Background: Melasma is a common pigmentary disorder predominantly affecting individuals with darker skin types. Although hydroquinone remains the gold standard treatment, its limitations, including slow onset, recurrence, and adverse effects, have prompted the exploration of adjunctive therapies such as low-fluence QS-Nd:YAG lasers. Methods: This prospective, split-face randomized controlled trial was conducted on 30 patients with dermal or mixed-type melasma. One side of the face received combination therapy with low-fluence QS-Nd:YAG laser (1064 nm) and 2% hydroquinone cream, while the other side was treated with 2% hydroquinone cream alone. Modified Melasma Area Severity Index (mMASI) scores, clinical photographs, and patient satisfaction were assessed at baseline, 6 weeks, and 10 weeks. Adverse effects were also recorded. Results: Combination therapy demonstrated greater short-term efficacy, with 63.6% of patients showing improvement compared to 31.8% on the hydroquinone-only side (p = 0.034). The mean mMASI score on the combination-treated side decreased significantly at 6 weeks (1.36 ± 0.51 to 0.95 ± 0.45, p = 0.001). However, rebound hyperpigmentation occurred in 36.4% of patients on the combination-treated side, and transient erythema was noted in all laser-treated patients. Patient satisfaction was low, with only 31.8% satisfied with laser treatment. Conclusion: While the combination of low-fluence QS-Nd:YAG laser and 2% hydroquinone cream showed superior short-term efficacy compared to hydroquinone monotherapy, the benefits were not sustained, and adverse effects were more frequent. Caution is advised when using this combination therapy, with a focus on maintenance strategies and patient counselling to mitigate risks.