Objective To evaluate the effect of cosmetic acupuncture combined with body acupuncture on melasma area and severity index in patients with melasma. Methods A total of 80 female patients with melasma admitted to the Second Affiliated Hospital of Nanjing Medical University from August 2025 to March 2026 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 received conventional body acupuncture therapy, and the observation group received cosmetic acupuncture on the basis of conventional body acupuncture. The melasma area and severity index, clinical efficacy, serum sex hormone levels and adverse reaction rate were compared between the two groups. Results After treatment, the scores of lesion area, pigment depth and pigment uniformity in the two groups were lower than those before treatment, and those in the observation group were lower than those in the control group (P <0.05). The total effective rate of the observation group was 95.00%, which was higher than 77.50% of the control group (P <0.05). After treatment, the levels of P and E2 in the two groups were lower than those before treatment, and those in the observation group were lower than those in the control group (P <0.05). There was no statistically significant difference in the incidence of adverse reactions between the two groups (P >0.05). Conclusion Cosmetic acupuncture combined with body acupuncture can effectively improve melasma lesions, synergistically regulate sex hormone metabolism, and enhance clinical efficacy, without increasing the risk of adverse reactions.