with melasma. Methods A total of 80 patients with melasma admitted to the Department of Dermatology, Wuxi Mingde Geriatric Hospital from May 2024 to February 2025 were selected, and they were divided into the control group and the observation group by the random number table method, with 40 patients in each group. The control group was treated with tranexamic acid, and the observation group was treated with tranexamic acid combined with 1064 nm Q-switched Nd:YAG laser. The skin symptoms, skin barrier function, clinical efffcacy and adverse reactions were compared between the two groups. Results After treatment, the scores of MASI and PGA in the observation group were lower than those in the control group (P<0.05). After treatment, the epidermal lipid content and stratum corneum hydration of lesion areas in the observation group were higher than those in the control group, and the transepidermal water loss was lower than that in the control group (P<0.05). The total effective rate of treatment in the observation group (90.00%) was higher than that in the control group (65.00%) (P<0.05). There was no statistically signiffcant difference in the incidence of adverse reactions between the two groups (P>0.05). Conclusion Tranexamic acid combined with 1064 nm Q-switched Nd:YAG laser achieves satisfactory efffcacy in the treatment of melasma. It can effectively improve patients’ skin symptoms and skin barrier function, without increasing the risk of adverse reactions.