Tranexamic Acid in the Treatment of Melasma: A Review of the Literature

Research situation, hot spots, and global trends of melasma therapy: Bibliometric insights and visual analysis from 2000 to 2023

BACKGROUND

Melasma is a prevalent pigmented disease, yet its pathogenesis remains unclear, posing challenges for effective treatment. Bibliometric analysis, a novel approach to literature research, offers the opportunity to evaluate research trends through qualitative and quantitative methods. This study utilizes bibliometric methods to analyze the existing literature on melasma treatment, examining influential publications, institutions, countries, and authors through statistical analysis.

METHODS

In order to retrieve manuscripts related to the topic of melasma treatment, we conducted a search using the search formula: (TS = (melasma or Chloasma or "mask of pregnancy")) AND TS = (treatment or therapy). We searched through the Web of Science Core Collection database, covering publications from 2000 to 2023. VOSviewer, CiteSpace and the Bibliometric online site (https://bibliometric.com/app) were used to conduct this bibliometric analysis. Our analysis focused on various factors including publications, authors co-authorship, institutions, countries, citation analysis, keywords co-occurrence, references co-citation and journal co-citation.

RESULTS

A total of 943 articles and 200 reviews were published between 2000 and 2023, accumulating a total of 8628 citations. The average number of citations per item was 18.85, and the average number of citations per year was 292.69. The most prolific author, Sungeun Chang, contributed a total of 9 articles. Cario University emerged as the top research institution. The United States led in terms of article publications with a count of 276. In the past 5 years, the research trends in this field have primarily focused on tranexamic acid and epidermal melasma, as indicated by the burst analysis of publications and keywords.

CONCLUSIONS

The United States continues to lead in terms of institutions and research output. The current emphasis is on the meticulous implementation of tranexamic acid and laser therapy. It is crucial to foster enhanced collaboration among countries, institutions, and authors to facilitate improved research.

Enhancing skin delivery of tranexamic acid via esterification: synthesis and evaluation of alkyl ester derivatives

Tranexamic acid (TA) is widely used clinically as a skin whitening agent for treating melasma and hyperpigmentation. However, oral administration of TA is often associated with adverse effects. Topical application could mitigate these issues, but the hydrophilic nature of TA limits its topical use. To overcome this limitation, we explored the design of TA alkyl ester prodrugs to enhance skin absorption. Our study specifically focused on the butyl and octyl ester derivatives of TA. The results demonstrated that TA4 and TA8 significantly improved skin penetration and deposition, by approximately 2-3 times compared to unmodified TA. Furthermore, these derivatives were rapidly hydrolyzed to release the parent drug within less than 2 h in both skin homogenates and blood. Safety assessments indicated no significant skin irritation in mice and revealed low cytotoxicity in HaCaT cells when exposed to the TA ester derivatives. We also developed a hydrogel formulation incorporating the TA derivatives, using hydroxyethyl cellulose, propylene glycol, Tween 80, and chlorobutanol. This formulation exhibited good skin absorption, stability, and user experience, making it a promising candidate for topical application. To sum up, the alkyl esterification prodrug design provides a promising approach for enhancing the skin delivery of TA.

Efficacy and safety of mesotherapy with tranexamic acid versus vitamin C in the treatment of melasma: A meta-analysis and systemic review

BACKGROUND

The exact pathogenesis of melasma is not yet known, and its treatment remains challenging. Mesotherapy with tranexamic acid (TXA) and vitamin C was both reported to have certain effects on melasma. In spite of that several articles have compared the efficacy and safety of the two drugs on melasma, most of them were clinical study with small sample size.

AIMS

To evaluate the efficacy and safety of mesotherapy with TXA versus vitamin C in treating melasma through meta-analysis and systemic review.

METHODS

The authors searched PubMed, Web of Science, Springer, and ScienceDirect for studies that compared mesotherapy with TXA versus vitamin C as a treatment for melasma. Primary outcomes were change in melasma area and severity index (MASI) before and after the treatment.

RESULTS

Finally, five studies with a total of 127 patients were included in the systematic review. There was no statistic difference in the change in MASI score between the TXA and vitamin C groups (mean difference, 0.16; 95% CI, -0.79 to 1.11).

CONCLUSIONS

Mesotherapy with both TXA and vitamin C is safe and effective in the treatment of melasma.

Potential Role of Tranexamic Acid in Rosacea Treatment: conquering Flushing Beyond Melasma

Rosacea is a chronic inflammatory skin disease that affects a patient's appearance and quality of life. It mainly affects the midface region and presents as erythema, flushing, telangiectasia, papules, pustules, and rhinophyma. Despite its prevalence, the precise pathophysiology of rosacea remains unknown, and novel pharmacological therapies are currently under investigation. Tranexamic acid (TA) is a synthetic, lysine-like compound that competitively inhibits fibrinogen production by synthesizing fibrinolytic enzymes. In addition to its popular application in hemorrhage treatment, TA has been used to manage a number of skin conditions, including melasma, chronic urticaria, and angioedema. TA is a better option for melasma treatment. However, the role of TA in treating rosacea has not yet been systematically elucidated. In this study, we reviewed all available literature on the use of TA for rosacea treatment. The included articles examined the therapeutic effects of TA in patients with rosacea, including traditional methods such as oral and topical administration and more novel approaches such as intradermal injections, microneedling, and laser-assisted delivery. Several recent clinical studies demonstrated that TA alleviates rosacea symptoms by restoring the permeability barrier, ameliorating the immune reaction, and inhibiting angiogenesis. In this review, we summarized the function and potential application of TA in rosacea treatment, aiming to facilitate the implementation of clinical applications.

Comparative efficacy and safety of tranexamic acid for melasma by different administration methods: A systematic review and network meta-analysis

BACKGROUND

Tranexamic acid (TA) is a new and promising drug for the treatment of melasma.

OBJECTIVES

This network meta-analysis aims to compare the efficacy and safety of various ways of administration of TA on melasma.

METHODS

We collected researches from PubMed, EMBASE, Cochrane Library and Web of Science. Melasma area severity index (MASI) is used to evaluate the severity of melasma. After treatment with different TA administration methods, a difference in MASI is named ΔMASI. We evaluate the curative effect by comparing the ΔMASI of different TA administration methods at a certain time point.

RESULTS

At the Weeks 4, 8, and 12 and the last follow-up, the ΔMASI of oral TA combined with routine topical agents (oTA + RTA) was higher than that of intradermal TA (iTA), topical TA (tTA) as well as microneedling TA (MNsTA), with statistical significance. At the 8th week, the ΔMASI of oTA was higher than that of iTA, with statistical significance. Compared with placebo, oTA showed statistically significant differences at Week 4, while tTA, iTA, and MNsTA showed statistically significant differences starting from Week 8.

CONCLUSIONS

Among various ways of administration of TA, oTA + RTA has the best effect on melasma. In the short term, the curative effect of oTA is better than that of iTA, and the onset time of oTA is faster than that of tTA, iTA and MNsTA. In the long run, the curative effect of TA alone has nothing to do with the mode of administration.

Role of interleukin-6 and endothelin-1 receptors in enhanced melanocyte dendricity of facial spots and suppression of their ligands by niacinamide and tranexamic acid

BACKGROUND

Hyperpigmented spots are common issues in all ethnicities with a hallmark characteristic of increased melanocyte dendricity.

OBJECTIVES

To determine (1) potential receptors and/or cytokines that are involved in increased melanocyte dendricity in multiple facial spot types; (2) treatment effects of skin-lightening compounds on identified cytokine release from keratinocytes and on dendricity in melanocytes.

METHODS

Facial spots (melasma, solar lentigo, acne-induced post-inflammatory hyperpigmentation) and adjacent non-spot skin biopsies were collected from Chinese women (age 20-70). The epidermal supra and basal layers were laser dissected to enrich keratinocyte or melanocyte biology respectively for transcriptome analysis. Melanocyte dendricity was assessed histologically by immunofluorescent staining. Effect of interleukin-6 (IL-6) and endothelin-1 (ET-1) on melanocyte dendricity and melanosome transfer were assessed in human melanocytes or melanocyte-keratinocyte co-culture models. Treatment effects of skin-lightening compounds (niacinamide, tranexamic acid [TxA], sucrose laurate/dilaurate mixture [SDL]) were assessed on IL-6 or ET-1 release from keratinocytes and on dendricity in melanocytes.

RESULTS

Transcriptome analysis revealed IL-6 receptor and ET-1 receptor were significantly upregulated compared to the adjacent normal skin, visually confirmed at the protein level through immunostaining. Melanocytes in spot areas are more dendritic than melanocytes in adjacent non-spot skin. The addition of IL-6 and ET-1 to cell culture models increased melanocyte dendricity and melanosome transfer. IL-6 release was significantly suppressed by niacinamide and its combination, while ET-1 release was significantly reduced by both niacinamide and TxA. In contrast, SDL acted directly upon melanocytes to reduce dendricity.

CONCLUSION

Interleukin-6 and ET-1 receptors are significantly upregulated in multiple facial spot types. The in vitro testing demonstrated their respective ligands increased melanocyte dendricity. Tested skin-lightening compounds showed reduction in release of IL-6/ET-1 from epidermal keratinocytes and/or inhibition of melanocyte dendricity. This work sheds light on pathophysiological mechanism of facial spots and potential new mechanisms of these skin-lightening compounds which warrant further human clinical validation.

Ginsenoside Re inhibits melanogenesis and melanoma growth by downregulating microphthalmia-associated transcription factor

Panax ginseng, also known as Korean ginseng, is a traditional remedy widely used in Asian countries. Its major active compounds are ginsenosides, specifically triterpenoid saponins. Among them, one notable ginsenoside called Re has shown various biological effects, including anti-cancer and anti-inflammatory properties. However, the potential beneficial effects of Re on melanogenesis and skin cancer remain poorly understood. To investigate this, we conducted a comprehensive study using biochemical assays, cell-based models, a zebrafish pigment formation model, and a tumor xenograft model. Our results revealed that Re effectively inhibited melanin biosynthesis in a dose-dependent manner by competitively inhibiting the activity of tyrosinase, an enzyme involved in melanin production. Moreover, Re significantly reduced the mRNA expression levels of microphthalmia-associated transcription factor (MITF), a key regulator of melanin biosynthesis and melanoma growth. Furthermore, Re decreased the protein expression of MITF and its target genes, including tyrosinase, TRP-1, and TRP-2, through a partially ubiquitin-dependent proteasomal degradation mechanism, mediated by the AKT and ERK signaling pathways. These findings indicate that Re exerts its hypopigmentary effects by directly inhibiting tyrosinase activity and suppressing its expression via MITF. Additionally, Re demonstrated inhibitory effects on skin melanoma growth and induced tumor vascular normalization in our in vivo experiments. This study represents the first evidence of Re-mediated inhibition of melanogenesis and skin melanoma, shedding light on the underlying mechanisms. These promising preclinical findings warrant further investigation to determine the suitability of Re as a natural agent for treating hyperpigmentation disorders and skin cancer.

Is Tranexamic Acid Use Effective in Preventing Postinflammatory Hyperpigmentation after Laser Treatment? A Systematic Review and Meta-Analysis

Postinflammatory hyperpigmentation (PIH) is one of the most prevalent complications of laser treatment. However, comprehensive evidence is lacking to confirm the effect of tranexamic acid (TXA) for the prevention of postlaser PIH. We classified laser combined with TXA as the experimental group and laser alone as the control group from the selected studies in order to determine the efficacy of the extra use of TXA. We conducted a comprehensive literature review of randomized controlled trials (RCTs) that matched TXA coupled with laser vs. laser alone. The melanin index (MI) scores were employed as the clinically improved outcomes. Seven RCTs and a total of 222 individuals were evaluated in this meta-analysis. The findings revealed no statistically significant difference between the TXA and control groups in terms of decrease in mean MI scores at the end of the research ( $P=0.45$ ). The subgroup analysis showed that at month 1, extra use of TXA after laser treatment resulting in a statistically significant decrease in MI as opposed to laser alone ( $P=0.04$ ). However, at months 2 ( $P=0.73$ ), 3 ( $P=0.85$ ), and 6 ( $P=0.64$ ), the decrease in MI scores was not statistically significant. In addition, there was no statistically significant difference between topical, oral, and intradermal TXA on the reduction of MI scores after treatment ( $P=0.61$ ). Furthermore, nausea and menorrhagia occurred in the oral TXA group. The current meta-analysis found limited temporary efficacy of TXA in preventing postlaser PIH after 1 month.

Disorders of hyperpigmentation. Part II. Review of management and treatment options for hyperpigmentation

Key challenges in the management of pigmentary disorders such as melasma and postinflammatory hyperpigmentation are their resistance to treatment, tendency to recur after treatment, and the risk of exacerbating hyperpigmentation with many treatment modalities. The second article in this 2-part continuing medical education series on pigmentary disorders focuses on the evidence behind medical and procedural treatments of dyschromias, including photoprotection, topical lightening agents, oral agents, chemical peels, and laser therapy.

Perspectives of topical formulations for melasma

Melasma is acquired hyperpigmentation that mainly affects the face, can cause negative changes in self-esteem, and mostly affects women. Treatment is difficult, and different drugs can be used in mono or combination therapy. In this article, we present a brief overview of melasma, how to evaluate it, and a synthesis of the most commonly used topical therapies and their indications, including sunscreens, pharmacological agents, and plant extracts. Hydroquinone (4%) in monotherapy or combined with corticosteroids (dexamethasone and fluocinolone acetonide) and retinoids (tretinoin); arbutin (1%); methimazole (5%); kojic (2%), azelaic (20%), and tranexamic (5%) acids are the pharmacological agents that stand out. Correct application of these substances determines a variable improvement in melasma but often causes adverse reactions such as erythema, itching, and burning at the application site. Vitamin C can contribute to the reduction of melasma and have little or no adverse effects while sunscreens are normally used as coadjuvant therapies. In conclusion, we have compiled specific topical therapies for treating melasma and discussed those that are the most used currently. We consider it important that prescribers and researchers evaluate the best cost-benefit ratio of topical therapeutic options and develop new formulations, enabling efficacy in the treatment with safety and comfort during application, through the reduction of adverse effects.

Effectiveness of combination therapy of broadband light and intradermal injection of tranexamic acid in the treatment of chloasma

OBJECTIVE

To investigate the efficacy and safety of broadband light (BBL) combined with intradermal injection of tranexamic acid for treating melasma.

METHODS

120 women with melasma admitted to our hospital from January 2021 to April 2022 were randomly categorized into the following groups: control group, treated with 250 mg tranexamic acid given orally twice daily, except during menstruation; group I, treated with BBL (Sciton, Inc., USA) monthly; group II, received intradermal injections of tranexamic acid monthly; and group III, treated with BBL with intradermal injection of tranexamic acid monthly. Treatment in each group lasted three months. The MASI (Melasma Area Severity Index) and VISIA (Canfield VISIA Complexion Analysis) were used for evaluation.

RESULTS

After treatment course, MASI scores and VISIA brown spot and red zone ranking improved in all four groups (p < 0.05). The decrease in MASI scores and improvement rates of VISIA brown spot and red zone rankings were not significantly different among the control group, group I, and group II; however, the decreased MASI scores and improvement rates of VISIA brown spot and red zone rankings were significantly higher in group III than in the other three groups (p < 0.05).

CONCLUSION

The effect of BBL combined with the intradermal injection of TA in the treatment of melasma is remarkable. This combination therapy can be an alternative and effective treatment for managing melasma.

Inflammatory response: The target for treating hyperpigmentation during the repair of a burn wound

Hyperpigmentation is a common complication in patients with burn injuries during wound healing; however, the mechanisms underlying its occurrence and development remain unclear. Recently, postinflammatory hyperpigmentation (PIH) was found to result from overproduction of melanin. Local or systemic inflammatory responses are often observed in patients who develop hyperpigmentation. However, we lack studies on the relationship between PIH and burn injury. Therefore, we comprehensively reviewed the existing literature on the melanogenesis of the skin, inflammatory mechanisms in pigmentation, and local or systemic alteration in inflammatory cytokines in patients suffering from burn trauma to elucidate the relationship between PIH and burn injury. We believe that this review will guide further research on regulating melanin production in the burn management process.

Efficacy and safety of topical agents in the treatment of melasma: What's evidence? A systematic review and meta-analysis

BACKGROUND

Various topical agents have been used to treat melasma; however, a large-scale evaluation among the currently available treatment is lacking.

OBJECTIVES

The aim of this study was to evaluate the efficacy and safety of topical agents for melasma.

METHODS

The MEDLINE, Embase, Web of Science, Cochrane, and Alt-Healthwatch databases were searched in November 2021. Original studies that reported pre- and post-treatment Melasma Area Severity Index (MASI)/modified Melasma Area Severity Index (mMASI) scores and/or adverse effects (AEs) were eligible for inclusion. The main outcome was the efficacy analyzed by the changes in the pre- and post-treatment with standardized mean difference (SMD) of MASI/mMASI scores; the AEs were calculated with incidence proportion by the reported percentage of skin irritations.

RESULTS

A total of 45 studies (2359 patients) and 55 studies (4539 patients) met the inclusion criteria for efficacy and AEs, respectively. Hydroquinone (HQ) monotherapy (SMD -1.3, 95% CI [-1.6 to -1.0]), HQ-containing combination therapy (-1.4, [-1.7 to -1.1]), cysteamine (-1.6, [-2.0 to -1.2]), tranexamic acid (-1.5, [-2.0 to -1.1]), azelaic acid (-1.3, [-1.7 to -1.0]), and kojic acid (-0.9, [-1.3 to -0.5]) demonstrated comparable efficacy, while zinc sulfate did not exhibit statistically significant improvement (-1.2, [-2.7 to 0.4]). HQ-containing combination therapy (50.9%) and cysteamine (42.2%) demonstrated the highest incidence of irritation, while azelaic acid (18.7%), kojic acid (5.3%), and tranexamic acid (0.8%) revealed a lower risk.

CONCLUSIONS

In this meta-analysis, non-HQ agents except zinc sulfate may be considered as an alternative to HQ-containing agents. However, treatment should be guided by patient's tolerance, availability, and physicians' experience.

Evaluation of oral tranexamic acid as a novel treatment for melasma with a high benefit-risk ratio

BACKGROUND

Melasma is an acquired melanogenesis dysfunction resulting in chronic hyperpigmentation commonly affecting the face and other frequently sun-exposed areas of the body. Melasma typically presents in women of reproductive age and can significantly impact self-esteem, negatively affecting one's quality of life. In the United States, melasma is often treated with application of topical agents that interfere with melanin synthesis, lasers, or chemical peels; however, in some East Asian countries, oral tranexamic acid (TXA) is widely administered to alleviate hyperpigmentation during and after childbirth. TXA is currently only FDA-approved to treat hypermenorrhea and reduce blood loss in surgery but may offer women in the United States an additional therapeutic option to treat melasma.

AIMS

The aim of this paper is to evaluate the safety and baseline efficacy of oral transmexic acid as a treatment for melasma.

METHODS

We retrospectively surveyed 42 patients of Fitzpatrick skin types III-VI that were prescribed 650 mg of TXA ½ tablet to be taken twice daily by mouth.

RESULTS

We found majority of patients saw noticeable improvement in their melasma. Of the 42 patients, only seven experienced side effects. The side effects noted were headaches, malaise and nausea, gastrointestinal upset, congestion, numbness in legs, hypomenorrhea, and hypermenorrhea. Patients who experienced unpleasant side effects discontinued taking oral TXA and were relieved of their symptoms. No long-term side effects were discovered, and the side effects experienced may be due to other confounding factors.

CONCLUSION

From this data, we concluded oral TXA is a safe and effective treatment option for patients with persistent melasma.

A Dermoscopic Evaluation of Melasma Treated with Tranexamic Acid

Background: Melasma is a great challenge to the dermatologist. Choosing the proper treatment and the evaluation method are hard issues. Tranexamic acid [TA] injections showed promising results. The dermoscope is a non -invasive hand held tool Objective: To evaluate the efficacy of TA injections in the management of melasma and to assess a new dermoscopic score for assessment of melasma severity. Patients & Methods: Twenty-seven patients were enrolled in the study. They were assessed clinically, and by dermoscopy. An intradermal tranexamic acid was injected on the melasma. Melasma Area and Severity Index [MASI] was used to assess the melasma. Results: high significant difference was found between pre [4.700±2.1213] and post [2.811±2.0870] treatment values of MASI score [p= 0.0001]. Clinically TA treatment showed a dramatic improvement in MASI. Conclusion: The intradermal usage of TA can actually decrease improved the melasma. This was confirmed by the MASI scores and the dermoscope. The dermoscope could be considered as a useful objective score for melasma.

Oral tranexamic acid with a triple combination cream versus oral tranexamic acid monotherapy in the treatment of severe melasma

BACKGROUND

Melasma is an acquired pigmentation disorder with a complex multifactorial etiopathogenesis. Oral tranexamic acid (TA) is a promising drug for its treatment, and may enhance outcomes when used in combination.

OBJECTIVE

To provide evidence of the efficacy and safety of oral TA as a monotherapy, and in combination with a triple combination cream, for treating melasma in the Hispanic population.

METHODS

44 female Hispanic patients with melasma were randomly assigned to receive 325 mg of oral TA every 12 h plus f-TCC (a triple action combination cream) every 24 h (group A) or 325 mg of oral TA every 12 h (group B) for 8 weeks, after which both groups were crossed-over, and treated for an additional 8 weeks. Evaluations of the mMASI score, the melanin index, and the MelasQoL were made at baseline and weeks 4, 8, 12, and 16.

RESULTS

There was a 50.04% and 65.45% improvement in mMASI at weeks 4 and 8, respectively in group A, compared to baseline, while for week 16, an improvement of 76.85% was achieved in group B compared to baseline. Highest scores were consistent with the use of the combined treatment modality in both groups, and was evidenced by the values of the melanin index obtained. There was no significant difference in MelasQoL scores between the 2 groups. No serious side effects were observed.

CONCLUSION

The combination of oral TA and f-TCC is more effective than oral TA alone in the treatment of severe melasma in Hispanic patients.

Tranexamic Acid Microinjection Alone Versus Its Combination With Fractional Carbon Dioxide Laser in Melasma Treatment: A Dermoscopic Evaluation

BACKGROUND

Melasma is a challenging pigmentation disorder.

OBJECTIVE

To assess and compare the efficacy of tranexamic acid (TXA) intradermal microinjection alone versus its combination with low-power, low-density fractional CO2 laser in a sequential pattern in melasma.

PATIENTS AND METHODS

This study included 29 patients with melasma. Half of the face was randomly assigned to fractional CO2 laser; the other half to TXA. This split-face session was repeated every 6 weeks for 3 sessions. In between, TXA was applied to the full face every 2 weeks. Treatment duration was 4 months. Dermoscopy, melanin index (M.I), and erythema index (E.I) were evaluated at baseline and 4 weeks after the last session.

RESULTS

Melanin index, E.I, total dermoscopic score and different dermoscopic patterns of pigmentation, and vascular features showed significant reduction posttreatment on both sides of the face. No statistically significant difference was found regarding the degree and percentage of improvement in M.I, E.I, and total dermoscopic score between both sides.

CONCLUSION

Tranexamic acid microinjection alone or combined with low-power, low-density fractional CO2 laser in a sequential pattern are comparatively effective and safe for melasma treatment; however, combined treatment is recommended. Dermoscopy is an essential noninvasive tool in the assessment of melasma and monitoring patients' response to treatment.

Skin Depigmenting Agents in Anti-Aging Cosmetics: A Medicinal Perspective on Emerging Ingredients

Human skin aging results from intrinsic and extrinsic factors. Uneven pigmentation is one of the major changes of extrinsic aging. Many compounds have been tested for depigmenting activity but only a few are actually used by the cosmetic industry, which is continually looking for new ingredients. In this study, the trends in the use of skin depigmenting ingredients in a panel of anti-aging formulations commercialized in the Portuguese pharmacy market were analyzed, by comparing the composition of the products marketed in 2011 with products launched or reformulated in 2018 (59% and 74%, respectively). The analysis of the top 12 ingredients put forward three novelties for 2018: tranexamic acid, bakuchiol, and 4-butylresorcinol. Regarding their mechanisms of action, tranexamic acid inhibits melanin synthesis through inhibition of the plasminogen/plasmin system. Bakuchiol depigmenting efficacy was attributed to the ability to block both α-melanocyte-stimulating hormone and tyrosinase activation, while 4-butylresorcinol exerts its action through the inhibition of both tyrosinase and tyrosinase-related protein-1 (TRP-1). Industry-optimized and efficient synthetic methodologies that embrace green chemistry, reducing the environmental impact, are commonly used. This analysis aims to bring insights to both formulators, involved in the development of depigmenting cosmetic products, and chemists performing the synthesis of new and existing compounds intended for this purpose.

Split-face comparative study between intradermal tranexamic acid injection alone versus intradermal tranexamic acid injection combined with Q-switched Nd:YAG laser in melasma treatment: dermoscopic and clinical evaluation

Melasma is a chronic, dark brown-pigmented patches and macules commonly on the face. Many treatment modalities for melasma have been used as hydroquinone, laser treatment, and recently tranexamic acid. Dermoscopy is used to diagnose and follow up the treatment of melasma and to detect underlying invisible vessels and their change with treatment. Melasma treatment evaluation by using combined Q-switched Nd:YAG laser with intradermal tranexamic acid injection versus tranexamic acid intradermal injection alone. This study was conducted on 40 female patients aged 35-45 years. It was a split-face study; for 12 weeks, the right side of the face was treated with low fluence Q-switched Nd:YAG laser combined with intradermal injection of tranexamic acid, while the left side was treated with an injection of tranexamic acid intradermal alone. The patients were clinically evaluated by using the modified melasma area and severity index (mMASI) score, and underwent dermoscopic evaluation before treatment, at the end of the treatment (12 weeks), and at (24 weeks) as follow-up. The efficacy, adverse effects, and recurrence after treatment were reported. There was a statistically significant decrease in mMASI score with combination treatment than with intradermal injection of tranexamic acid alone after treatment at 12 weeks and at the end of follow-up at 24 weeks. Combination of an injection of tranexamic acid intradermal and low fluence Q-switched Nd:YAG laser is an effective and safe treatment for melasma with minimal side effects more than the intradermal tranexamic acid injection alone.

Tranexamic acid inhibits melanogenesis partially via stimulation of TGF-β1 expression in human epidermal keratinocytes

Oral tranexamic acid (TA) has been an effective treatment for melasma with unclear mechanism. The present study aimed to demonstrate the effect of TA on melanogenesis via regulation of TGF-β1 expression in keratinocytes. We firstly determined the expression level of TGF-β1 in TA-treated keratinocyte-conditioned medium (KCM). Then, the mRNA and protein levels of microphthalmia-associated transcription factor (MITF), tyrosinase (TYR) and tyrosinase-related protein 1 (TRP-1) of human epidermal melanocytes (NHEMs) in the presence of TA-treated KCM were evaluated via RT-PCR and western blot analysis. Moreover, melanin content and tyrosinase activity were quantified. TGF-β1 gene was knocked down by small interfering RNA (siRNA) in keratinocytes. The mRNA and protein levels of TGF-β1 in keratinocytes were significantly increased after TA treatment. Melanin contents, tyrosinase activity, protein and mRNA levels of TYR, MITF and TRP-1 were downregulated in NHEMs in the presence of TA-treated KCM. Knockdown of TGF-β1 in keratinocytes could attenuate the inhibitory effect of TA-treated KCM on melanogenesis. TA could stimulate TGF-β1 expression in keratinocytes, which further inhibits melanogenesis through the paracrine signalling.

Short Practical Regimen of Acupuncture for Melasma: A Prospective Cohort Study in a Tertiary Hospital in Thailand

Background: Acupuncture shows benefits for patients with melasma, although no optimal number of sessions have been determined.

Methods: The prospective observational study was conducted in melasma patients who were treated with acupuncture procedures two times a week and were evaluated after the 5th and the 10th sessions of acupuncture, with a 1-week follow-up after the last session. Participants Groups A and B received five and 10 acupuncture sessions, respectively. Melasma was assessed by using the melanin index (MI), melasma area and severity index (MASI), patient-reported improvement scores, and acupuncture-related adverse events.

Results: Out of 113 participants, 67 received five sessions of acupuncture treatment while 39 received 10 sessions. At 1 week after five sessions of acupuncture in Group A, the mean MI decreased by 28.7 (95% CI −38.5 to −18.8, p < 0.001), whereas the median MASI decreased by 3.4 (95% CI −6.9 to −1.2, p < 0.001) points. At 1 week after ten sessions of acupuncture in Group B, the mean MI decreased by 31.3 (95% CI −45 to −17.6, p < 0.001), whereas the median MASI decreased by 5.4 (95%CI −9.9 to −3, p < 0.001) points. The first five sessions of acupuncture had a higher incremental effect than the last five sessions, although there was no statistically significant difference. Twenty-nine participants reported minor side effects. Group B had a risk ratio (RR) of having adverse events 1.8 times (95% CI 1.0–3.4, p = 0.05) compared with Group A.

Conclusion: Short acupuncture regimens of 5–10 sessions in melasma seem to be effective and practical with minor side effects.

Treating melasma with the 1064 nm Nd:YAG laser with a 650-microsecond pulse duration: A clinical evaluation

BACKGROUND

The effective treatment of melasma remains a challenge that necessitates a multifaceted approach that includes strict sun protection, bleaching creams, chemical peels, and laser therapy. The 1064 nm Nd:YAG laser with a 650-microsecond pulse duration provides a safe option for all skin types.

METHODS

We treated 10 patients with the 1064 nm Nd:YAG laser with a 650-microsecond pulse duration. Treatments were performed every 2-4 weeks.

RESULTS

Using a conservative treatment protocol, lightening of melasma occurred as early as 3 weeks post-treatment, with all subjects requiring several treatment sessions to achieve adequate resolution of their melasma. The majority of subjects experienced up to 25% improvement after two treatments, and an even more noticeable improvement after the 3rd treatment session. None reported any associated pain or discomfort.

CONCLUSIONS

Advantages of this laser modality include essentially no pain or downtime, lower risk of rebound, and the ability to safely treat all skin types with melasma. Therefore, the 1064 nm Nd:YAG laser with a 650-microsecond pulse duration serves as a treatment option for melasma.

Microneedling-assisted topical tranexamic acid solution versus 4% hydroquinone for treating melasma: A split-face randomized study

BACKGROUND

Melasma, also known as chloasma or mask of pregnancy, is a common, acquired, hyperpigmentary disorder usually affecting females. Tranexamic acid (TA), a derivative of amino acid lysine, has shown promising results over the past few years when used along with other therapies and when used as a stand-alone therapy.

AIM OF THE WORK

In this study, we aimed to evaluate and compare the effectiveness of topically applied tranexamic acid after microneedling versus topically applied hydroquinone (HQ) 4% alone in patients with melasma.

PATIENTS AND METHODS

Fifty selected patients were divided randomly according to the random number allocation method into two groups (25 patients each) of A (topical 4% hydroquinone, nightly application) and B (microneedling + topical 4% TA, every other week).

RESULTS

After eight weeks of treatment, the mean modified MASI score of the HQ treated side changed from 6.604 ± 4.02 to 3.032 ± 1.19 with a mean decrease percentage of 54.8% ± 19.4%. This reduction in modified MASI score was found to be statistically significant, (p < 0.001). MASI score of group B (TA +microneedling) changed from 6.348 ± 3.84 to 3.712 ± 1.19 with mean decrease percentage of 57.4% ± 23.4% which was also statistically significant, (p < 0.001).

CONCLUSION

We demonstrated safety and efficacy of both used modalities and with minimal side effects. Topical HQ application achieved minimal non-significant higher satisfactory results among raters and subjects.

Tranexamic acid versus fractional carbon dioxide laser in post-acne hyperpigmentation

Post-acne hyperpigmentation is a common undesirable sequela of acne vulgaris that causes distress for many patients. This study's objective was to compare the efficacy of both low-power/low-density fractional carbon dioxide (CO₂ ) laser and tranexamic acid (TXA) microinjection on post-acne hyperpigmentation. Twenty-five post-acne hyperpigmentation patients (resistant to regular treatment for more than 6 months) were enrolled in this randomized split-face study. One side of the face was randomly assigned to low-power fractional CO₂ laser every 4 weeks, and the other side was assigned to TXA intradermal-microinjection every 2 weeks for 3 months. Efficacy was evaluated using digital photography, dermoscopy, post-acne hyperpigmentation index (PAHPI), melanin index (MI), and erythema index (EI) at baseline and 4 weeks after the last session. Both fractional CO₂ laser and TXA microinjection treatment sides showed a significant reduction in the PAHPI and MI (p < 0.001). There was statistically significant difference with better percentage of improvement regarding total dermoscopic score on the fractional CO₂ laser side than the TXA microinjections side (p < 0.009). Both fractional CO₂ laser and TXA microinjection are effective and safe treatment options for post-acne hyperpigmentation with potential superiority of fractional CO₂ laser. We also believe that dermoscopy could be helpful tool for assessment of pigmentation depth in patients on treatment by analyzing the color pattern. ClinicalTrials.govID: NCT03765021.

A split face comparative study between intradermal tranexamic acid and Erbium-YAG laser in treatment of melasma

BACKGROUND

Although there are different treatment modalities of melasma, it remains a challenging problem. Erbium-YAG laser proved its efficacy in melasma improvement with minimal downtime. Tranexamic acid (TA) is a new promising treatment of melasma.

OBJECTIVE

The first objective is to compare between the efficacy of intradermal injection of TA and Erbium-YAG laser in the treatment of melasma. The second objective is to use the dermoscope as an objective evaluation method.

PATIENTS AND METHODS

A split face study was conducted on 28 patients. One side of the face received intradermal TA injection. The other side was treated with laser. Melasma Area and Severity Index (MASI) and the dermoscope were used for evaluation of treatment.

RESULTS

The MASI scores showed a significant decrease in TA treated side. The dermoscope assessment showed no significant difference in both treatment modalities.

CONCLUSION

A promising results were obtained by both intradermal TA and Erbium:YAG laser; however, the TA yields a higher patient satisfaction because of its high efficiency and low cost.

Randomized, double-blind, placebo-controlled split-face trial of the efficacy of tranexamic acid by drug delivery through microneedling in the treatment of melasma

BACKGROUND

Melasma is a prevalent skin pigmentation disorder that is difficult to treat. Tranexamic acid (TA) is a potential agent, but there are few studies on its effectiveness under the transdermal route (drug delivery-Dd). One of these Dd pathways is through microneedling, which seems to be effective itself.

OBJECTIVE

To evaluate the efficacy of tranexamic acid when applied in the form of drug delivery through microneedling in the treatment of facial melasma.

METHODS

A randomized controlled double-blind split-face trial with 3 monthly sessions in 20 melasma patients: microneedling was performed in the entire face, and then TA solution was applied to one hemiface and placebo to the other. The effectiveness was measured using Hemi-MASI (Melasma Area and Severity Index), images pixels, and perceptions of experts and patients.

RESULTS

Hemi-MASI regressed 22% in control and 29% in TA side. A good/better improvement was found in 37.5% of the control and 42.5% of TA by the experts and 60% of the patients for both sides. Pixels increased by 5 and 7, respectively. In none of these criteria, there was a significant difference between the sides.

CONCLUSION

Tranexamic acid in drug delivery through microneedling did not bring additional benefit to the treatment of melisma.

Efficacy and safety of tranexamic acid in the treatment of adult melasma: An updated meta-analysis of randomized controlled trials

WHAT IS KNOWN AND OBJECTIVE

Tranexamic acid (TXA) is a novel treatment option for melasma; however, no consensus exists on its use. This study evaluates the efficacy and safety of TXA for melasma.

METHODS

A comprehensive literature review was conducted to search for randomized controlled trials comparing TXA alone, TXA as adjuvant to routine treatment and placebo. Changes in the Melasma Area Severity Index (MASI)/modified MASI (mMASI) between pre- and post-treatment and between a certain melasma treatment and TXA were the primary outcomes. Twenty-four trials comparing oral, topical or intradermal TXA with routine treatment were included in the meta-analysis.

RESULTS AND DISCUSSION

The change in MASI/mMASI scores at 4 (MD, 3.58; 95% confidence interval (CI), 2.15-5.01), 8 (MD, 5.08; 95% CI, 3.34-6.81), 12 (MD, 4.89; 95% CI, 3.80-5.97) and 16 (MD, 6.55; 95% CI, 2.62-10.48) weeks after treatment was all less than the baseline scores, regardless of the delivery route. The reduction in the MASI/mMASI scores between TXA adjuvant and routine treatment at 4 (MD, -0.43; 95% CI, -0.79 to -0.08), 8 (MD, -0.81; 95% CI, -1.09 to -0.54), 12 (MD, -1.10; 95% CI, -1.78 to -0.43) and 16 (MD, -1.12; 95% CI, -1.51 to -0.74) weeks was significant. However, the superiority of TXA was not detected when the topical or intradermal route was adopted. No serious adverse events occurred with the use of TXA.

WHAT IS NEW AND CONCLUSION

These results suggest that oral TXA is an available, effective and safe alternative treatment for melasma.

Liposomal azelaic acid 20% cream vs hydroquinone 4% cream as adjuvant to oral tranexamic acid in melasma: a comparative study

BACKGROUND

Melasma negatively impacts patient's quality of life (QoL). Although hydroquinone 4% is the most prescribed treatment, several side effects had been reported. The traditionally used azelaic acid 20% has poor tolerability and low skin absorption rate.

AIM

To assess the efficacy and tolerability of the liposomal form of azelaic acid 20% as an adjuvant to oral tranexamic acid in the treatment of melasma.

PATIENTS AND METHODS

Fifty females suffering from melasma were divided into two equal groups. The first group used a liposomal form of azelaic acid 20%, and the second group used hydroquinone 4%. Oral tranexamic acid 250 mg was taken by both groups as a single oral daily dose. Melasma severity and the patient's QoL were assessed.

RESULTS

A significant improvement of melasma was detected in females who used the liposomal form of azelaic acid 20% than those who used hydroquinone 4%. This was associated with a significant positive effect on their QoL. Furthermore, the liposomal form of azelaic acid 20% was more significantly tolerable than hydroquinone 4%.

CONCLUSION

The use of the liposomal form of azelaic acid provides an effective and well-tolerated addition to the treatment of melasma.

Intravenous Tranexamic Acid for Brain Contusion with Intraparenchymal Hemorrhage: Randomized, Double-Blind, Placebo-Controlled Trial

INTRODUCTION

Controlling of secondary traumatic brain injuries (TBI) is necessary due to its salient effect on the improvement of patients with TBI and the final outcomes within early hours of trauma onset. This study aims to investigate the effect of intravenous tranexamic acid (TAX) administration on decreased hemorrhage during surgery.

METHODS

This double-blind, randomized, and placebo-controlled trial was conducted on patients referring to the emergency department (ED) with IPH due to brain contusion within 8 h of injury onset. The patients were evaluated by receiving TXA and 0.9% normal saline as a placebo. The following evaluation and estimations were performed: intracranial hemorrhage volume after surgery using brain CT-scan; hemoglobin (Hb) volume before, immediately after, and six hours after surgery; and the severity of TBI based on Glasgow Coma Score (GCS).

RESULTS

40 patients with 55.02 ± 18.64 years old diagnosed with a contusion and intraparenchymal hemorrhage. Although the (Mean ± SD) hemorrhage during surgery in patients receiving TXA (784.21 ± 304.162) was lower than the placebo group (805.26 ± 300.876), no significant difference was observed between two groups (P=0.83). The (Mean ± SD) Hb volume reduction immediately during surgery (0.07 ± 0.001 and 0.23 ± 0.02) and six hours after surgery (0.04 ± 0.008 and 0.12 ± 0.006) was also lower in TXA group but had no significant difference (P = 0.89 and P = 0.97, respectively).

CONCLUSION

Using TXA may reduce the hemorrhage in patients with TBI, but this effect, as in this study, was not statistically significant and it is suggested that a clinical trial with a larger population is employed for further investigation.

The efficacy and safety of topical tranexamic acid (liposomal or lotion with microneedling) versus conventional hydroquinone in the treatment of melasma

BACKGROUND

Robust evidence regarding the efficacy of topical tranexamic acid (TA) on melasma in Chinese population is lacking.

OBJECTIVE

To evaluate the efficacy and safety of 1.8% liposomal TA and microneedling with 5% TA solution on melasma.

METHODS

Sixty melasma patients were enrolled and randomized to receive 1.8% liposomal TA twice daily, microneedling with 5% TA solution weekly or 2% hydroquinone every night. Objective and subjective assessments were obtained at baseline, 4, 8, and 12 weeks.

RESULTS

27.8% of patients of liposomal TA group, 33.3% of microneedling with TA solution group, and 30.0% of hydroquinone group were recognized as "more than 50% improvement." At the endpoint, the melanin index (MI) in all treatment groups was significantly decreased, while the improvement of MI in microneedling with TA solution group and hydroquinone group is higher than liposomal TA group. The erythema index (EI) was significantly diminished in liposomal TA group and microneedling with TA solution group. Dermatoscopy and reflectance confocal microscopy revealed decreased brown granules in all groups and reduced telangiectasia in liposomal TA group and microneedling with TA solution group.

CONCLUSION

1.8% liposomal TA and microneedling with 5% TA solution are both effective and safe on melasma.

Combination treatment algorithm for pigmentary disorders of the face: A prospective observational study in Asian patients

BACKGROUND

Most patients with facial pigmentary disorders have multiple disorders. However, there is no definitive treatment algorithm improving various pigmentary disorders simultaneously.

OBJECTIVES

To investigate the clinical efficacy and safety of the combination of the Q-switched alexandrite and the carbon dioxide lasers with ZO SKIN HEALTH^Ⓡ for facial pigmentary disorders.

PATIENTS/METHODS

This prospective observational study enrolled 251 patients with at least one facial pigmentary disorder. We assessed treatment efficacy and investigated which disorders were most responsive to combination treatment and the relationship between doctors' skills, outcomes, and dropout rates.

RESULTS

There were 246 patients with lentigo senilis, 186 with moles, 79 with melasma, 53 with seborrheic keratosis, 17 with acquired dermal melanocytosis (ADM), and 16 with freckles. Overall, 227 patients completed treatment. Post-treatment outcomes were excellent in 97, good in 113, fair in 17, and poor in 0 patients. Freckles were the most responsive, and ADM was the least responsive. Patient withdrawal and treatment outcomes did not differ significantly based on the doctors' skills. Overall, 3.2% of patients had adverse events.

CONCLUSIONS

Our combination algorithm improved several pigmentary disorders of the face simultaneously, regardless of the doctors' proficiency level.

Clinical efficacy of dissolvable microneedles armed with anti-melanogenic compounds to counter hyperpigmentation

BACKGROUND

Hyperpigmentation is a complex physiological process associated with alterations of skin color due to melanin overproduction and distribution. Both intrinsic and extrinsic factors influence discoloration with the involvement of multiple pathways in cooperative manners. Restoring natural skin color requires a multi-targeted approach. Latest advances in anti-melanogenic compounds and microneedle delivery system have presented opportunities for tackling hyperpigmentationsuccessfully.

AIMS

This work was aimed at assessing the dermal tolerability and efficacy of hyaluronic acid-based microneedle patches loaded with anti-melanogenic actives for improvements of skin discoloration.

PATIENTS/METHODS

The test products consist of hyaluronic acid with niacinamide, ascorbic acid 2-glucoside, tranexamic acid, resveratrol, 4-n-butyl-resorcinol, and Halidrys siliquosa extract. In a monocentric 12 weeks clinical trial, the HA-MNs patches were applied to the affected areas of the faces on subjects with hyperpigmented skin. The color properties of the skin were analyzed spectrophotometrically.

RESULTS

The products were tolerated remarkably; none of the subjects informed any primary or cumulative skin responses. Evaluation of color related measurable skin properties provided insight into the general effectiveness: The individual topology measurements showed 51.4% noticeable improvements in hyperpigmented zones, which were also in good agreement with the personal impressions of the subjects determined by questionnaires before and after the treatments.

CONCLUSIONS

The concentrated blends of actives in microneedle patches act in a multi-targeted manner, and they could be worked in a complementary fashion for the improvement of skin color and appearance. The study has established the overall convenience of the HA-MNs with the formulation of anti-melogenic compounds against skin discoloration.

Comparison of efficacy of Tranexamic Acid Mesotherapy versus 0.9% normal Saline for Melasma; A split face study in a Tertiary Care Hospital of Karachi

Objectives:

To compare the efficacy of tranexamic acid mesotherapy versus 0.9% normal saline for melasma by split-face study.

Methods:

It was a non-randomized clinical trial performed at the Dermatology ward of JPMC from September 2018 to June 2019 after getting approval from the Ethical Committee. A total of sixty patients were recruited in the study, who had symmetrical melasma on their faces. Both halves of the face were treated by Injection Tranexamic Acid (TA) with a dose of 4mg/ml and Normal Saline (NS) two weekly for twelve weeks. Hemi Modified Melasma Area and Severity Scoring (H-mMASI) was calculated at the start and end of the study. Analyses were done by SPSS version 23. P < 0.05 was taken as significant.

Results:

Mean of H-mMASI score was compared on both sides at the end of study, which showed significant reduction in mean score from 3.19 ±2.57 to 1.52 ± 1.2 (P < 0.05) on A side as compared to decline in scores on NS side from 3.46 ± 2.7 to 3.45 ± 2.6 (P > 0.05). Erythema, swelling, and burning were documented as temporary side effects on both sides.

Conclusion:

Tranexamic Acid (TA) mesotherapy can be considered as the most cost-effective, safe and directly observed therapy for melasma which showed significant improvement when old prior therapies have failed.

Comparison of the efficacy of intradermal injected tranexamic acid vs hydroquinone cream in the treatment of melasma

Background

Melasma is a common benign acquired pigmentary dermatosis due to a disorder in the function of the melanogenesis process. Although several treatments are currently used, it remains a great challenge.

Aim

The aim of this study is to compare the efficacy of intradermal injected tranexamic acid (TA) vs hydroquinone (HQ) cream in the treatment of melasma.

Materials and methods

In this prospective split face controlled clinical trial, 49 patients were randomly divided into two groups of A (24 persons) and B (25 persons). Patients received TA intradermal injections every 2 weeks on the right side of the face with a concentration of 4 mg/ mL in group A and a concentration of 10 mg/mL in group B. The left side in both groups was treated twice daily with topical 4% HQ cream, and treatment continued for 12 weeks in both groups. Melasma Area and Severity Index (MASI) scores were measured for each side of the face at baseline and at weeks 4, 8, 12, and 24. SPSS, version 22, P<0.05, was used for data analysis.

Results

Forty-one patients (21 in group A and 20 in group B) completed the study. The MASI score in the 12th week significantly decreased compared to the baseline for group A, group B, and HQ cream. However, no statistically significant difference was observed between the MASI score of patients in groups A and B. Also, the comparison of TA at the concentration of 4 mg/ mL compared to the 4% HQ cream showed that the MASI scores in the eighth week (P=0.02) and the 12th week (P=0.02) were significantly less in the HQ group. However, no significant difference was observed between the MASI score changes in Group B (10 mg/mL) and the 4% HQ group. Also, patients in group A had higher satisfaction than patients in group B (P=0.001).

Conclusion

Injection of TA intradermally can be an effective treatment for melasma.

New oral and topical approaches for the treatment of melasma

Melasma is a common, therapeutically challenging, and universally relapsing disorder of hyperpigmentation that is most often observed in women and individuals with Fitzpatrick Skin Types III through VI. The pathogenesis of melasma is complex and protean. Contributing factors that are often implicated in the etiopathogenesis of this condition include a genetic predisposition, intense ultraviolet radiation exposure, and hormonal influences. Therapeutic interventions for melasma include a multimodality approach incorporating photoprotection agents, topical and oral skin lighteners, and resurfacing procedures. Given our expanding knowledge of the pathogenesis of melasma, new and effective treatments are expanding our therapeutic armamentarium. This article reviews new and emerging oral and topical treatments for melasma.

Evaluation of Therapeutic Efficacy and Safety of Tranexamic Acid Local Infiltration in Combination with Topical 4% Hydroquinone Cream Compared to Topical 4% Hydroquinone Cream Alone in Patients with Melasma: A Split-Face Study

Introduction

Melasma is an acquired pigmentary disorder characterized by hyperpigmented macules and/or patches affecting sun-exposed skin. Tranexamic acid (TA) can reduce melanin content of epidermis. Thus, we conducted this study to evaluate the efficacy and safety of tranexamic acid local infiltration in combination with topical 4% hydroquinone cream compared to topical 4% hydroquinone cream alone in patients with melasma.

Material and Methods

This study was a prospective assessor- and analyst-blind, randomized split-face clinical trial which was performed on patients with bilateral malar epidermal melasma. A total of 55 patients were enrolled, and each side of their face was randomly allocated to either TA+HQ or HQ alone treatment. The MASI score was applied as an objective measurement to compare two treatment groups. The patient's satisfaction of melasma treatment was evaluated using a four-scale grading, as well.

Results

The mean of MASI score in week 16 decreased in both groups significantly (p < 0.01). The therapeutic outcomes were significantly better in TA+HQ group than HQ group (p=0.001). Patients satisfaction with treatment was significantly higher in the TA + HQ group. The difference between the two groups regarding side effect occurrence was not statistically significant.

Conclusion

Addition of tranexamic acid injections to conventional hydroquinone therapy can increase the efficacy of topical treatment. This trial is registered with IRCT2015110324865N1.