Objective To analyze the effect of modified Xiaoyao powder combined with acupuncture on symptom improvement in patients with melasma. Methods A total of 50 patients with melasma admitted to the Department of Dermatology, Changchun Hospital of Traditional Chinese Medicine from January to December 2025 were selected, and they were divided into the control group and the observation group by the random number table method, with 25 patients in each group. The control group was treated with modified Xiaoyao powder, and the observation group was treated with modified Xiaoyao powder combined with acupuncture. The symptom improvement, treatment effect and adverse reactions were compared between the two groups. Results After treatment, the MASI score of the observation group was lower than that of the control group (P <0.05). The total effective rate of the observation group (96.00%) was higher than that of the control group (72.00%) (P <0.05). The incidence of adverse reactions in the observation group (4.00%) was lower than that in the control group (8.00%), but the difference was not statistically significant (P >0.05). Conclusion The application of modified Xiaoyao powder combined with acupuncture in patients with melasma has a good effect, which can effectively alleviate melasma-related symptoms, without increasing the risk of adverse reactions.