Objective To analyze the effect of tranexamic acid combined with laser treatment on disease severity and skin condition in patients with melasma. Methods A total of 112 patients with melasma diagnosed and treated in the First People's Hospital of Yulin from March 2022 to November 2024 were selected as the research subjects. They were divided into the control group and the study group by the Excel random function method, with 56 patients in each group. The control group was given laser treatment, and the study group was given tranexamic acid adjuvant treatment on the basis of the control group. The treatment effect, disease severity [modified Melasma Area and Severity Index (mMASI)], skin image detection indexes, adverse reaction rate and treatment satisfaction were compared between the two groups. Results The total effective rate of treatment in the study group was 98.21%, which was higher than 87.50% in the control group (P <0.05). After treatment, the mMASI score in the two groups was lower than that before treatment, and that in the study group was lower than that in the control group (P <0.05). Compared with before treatment, the scores of spots, ultraviolet spots and red areas in the two groups decreased after treatment, and compared with control group, the scores of spots, ultraviolet spots and red areas in the study group were lower (P <0.05). There was no significant difference in the incidence of adverse reactions between the study group and the control group (P >0.05). The treatment satisfaction rate in the study group was higher than that in the control group (P <0.05). Conclusion The effect of tranexamic acid combined with laser in the treatment of melasma is good, which can reduce the disease severity, improve the skin condition, enhance the treatment satisfaction of patients, and does not increase the incidence of adverse reactions.