Objective To explore the effect of traditional Chinese acupuncture combined with tranexamic acid on skin lesions and skin physiological parameters in female patients with melasma. Methods A total of 122 female patients with melasma admitted to the Department of Traditional Chinese Medicine, Rehabilitation Hospital of Kailuan General Hospital from February 2023 to February 2025 were selected as the research subjects. According to the random number table method, they were divided into the control group and the observation group, with 61 patients in each group. The control group was treated with tranexamic acid alone, and the observation group received traditional Chinese acupuncture combined with tranexamic acid. The melasma Area and Severity Index (MASI), skin lesions, sex hormone levels and skin physiological parameters were compared between the two groups. Results After 6 months of treatment, the MASI score of the observation group was lower than that of the control group (P<0.05). After 6 months of treatment, the skin lesion score of the observation group was lower than that of the control group (P<0.05). After 6 months of treatment, the levels of FSH, LH and E2 in the observation group were lower than those in the control group (P<0.05). The epidermal lipid content and stratum corneum hydration of the observation group were higher than those of the control group, while the TEWL was lower than that of the control group (P<0.05). There was no signiffcant difference in melanin index between the two groups (P>0.05). Conclusion For female patients with melasma, traditional Chinese acupuncture combined with tranexamic acid can reduce MASI and effectively improve skin lesions. This combined regimen can regulate sex hormone levels and optimize multiple skin physiological parameters.