Objective To analyze the effect of Taohong Siwu decoction on symptom improvement in patients with melasma. Methods A total of 100 patients with melasma admitted to Taizhou People's Hospital from January 2023 to January 2025 were selected, and they were divided into group A and group B by the random number table method, with 50 patients in each group. Group A was treated with routine drug treatment, and group B was treated with Taohong Siwu decoction on the basis of group A. The symptom improvement, treatment effect, incidence of adverse reactions and recurrence rate were compared between the two groups. Results The MASI score of the two groups after treatment was lower than that before treatment, and that of group B was lower than that of group A (P<0.05). The total effective rate of group B (90.00%) was higher than that of group A (72.00%) (P<0.05). The incidence of adverse reactions in group B was 8.00%, compared with 4.00% in group A, the difference was not statistically signiffcant (P>0.05). The recurrence rate of group B was 17.65%, which was lower than that of group A(36.36%), but the difference was not statistically signiffcant (P>0.05 ). Conclusion The use of Taohong Siwu decoction in patients with melasma can effectively improve the clinical symptoms and improve the overall efffcacy, without increasing the risk of adverse reactions and recurrence, showing good safety.