Effect of tranexamic acid on melasma: a clinical trial with histological evaluation

Melatonin partially rescues defects induced by tranexamic acid exposure during oocyte maturation in mice

Tranexamic acid (TXA) is widely used among young women because of its ability to whiten skin and treat menorrhagia. Nevertheless, its potential effects on oocyte maturation and quality have not yet been clearly clarified. Melatonin (MT) is an endogenous hormone released by the pineal gland and believed to protect cells from oxidative stress injury. In the present study, we used an in vitro maturation model to investigate the toxicity of TXA and the protective role of MT in mouse oocytes. Compared with the control group, the TXA-exposed group had significantly lower nuclear maturation (57.72% vs. 94.08%, P < 0.001) and early embryo cleavage rates (38.18% vs. 87.66%, P < 0.001). Further study showed that spindle organization (52.56% vs. 18.77%, P < 0.01) and chromosome alignment (33.23% vs. 16.66%, P < 0.01) were also disrupted after TXA treatment. Mechanistically, we have demonstrated that TXA induced early apoptosis of oocytes (P < 0.001) by raising the level of reactive oxygen species (P < 0.001), which was consistent with an increase in mitochondrial damage (P < 0.01). Fortunately, all these effects except the spindle defect were successfully rescued by an appropriate level of MT. Collectively, our findings indicate that MT could partially reverse TXA-induced oocyte quality deterioration in mice by effectively improving mitochondrial function and reducing oxidative stress-mediated apoptosis.NEW & NOTEWORTHY Tranexamic acid is increasingly used to whiten skin, reverse dermal damages, and treat heavy menstrual bleeding in young women. However, its potential toxicity in mammalian oocytes is still unclear. Our study revealed that tranexamic acid exposure impaired the mouse oocyte quality and subsequent embryo development. Meanwhile, melatonin has been found to exert beneficial effects in reducing tranexamic acid-induced mitochondrial dysfunction and oxidative stress.

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.

Update on Melasma Treatments

Melasma is a prevalent hyperpigmentation condition known for its challenging treatment due to its resemblance to photoaged skin disorders. Numerous studies have shed light on the intricate nature of melasma, which often bears similarity to photoaging disorders. Various therapeutic approaches, encompassing topical and systemic treatments, chemical peeling, and laser therapy, have exhibited efficacy in managing melasma in previous research. However, melasma often reoccurs despite successful treatment, primarily due to its inherent photoaged properties. Given that melasma shares features with photoaging disorders, including disruptions in the basement membrane, solar elastosis, angiogenesis, and mast cell infiltration in the dermal layer, a comprehensive treatment strategy is imperative. Such an approach might involve addressing epidermal hyperpigmentation while concurrently restoring dermal components. In this article, we provide a comprehensive review of conventional treatment methods frequently employed in clinical practice, as well as innovative treatments currently under development for melasma management. Additionally, we offer an extensive overview of the pathogenesis of melasma.

A novel professional-use synergistic peel technology to reduce visible hyperpigmentation on face: Clinical evidence and mechanistic understanding by computational biology and optical biopsy

Topicals and chemical peels are the standard of care for management of facial hyperpigmentation. However, traditional therapies have come under recent scrutiny, such as topical hydroquinone (HQ) has some regulatory restrictions, and high concentration trichloroacetic acid (TCA) peel pose a risk in patients with skin of colour. The objective of our research was to identify, investigate and elucidate the mechanism of action of a novel TCA- and HQ-free professional-use chemical peel to manage common types of facial hyperpigmentation. Using computational modelling and in vitro assays on tyrosinase, we identified proprietary multi-acid synergistic technology (MAST). After a single application on human skin explants, MAST peel was found to be more effective than a commercial HQ peel in inhibiting melanin (histochemical imaging and gene expression). All participants completed the case study (N = 9) without any adverse events. After administration of the MAST peel by a dermatologist, the scoring and VISIA photography reported improvements in hyperpigmentation, texture and erythema, which could be linked to underlying pathophysiological changes in skin after peeling, visualized by non-invasive optical biopsy of face. Using reflectance confocal microscopy (VivaScope®) and multiphoton tomography (MPTflex™), we observed reduction in melanin, increase in metabolic activity of keratinocytes, and no signs of inflammatory cells after peeling. Subsequent swabbing of the cheek skin found no microbiota dysbiosis resulting from the chemical peel. The strong efficacy with minimum downtime and no adverse events could be linked to the synergistic action of the ingredients in the novel HQ- and TCA-free professional peel technology.

Characteristics of dermal vascularity in melasma and solar lentigo

BACKGROUND /PURPOSE

Melasma and solar lentigo (SL) are major benign hyperpigmented lesions, and both have been shown to involve the dermal vasculature. This review discusses current knowledge regarding the clinical characteristics of dermal vascularity in melasma and SL, as well as the results of relevant molecular biological investigations.

METHODS

PubMed and Google Scholar were searched in December 2023 to identify articles related to melasma, SL, and the dermal vasculature in these lesions.

RESULTS

Vascular morphologies in melasma and SL have been detected by histological and non-invasive methods, including modalities such as optical coherence tomography. Biological studies have indicated that factors secreted from vascular endothelial cells, such as stem cell factor and endothelin-1, can promote melanogenesis. With respect to phototherapy, blood vessel-targeting laser treatments are expected to provide long-term suppression of pigmentation, but this regimen is only effective when dilated capillaries are visible.

CONCLUSION

In both melasma and SL, clinical and experimental investigations are revealing the contributions of dermal vascularity to hyperpigmentation. More effective treatment may require identification of hyperpigmentation subtypes. In the future, knowledge of treatment (including phototherapy) is expected to accumulate through reliable and validated non-invasive measurements.

Prescribing practices of tranexamic acid for melasma: Delphi consensus from the Pigmentary Disorders Society

Introduction There is ambiguity regarding usage of tranexamic acid for melasma in India, be it in its pre-administration evaluation, administration route, dosing or monitoring. Hence, we conducted this study to understand various tranexamic-acid prescribing patterns and provide practical guidelines. Materials and methods A Google-form-based questionnaire (25-questions) was prepared based on the key areas identified by experts from the Pigmentary Disorders Society, India and circulated to practicing dermatologists across the country. In rounds 2 and 3, the questionnaire was re-presented to the same group of experts and their opinions were sought. The results of the practitioners' survey were denoted graphically alongside, to guide them. Consensus was deemed when at least 80% of respondents chose an option. Results The members agreed that history pertaining to risk factors for thromboembolism, cardiovascular and menstrual disorders should be sought in patients being started on oral tranexamic-acid. Baseline coagulation profile should be ordered in all patients prior to tranexamic-acid and more exhaustive investigations such as complete blood count, liver function test, protein C and S in patients with high risk of thromboembolism. The preferred oral dose was 250 mg orally twice daily, which can be used alone or in combination with topical hydroquinone, kojic acid and sunscreen. Repeated dosing of tranexamic-acid may be required for those relapsing with melasma following initial tranexamic-acid discontinuation. Coagulation profile should ideally be repeated at three monthly intervals during follow-up, especially in patients with clinically higher risk of thromboembolism. Treatment can be stopped abruptly post improvement and no tapering is required. Limitation This study is limited by the fact that open-ended questions were limited to the first general survey round. Conclusion Oral tranexamic-acid provides a valuable treatment option for melasma. Frequent courses of therapy may be required to sustain results and a vigilant watch is recommended for hypercoagulable states during the course of therapy.

Targeting the dermis for melasma maintenance treatment

Melasma relapse is almost common after discontinuation of conventional treatment. Recent studies suggesting that photoaging dermis is the main pathomechanism of melasma, emphasize the dermal targeting therapy. We investigated maintenance effect of microneedling radiofrequency (RF) for melasma treatment. Subjects with melasma were administered oral tranexamic acid and triple combination cream for 2 months and a randomly assigned half face was treated with RF. After discontinuation of conventional therapy, the half face RF continued monthly over 6 months. Modified melasma area severity index (mMASI) score and L* value by a chromameter were collected monthly. Fifteen subjects were enrolled and eleven completed the 8-month study. At 2nd month of conventional therapy, all subjects showed improvement with a 64% reduction in mMASI score. With continuous RF treatment, the improvement was well maintained; whereas in untreated side, the Δ L* gradually decreased, returning to the baseline after the conventional therapy ended. The continuous microneedling RF therapy is beneficial in maintaining the conventional therapy of melasma suggesting the protective effect of dermal targeting therapy in melasma development.(Clinical Trial registration number: NCT05710068, date of first registration: 02/02/2023).

The efficacy and safety of microneedling with topical tranexamic acid for melasma treatment: A systematic review and meta-analysis

OBJECTIVE

Microneedling with topical tranexamic acid (TXA) is a novel treatment option for melasma; however, the efficacy and safety of this combined administration therapy is in controversial. This study is conducted to address this issue of this technique in melasma.

METHODS

An extensive literature review was performed to identify relevant trials, including randomized split-face studies, randomized controlled trials and prospective non-randomized split-face studies, comparing microneedling plus topical TXA to routine treatments or placebo. The primary outcomes were changes of the Melasma Area Severity Index (MASI)/modified MASI (mMASI)/hemi MASI between before and after treatment, as well as the changes between a particular treatment and microneedling plus TXA. The mean differences (MDs) and 95% confidence intervals (CIs) were calculated for the reduction of melasma severity scores from baseline to each time point. In contrast, the standard mean differences (SMDs) and 95% CIs were calculated for the differences in reduction in melasma severity scores between the experimental and control groups at each time point.

RESULTS

A total of 16 trials were included in the systematic review and data synthesis. The pooled analysis demonstrated that MASI, mMASI, and hemiMASI scores decreased significantly at 4 weeks (MD = 1.85; 95% CI = 1.15-2.54), 8 weeks (MD = 3.28; 95% CI = 2.31-4.24), 12 weeks (MD = 4.73; 95% CI = 2.79-6.50), 16 weeks (MD = 3.18; 95% CI = 1.50-4.85), and 20 weeks (MD = 3.20; 95% CI = 1.95-4.46) after treatment when compared with baseline. The reduction in melasma severity scores of microneedling with TXA group at 4 weeks was more significant than the routine treatment group (SMD = 0.97; 95% CI = 0.09-1.86), while insignificant at 8 weeks (SMD = 1.21; 95% CI = -0.17 to 2.59), 12 weeks (SMD = 0.63; 95% CI = -0.03 to 1.29), 16 weeks (SMD = 0.61; 95% CI = -2.85 to 4.07), or 20 weeks (SMD = 1.04; 95% CI = -1.28 to 3.36).

CONCLUSION

Despite the high heterogeneity across these studies, the current findings indicated that microneedling with topical TXA is an alternative treatment option for melasma treatment; and more well-designed studies are needed to confirm it.

Clinical Development and Evaluation of a Multi-Component Dissolving Microneedle Patch for Skin Pigmentation Disorders

Excessive melanin deposition in the skin leads to various skin pigmentation diseases, such as chloasma and age spots. The deposition is induced by several factors, including tyrosinase activities and ultraviolet-induced oxidative stress. Herein, we propose a multi-component, multi-pathway drug combination, with glabridin, 3-O-ethyl-L-ascorbic acid, and tranexamic acid employed as, respectively, a tyrosinase inhibitor, an antioxidant, and a melanin transmission inhibitor. Considering the poor skin permeability associated with topical application, dissolving microneedles (MNs) prepared with hyaluronic acid/poly(vinyl alcohol)/poly(vinylpyrrolidone) were developed to load the drug combination. The drug-loaded microneedles (DMNs) presented outstanding skin insertion, dissolution, and drug delivery properties. In vitro experiments confirmed that DMNs loaded with active ingredients had significant antioxidant and inhibitory effects on tyrosinase activity. Furthermore, the production of melanin both in melanoma cells (B16-F10) and in zebrafish was directly reduced after using DMNs. Clinical studies demonstrated the DMNs' safety and showed that they have the ability to effectively reduce chloasma and age spots. This study indicated that a complex DMN based on a multifunctional combination is a valuable depigmentation product worthy of clinical application.

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.

A combination treatment of drug-laser-photon for melasma: A retrospective study of clinical cases

BACKGROUND

Combinational therapy such as taking tranexamic acid while using laser treatment has been proved potential efficacy by many experiments. However, there is few research which contains large samples and consistent observations.

OBJECTIVE

We evaluated clinical efficacy and safety of a new systemic treatment of drug-laser-photon therapy.

METHODS

Retrospective and randomized investigator-blinded study of 75 patients with mixed type melasma was analyzed. At each visit, standardized photographs were taken using VISIA. Modified melasma area and severity index (mMASI) scores were marked using photographs by two dermatologists.

RESULTS

The mMASI score decreased significantly from 6.92 to 3.84 after the treatment. The VISIA analyze right cheek data shows: Spots (from 49.67 ± 3.43 to 56.09 ± 3.31), UV spots (from 41.39 ± 24.45 to 44.56 ± 25.86), and Brown spots (from 23.97 ± 17.89 to 28.16 ± 21.28) are statistically increased (p = 0.035, p = 0.018, p = 0.07). All patients feel varying degrees of improvement, about 10.17% felt very much improved, 30.51% felt much improved (51%-75%), 45.76% felt moderately improved (26%-50%), and 13.56% felt little improved (1%-25%).

LIMITATIONS

This study was no control group.

CONCLUSION

The efficacy and safety profile of the combination of drug-laser-photon therapy systemic treatment in melasma patients has been proved. It has potential possibility to become a new, reliable, widely suitable therapy strategy.

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.

Efficacy and safety of Politranexamide® liposomal emulsion on facial melasma: A comparative study

INTRODUCTION

Melasma is a human melanogenesis dysfunction that results in localized, chronic acquired hypermelanosis of the skin difficult to treat.

METHODS

This prospective, randomized, single-blind, study aimed to compare the efficacy and tolerability of a liposomal emulsion based on Politranexamide® (SAMPLE A) with that of a competitor based on acetylglucosamine, ethyl linoleate and phenyl ethyl resorcinol (SAMPLE B) in patients affected by facial melasma on 26 patients. Disease severity was assessed by the Melasma Area Severity Index (MASI) at baseline and after 6 and 12 weeks of therapy. All patients were subjected to photo documentation using DermaView camera and Antera 3D camera.

RESULTS

The mean MASI score at baseline was 10.93 ± 7 in the group A and 9.34 ± 6.29 in the group B, respectively. A significant decrease in MASI score from baseline was noted in both treatment groups as early as 6 weeks of follow-up (p = 0.00096 for SAMPLE A and p = 0.0049 for SAMPLE B) and was confirmed at the end of the treatment (p = 0.0006 for SAMPLE A and p = 0.00039 for SAMPLE B). Intergroup comparison revealed a greater improvement of melasma among patients in group A compared to those in group B that was quite statistically significant at weeks 6 (p = 0.055009) and significant after 12 weeks of follow-up (p = 0.032942). Both treatment groups experienced an improvement in Antera average level of melanin.

CONCLUSION

Our results suggested Politranexamide® to be a useful and safe therapeutic option in treating melasma, more effective than competitor used in this study.

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.

Mechanism of Action of Topical Tranexamic Acid in the Treatment of Melasma and Sun-Induced Skin Hyperpigmentation

Tranexamic acid (TXA) has anti-plasmin activity and has been shown when administered orally to be effective against melasma, for which it is considered first-line pharmacotherapy. Several studies have shown that topically applied TXA is also effective against melasma and skin hyperpigmentation caused by sunburn and inflammation. The TXA concentration in the epidermis and dermis/vasculature has been estimated from its distribution in the skin after closed application, and topically applied TXA has thus been shown to act on neutrophils and mast cells in the dermis and on the vascular system. It is unlikely that topically applied TXA acts on dermal neutrophils or mast cells or on the vascular system to form thrombi. As discussed in the present review, studies on the effects of topical TXA on the hyperpigmentation process indicate that the resulting skin-lightening mechanism involves the suppression of cytokine/chemical mediator production, which stimulates melanin production via the keratinocyte-derived urokinase-type plasminogen activator and plasminogen derived from dermal vascular in the basal layer of the epidermis, thereby suppressing the production of excessive melanin to prevent hyperpigmentation.

Comparison of the Efficacy of Intralesional Tranexamic Acid Versus Topical 4% Hydroquinone in Treating Melasma

Objectives: To compare the efficacy of intralesional tranexamic acid and topical 4% hydroquinone in the treatment of melasma.

Study design: This comparative prospective study was conducted at the Dermatology Department, Pak Emirates Military Hospital Rawalpindi, Pakistan from October 16, 2018 to April 16, 2019.

Methodology: A total of 290 patients with melasma, 18 to 50 years of age, were included in this study. Patients with a history of discoid lupus erythematosus, pregnancy, lactation, anemia, and oral contraceptives or hormone replacement therapy were excluded from the study. Randomization was 1:1 for groups A and B, i.e., each upcoming patient was included in the next group. This randomization was supervised by another clinician. One hundred forty-five patients were placed in group A (intralesional tranexamic acid), while 145 were enrolled in group B (topical 4% hydroquinone). Follow-up was done at four weekly intervals for 12 weeks. After 12 weeks, the final response was assessed.

Results: In group A, the average age was 33.74 ± 6.67 years, while in group B it was 32.08 ± 6.08 years. Among the entire patients, the majority of the patients, 207 (71.38%), were in the age range of 18 to 35 years. Intralesional tranexamic acid was efficacious in 64 (44.14%) patients, while 47 (32.41%) of group B (topical 4% hydroquinone) showed complete improvement (p-value = 0.040).

Conclusion: This study concluded that using intralesional tranexamic acid is more effective in treating melasma than topical 4% hydroquinone.

The optimal dose of oral tranexamic acid in melasma: A network meta-analysis

Background

Melasma is a chronic skin condition that adversely impacts quality of life. Although many therapeutic modalities are available there is no single best treatment for melasma. Oral tranexamic acid has been used for the treatment of this condition but its optimal dose is yet to be established.

Objectives

We used network meta-analysis to determine the optimal dose of oral tranexamic acid for the treatment of melasma.

Methods

We conducted a comprehensive search of all studies of oral tranexamic acid for the treatment of melasma up to September 2020 using PubMed, EMBASE and the Cochrane Library database. The quality of the studies was evaluated using the Jadad score and the Cochrane’s risk of bias assessment tool. Only high quality randomised controlled trials were selected. Some studies lacked standard deviation of changes from baseline and these were estimated using the correlation coefficient obtained from another similar study.

Results

A total of 92 studies were identified of which 6 randomized controlled trials comprising 599 patients were included to form 3 pair-wise network comparisons. The mean age of the patients in these studies ranged from 30.3 to 46.5 years and the treatment duration ranged from 8 to 12 weeks. The Jadad scores ranged from 5 to 8.

The optimal dose and duration of oral tranexamic acid was estimated to be 750 mg per day for 12 consecutive weeks.

Limitations

Some confounding factors might not have been described in the original studies. Although clear rules were followed, the Melasma Area and Severity Index and the modified Melasma Area and Severity Index were scored by independent physicians and hence inter-observer bias could not be excluded.

Conclusion

Oral tranexamic acid is a promising drug for the treatment of melasma. This is the first network meta-analysis to determine the optimal dose of this drug and to report the effects of different dosages. The optimal dose is 250 mg three times per day for 12 weeks, but 250 mg twice daily may be an acceptable option in poorly adherent patients. Our findings will allow physicians to balance drug effects and medication adherence. Personalized treatment plans are warranted.

Update on Melasma-Part I: Pathogenesis

Melasma is a multifactorial dyschromia that results from exposure to external factors (such as solar radiation) and hormonal factors (such as sex hormones and pregnancy), as well as skin inflammation (such as contact dermatitis and esthetic procedures), in genetically predisposed individuals. Beyond hyperfunctional melanocytes, skin with melasma exhibits a series of structural and functional alterations in the epidermis, basement membrane, and upper dermis that interact to elicit and sustain a focal hypermelanogenic phenotype. Evolution in the knowledge of the genetic basis of melasma and the cutaneous response to solar radiation, as well as the roles of endocrine factors, antioxidant system, endothelium proliferation, fibroblast senescence, mast cell degranulation, autophagy deficits of the melanocyte, and the paracrine regulation of melanogenesis, will lead to the development of new treatments and preventive strategies. This review presents current knowledge on these aspects of the pathogenesis of melasma and discusses the effects of specific treatments and future research on these issues.

Timeline of the Development of Skin-Lightening Active Ingredients in Japan

Japanese pharmaceutical cosmetics, often referred to as quasi-drugs, contain skin-lightening active ingredients formulated to prevent sun-induced pigment spots and freckles. Their mechanisms of action include suppressing melanin production in melanocytes and promoting epidermal growth to eliminate melanin more rapidly. For example, arbutin and rucinol are representative skin-lightening active ingredients that inhibit melanin production, and disodium adenosine monophosphate and dexpanthenol are skin-lightening active ingredients that inhibit melanin accumulation in the epidermis. In contrast, oral administration of vitamin C and tranexamic acid in pharmaceutical products can lighten freckles and melasma, and these products are more effective than quasi-drugs. On the basis of their clinical effectiveness, skin-lightening active ingredients can be divided into four categories according to their effectiveness and adverse effects. This review discusses academic research and development regarding skin-lightening ingredients in Japan.

Efficacy of Cysteamine and Methimazole in Treating Melasma A Comparative Narrative Review

Melasma is a chronic and acquired pigmentary condition that primarily affects women and undermines patient satisfaction and confidence. Melasma mostly affects females, accounting for 90% of all cases. It affects people of all races, particularly those with skin types IV and V who live in areas with lots of UV radiation. According to the studies, Melasma lesions are seen throughout the face in centrofacial, malar, and mandibular patterns. Melasma lesions on the forehead, cheeks, nose, upper lip, and/or chin are the most prevalent centrofacial pattern. Melasma lesions can also be detected along the periorbital area, especially in Asian people. Melasma is notably resistant to treatment, with many patients experiencing only temporary relief and relapses. Combining therapies that target numerous pathologic components, including photodamage, inflammation, aberrant vascularity, and abnormal pigmentation, generally results in the most dramatic therapeutic improvements. Treatments for dark circles include topical depigmenting medicines like hydroquinone, kojic acid, azelaic acid, and topical retinoic acid, and physical treatments such as chemical peels, surgical adjustments, and laser therapy. The objective of therapy should be to figure out what's causing the hyperpigmentation and what's contributing to it. This article provides an overview of melasma therapies and the efficacy of methimazole and cysteamine for melasma therapy.

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.

Comparison of Clinical Results of Oral Tranexamic Acid and Platelet Rich Plasma Therapies in Melasma Treatment

The pathogenesis of melasma is not fully understood yet and this often causes difficulties in treatment. In our study, we aimed to compare the clinical results of oral TA and PRP therapies in patients with melasma. The clinical results of 30 melasma patients treated with oral TA and 30 melasma patients treated with PRP over the age of 18 who applied to the İnönü University Turgut Özal Medical Center Dermatology and Venereal Diseases Outpatient Clinic between September 2017 and June 2019 were retrospectively evaluated. Both oral TA and PRP therapies provided statistically significant improvement in melasma patients. 75% improvement in the MASI score was statistically significantly higher in the oral TA group compared to the PRP group. Although oral TA and PRP are both successful in the treatment of melasma, it has been found in our study that oral TA gives better results. More studies are needed to support our study, which is the first study comparing oral TA and PRP therapies in the literature. This article is protected by copyright. All rights reserved.

Comparison of fractional erbium:YAG laser-assisted tranexamic acid delivery alone and in combination with oral tranexamic acid in melasma

Tranexamic acid (TA) emerged as a promising agent for melasma. However, due to its hydrophilic structure, topical TA should be combined with a penetration-enhancing strategy to augment efficacy. To evaluate the efficacy of fractional erbium:YAG laser-assisted delivery (LAD) of topical TA 5% either with or without oral TA treatment in recalcitrant melasma patients. The authors retrospectively assessed the treatment outcomes of melasma patients treated by fractional erbium:YAG LAD of topical TA 5%. Patients receiving a standard protocol including four biweekly laser sessions were eligible. The study included two groups: group 1 patients received oral TA and LAD of topical TA 5%, and group 2 patients received only LAD of topical TA 5%. Two blinded dermatologists reported pre-treatment and post-treatment modified MASI (mMASI) scores. Mean mMASI scores in both group 1 (n = 15) and group 2 (n = 19) were significantly lower at the end of the treatment than baseline values (p = 0.001; p = 0.022, respectively). The decrease of mMASI scores were higher in group 1 (median = 2.1) (64.7%) than in group 2 (median = 1.2) (41.8%) (p = 0.027). Fractional erbium:YAG LAD of topical TA 5% is an efficient treatment regimen for melasma patients recalcitrant to conventional treatment approaches. The implementation of oral TA to this regimen improves the therapeutic outcomes.

The uses of tranexamic acid in dermatology: a review

Tranexamic acid is a plasmin inhibitor that is used off-label for the treatment of melasma. The use of tranexamic acid has expanded in the field of dermatology based on its anti-inflammatory and anti-melanin-producing properties, which include the treatment of rosacea, urticaria, and post-inflammatory hyperpigmentation. Tranexamic acid may have more uses in dermatology that require future studies. It should be used with caution during the COVID-19 pandemic given its procoagulant nature.

Evaluation of the efficacy and safety of the 1064 nm picosecond Nd:YAG laser with a topically applied gold and diamond suspension for facial skin rejuvenation: a pilot study

To investigate the efficacy and safety of combined treatment with a serum comprising a micro-diamond suspension and micro-gold cage with a 1064 nm picosecond neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for facial skin rejuvenation. Topical serum was applied to the entire face and allowed to penetrate the skin and hair follicles for 20 min. Each participant was then treated with a 1064 nm picosecond Nd:YAG laser on the face. Photographs of each participant were taken at baseline, immediately after treatment, and 2 weeks after treatment using an imaging tool (Mark-Vu®; PSI PLUS, Suwon, Republic of Korea). Global improvement scores by two blinded investigators and participants' satisfaction scores were also assessed. The melanin index (MI), transepidermal water loss (TEWL), and skin hydration were evaluated using a device. Parameters associated with skin rejuvenation were assessed using Mark-Vu®. Adverse events were observed and reported by participants and physicians during the treatment and follow-up visit. At week 2, 40% (4/10) of the participants showed more than moderate clinical improvement in the investigator's global improvement assessment. No significant differences were observed in the MI, TEWL, skin hydration level, or skin parameters of Mark-Vu®. At week 2, 40% of the participants reported a high satisfaction score and minimal side effects. The novel topical facial serum comprising micro-diamond suspension and micro-gold cage is safe and effective when combined with laser treatment for facial rejuvenation. This article is protected by copyright. All rights reserved.

Dietary Supplements and the Skin: Focus on Photoprotection and Antioxidant Activity—A Review

Skin health is not only significantly affected by ageing, but also by other lifestyle-related factors, such as sun exposure, exercise and eating habits, smoking or alcohol intake. It is known that the cutaneous tissue can exhibit visible signs of senescence, in the form of, for example, dull complexion, loss of firmness, or changes in pigmentation. Consumers attempt to improve skin health and appearance not only by cosmetic products, but also with the consumption of food supplements. Recently, there has been an increase in the amount of food supplements with claims that are related to skin and hair health. Nevertheless, the literature is still scarce in evidence of the efficacy of this type of products. Considering this scenario, we aim in this review to assemble studies and methodologies that are directed at the substantiation of the cutaneous health claims of food supplements. For example, we reviewed those that were indicative of antioxidant properties, improvement in pigmentation disorders, increased hydration or protection against the damages caused by ultraviolet radiation.

Safety and Efficacy of Local Tranexamic Acid for the Prevention of Surgical Bleeding in Soft-Tissue Surgery: A Review of the Literature and Recommendations for Plastic Surgery

BACKGROUND

Although high-bleed surgery routinely utilizes the antifibrinolytic drug tranexamic acid, most plastic surgical procedures are conducted in soft tissue with low-volume bleeding. Unease regarding possible systemic adverse effects prevents widespread systemic use, but local use of tranexamic acid is gaining popularity among plastic surgeons. Randomized controlled trials on topical use of tranexamic acid are mainly from high-bleed surgeries, and few studies address the effect in soft tissue. This article reviews the scientific evidence regarding local use of tranexamic acid in soft-tissue surgery, discusses pharmacological effects and possible adverse reactions, and presents recommendations for use in plastic surgery.

METHODS

A systematic search of databases for studies on local use of tranexamic acid in soft-tissue surgery was performed. Randomized controlled trials were included for a systematic review on effect; a narrative review regarding other clinically relevant aspects is based on extensive literature searches combined with the authors' own research.

RESULTS

Fourteen randomized controlled trials, including 1923 patients, were included in the systematic review on local use of tranexamic acid in soft-tissue surgery.

CONCLUSIONS

Local use of tranexamic acid may reduce blood loss comparably to intravenous prophylactic use with negligible risk of systemic adverse effects, but high-quality randomized controlled trials are few. Prolonged exposure to high local concentrations is discouraged, and direct contact with the central nervous system may cause seizures. No single superior means of administration or dosage is supported in the literature, and lowest effective dose is unknown. There may not be one single ideal dosing regimen, but rather many possibilities adaptable for different surgical situations.

Dermal Pathology in Melasma: An Update Review

BACKGROUND

Melasma is a complex and multipathophysiological condition that is challenging to treat. The roles of each element in the dermis were highlighted in this recent year due to targeting it with emerging therapies. Although some studies have demonstrated abnormal findings in the dermis of melasma lesions, there are no integrated data regarding these findings.

PURPOSE

This article aims to discuss each finding in the dermis of melasma lesions and to provide some ideas about treatment options.

METHODS

An Internet search was completed using the MEDLINE, Embase, Scopus, and Google Scholar databases for relevant literature through June 2021 and reference lists of respective articles. Only the articles published in English language were included.

RESULTS

Several studies have focused on the dermal changes in melasma. Common findings included basement membrane disruption, pendulous melanocytes, marked solar elastosis, increased melanophages, increased mast cells, and neovascularization. In addition, each of them had the specified mechanism that may relate with the others.

CONCLUSION

Several changes in the dermis of melasma lesion may be connected with pathological changes in the epidermis. This may serve as a potential target treatment for melasma, which requires a multimodal approach.

Evaluating the tolerance and efficacy of laser-assisted delivery of tranexamic acid, niacinamide, and kojic acid for melasma: A single center, prospective, split-face trial

Although many treatment options are available, the treatment of melasma remains challenging. To investigate the efficacy and safety of combined treatment for melasma with a quality (Q)-switched 1064-nm neodymium: yttrium-aluminum-garnet (Nd:YAG) laser and a topical mixture of tranexamic acid, niacinamide, and kojic acid. Twenty-five patients with melasma were enrolled. One side of the face was treated with low-fluence Q-switched 1064-nm Nd:YAG laser alone, while the other side was treated with a combination of laser treatment and a topical mixture of tranexamic acid, niacinamide, and kojic acid. Each treatment consisted of five sessions at 2-week intervals, and patients were followed up 4 weeks after the last treatment. Overall improvement was assessed using the hemi Melasma Area and Severity Index (MASI) score. A specialized imaging system (Markview®, PSIPLAUS Inc., Suwon, Korea) was used to record images of the patients' faces, and photographic assessment was performed by two independent evaluators at 2, 4, 6, 8, and 12 weeks using a five-point grading scale. Although both sides of the face showed clinical improvement, combination treatment demonstrated a greater improvement in the mean hemi MASI score compared to laser treatment alone. Improvement in melasma at 12 weeks, according to the evaluation of patient images by two independent evaluators, was greater with combination treatment. This study demonstrated that the combination of treatment with a low-fluence Q-switched 1064-nm Nd:YAG laser and a topical mixture of tranexamic acid, niacinamide, and kojic acid would be a good option for melasma treatment.

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.

Comparison of the Efficacy of Melasma Treatments: A Network Meta-Analysis of Randomized Controlled Trials

Background: Melasma is an acquired pigmentation disorder with challenges in treatment because of its refractory nature and high risk of recurrence.

Objectives: This study aimed to compare the efficacy and side effects of 14 common therapies for melasma using a systematic review and network meta-analysis (NMA).

Methods: The PubMed, Embase, and Cochrane Library databases were searched till December 2020 using the melasma area and severity index as a therapeutic index. A total of 59 randomized controlled trials (RCTs) met the inclusion criteria and were selected.

Results: The ranking of relative efficacy compared with placebo in descending order was Q-switched Nd:Yag 1,064-nm laser (QSND), intense pulsed light, ablative fractional laser (AFL), triple combined cream (TCC), topical vitamin C, oral tranexamic acid (oTA), peeling, azelaic acid, microneedles (MNs), topical tranexamic acid (tTA), tretinoin, picosecond laser, hydroquinone (HQ), and non-AFL. Moreover, QSND was more effective than HQ and tTA against melasma. The ranking of percentage (%) of side effects in ascending order for each of 14 therapies with more than 80 participants was tretinoin (10.1%), oTA (17.6%), HQ (18.2%), AFL (20.0%), QSND (21.5%), TCC (25.7%), tTA (36.75%), peeling (38.0%), and MN (52.3%). Taking both efficacy and safety into consideration, TCC was found to be the most favorable selection among the topical drugs for melasma. QSND and AFL were still the best ways to treat melasma among photoelectric devices. oTA as system administration was a promising way recommended for melasma. Among 31 studies, 87% (27/31) studies showed that the efficacy of combination therapies is superior to that of single therapy. The quality of evidence in this study was generally high because of nearly 50% of split-face RCTs.

Conclusions: Based on the published studies, this NMA indicated that QSND, AFL, TCC, and oTA would be the preferred ways to treat melasma for dermatologists. However, more attention should be paid to the efficacy and safety simultaneously during the clinical application. Most of the results were in line with those of the previous studies, but a large number of RCTs should be included for validation or update.

Systematic Review Registration: identifier: CRD42021239203.

A Review of Oral Therapies for the Treatment of Skin Hyperpigmentation

This review article examines evidence supporting the use of oral therapies in treating idiopathic, actinic, and metabolically induced skin hyperpigmentation. A thorough review of the literature regarding oral treatments for hyperpigmentation was systematically conducted through PubMed. Keywords used in the primary search include "Hyperpigmentation," "Melanosis" or "Melasma," "Lightening," "Oral," and "Therapeutics." The search was limited to the English language, and no timeframe restrictions were implemented. Numerous orally administered therapies have been proposed for the treatment of skin hyperpigmentation. There is an abundant body of literature demonstrating the efficacy of orally administered tranexamic acid, glutathione, isotretinoin, and proanthocyanidin. It is reasonable to expect that the most effective oral therapies will address known underlying causes of hyperpigmentation such as thyroid disease, diabetes, and hormonal imbalance. Improvement due to oral therapy of otherwise unresponsive skin hyperpigmentation or hyperpigmentation of unknown cause is less predictable. This review is limited by the strength of evidence contained within the available studies. Clinical studies investigating the treatments discussed within this article are limited in number, at times lack blinding in the study design, and are based on small sample sizes. Based on existing research, the most promising oral remedies for hyperpigmentation appear to be tranexamic acid, glutathione, isotretinoin, and proanthocyanidin. Additional studies to better establish safety and efficacy are necessary.

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.

The pathogenesis of melasma and implications for treatment

BACKGROUND

Melasma is a complex and poorly understood disorder, with high rates of treatment failure and recurrences.

OBJECTIVES

We aimed to review the current knowledge of the pathogenesis of melasma and apply this knowledge to clinical implications on relevant therapeutic interventions.

METHODS

A systematic PubMed search was performed using the search term "((melasma[Text Word]) OR facial melanosis[Text Word]) AND (pathogenesis OR causality[MeSH Terms])" for articles published between 1990 and 2020. Included articles were then evaluated by two authors and assessed for relevant pathomechanistic pathways, after which they were divided into groups with minimal overlap. We then reviewed current treatment modalities for melasma and divided them according to the involved pathomechanistic pathway.

RESULTS

A total of 309 search results were retrieved among which 76 relevant articles were identified and reviewed. Five main pathomechanisms observed in melasma were identified: (1) melanocyte inappropriate activation; (2) aggregation of melanin and melanosomes in dermis and epidermis; (3a) increased mast cell count and (3b) solar elastosis; (4) altered basement membrane; and (5) increased vascularization. Treatment modalities were then divided based on these five pathways and detailed in 6 relevant tables.

CONCLUSION

The pathophysiology of melasma is multifactorial, resulting in treatment resistance and high recurrence rates. This wide variety of pathomechanisms should ideally be addressed separately in the treatment regimen in order to maximize results.

Fractional Erbium:YAG Laser (2940 nm) plus Topical Hydroquinone Compared to Intradermal Tranexamic Acid plus Topical Hydroquinone for the Treatment of Refractory Melasma: A Randomized Controlled Trial

OBJECTIVES

Melasma is a chronic acquired condition characterized by grayish-brown macules and patches with a distinct border on the face. Although various treatments methods have been suggested for treating melasma, none has been completely successful. The aim of the study was to compare the efficiency of erbium: yttrium-aluminum-garnet (Er:YAG) laser and 4% hydroquinone (HQ) with the effects of intradermal tranexamic acid (TA) and 4% HQ for the treatment of refractory melasma.

METHODS

The study included 31 female patients with refractory melasma. The left or right side of the patient's face was chosen randomly to receive laser therapy with topical HQ on the one side (i.e., the laser side) and intradermal injection of TA plus topical HQ on the other side (i.e., the mesotherapy side). Digital photography was performed at baseline, at the end of the treatment, and three months after the treatment as follow-up. Two independent dermatologists evaluated the modified Melasma Area and Severity Index (mMASI) score according to the pictures. Overall, 27 patients completed the study and went through the clinical evaluation.

RESULTS

Treatment using HQ in combination with either Er:YAG laser therapy or intradermal injection of TA significantly improved the hemi-mMASI and resulted in higher patient satisfaction. While the improvement was not significantly different between the two regiments after the treatment and upon follow up and both were equally efficient in the treatment of refractory melasma (p = 1.308), recurrence rate was higher after treatment with Er:YAG laser than TA (12% vs 34%).

CONCLUSION

This study confirmed the comparable efficacy of TA plus topical HQ versus Er:YAG laser plus topical HQ for the treatment of refractory melasma. Both groups improved significantly and no subject left the treatment because of adverse effects.

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.

Efficacy of topical versus intradermal injection of Tranexamic Acid In Egyptian melasma Patients: A randomised clinical trial

BACKGROUND

Melasma is one of the common pigmentary problems affecting females in our community, owing to the frequent use of hormonal contraceptives as well as our sunny climate. A lot of treatment options are available but none of them is completely satisfactory. Many patients prefer the use of topical preparations and minimally invasive methods. Tranexamic acid (TA) is a potential treatment option for hyperpigmentation with different delivery routes.

AIM

We designed the study in order to evaluate the efficacy of TA in melasma using 2 different routes of delivery.

PATIENTS AND METHODS

A randomised clinical trial was performed on 60 female patients with melasma, they randomly divided into three groups; A, B and C. Group (A) patients received TA (4 mg/mL) intradermal injections every 2 weeks with, group B received TA (10 mg/mL) intradermal injections every 2 weeks, group C received TA cream (10% concentration) twice daily, treatment continued for 12 weeks in all groups. Melasma Area and Severity Index (MASI) scores were measured for each patient before and after completion of treatment.

RESULTS

The percentage of MASI score reduction was highest in group B (62.7%) versus (39.1%) in group A, while the percentage of MASI reduction was the lowest in group C (4.2%).

CONCLUSION

Tranexamic acid is a safe effective and well-tolerated treatment option for melasma patients. Intradermal injection of TA leads to better results than the topical application. Topical TA cream (even in a high concentration) produce fair improvement of melasma.

The efficacy of oral vs different dilutions of intradermal tranexamic acid microinjections in melasma-A randomized clinical trial

Melasma is a common acquired disorder of pigmentation, remains challenging despite numerous treatment modalities. Tranexamic acid (TXA) has emerged as a potential treatment for melasma. Different forms of TXA (oral, topical, and intradermal microinjections) have shown promising results. To evaluate and compare the efficacy of oral vs different dilutions of intradermal TXA in melasma. A total of 45 female patients with melasma were randomly and equally assigned to three treatment groups. Group A (oral TXA 250 mg bid), Group B (100 mg/mL intradermal TXA) & Group C (4 mg/mL intradermal TXA) every 2 weeks, treatment period was 8 weeks. At 8 weeks, a significant reduction in the mMASIwas noted in groups A, B, and C (P value .002, .003, and .005). Melanin index (MI) was significantly reduced in groups A, B, and C (P value .016, .005, and .003). Erythema index (EI) showed significant improvement in group A (P value .028), however was statistically insignificant for groups B and C. No statistically significant difference was found between the three groups as regards changes in mMASI, MI, and EI at 8 weeks. Both oral and intradermal microinjections of TXA regardless dilution appear to be effective and safe in treatment of melasma with comparable results.

The Vascular Component of Melasma: A Systematic Review of Laboratory, Diagnostic, and Therapeutic Evidence

BACKGROUND

Melasma is a common acquired disorder of hyperpigmentation, classically manifesting as symmetric brown patches on the face. Although the exact pathogenesis is not fully understood, vascular abnormalities have been implicated in melasma.

OBJECTIVE

To evaluate the laboratory and clinical evidence regarding the safety and efficacy of antivascular agents for the treatment of melasma.

METHODS

A systematic review of PubMed, EMBASE, and Cochrane was conducted on May 13, 2020, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Original research articles investigating the role of vascularity and/or evaluating the use of antivascular therapeutics in melasma were included. Clinical recommendations were based on the American College of Physicians guidelines.

RESULTS

A total of 34 original research articles as follows were identified: 4 laboratory studies, 15 diagnostic studies, and 15 therapeutic studies.

CONCLUSION

There is promising evidence supporting the use of tranexamic acid and laser/light therapies to treat the vascular component of melasma, and more rigorous clinical trials are needed to validate their efficacy. Clinicians may consider treatment with one or more antivascular therapeutics in patients with melasma. Further research is warranted to characterize the role of cutaneous vascularization in melasma and may provide insights for novel therapies.

Efficacy and safety of tranexamic acid 5% cream vs hydroquinone 4% cream in treating melasma: A split-face comparative clinical, histopathological, and antera 3D camera study

Various tranexamic acid (TA) formulations have been evaluated for treating melasma, yet the effectiveness of this therapy has not been efficiently comparatively analyzed. To assess and compare the therapeutic efficacy and safety of TA 5% vs hydroquinone (HQ) 4% creams in treating melasma. 100 melasma female patients were treated with daily application of TA 5% cream on right-sided facial lesions and HQ 4% cream on left-sided lesions for 12 weeks. Photographic documentation using digital and Antera 3D camera, Wood's light examination, calculation of Hemi Melasma Area and Severity Index (Hemi MASI), Melasma quality of life (MELASQOL) scores and area% of melanin through histopathological examination was done before and after treatment. Both TA 5% and HQ 4% creams yielded significant improvement of all melasma lesions after 12 weeks of treatment, with no significant difference in treatment response regarding Hemi MASI, MELASQOL scores and Antera average level of melanin (P > .05); however, significant reduction in area % of melanin was recorded with TA 5% than HQ 4% creams (P = .000). TA appears to be a promising therapeutic option in treating melasma with fewer adverse effects, same or even better results in comparison to HQ cream.

Effect of oral tranexamic acid on erythema index in patients with melasma

Melasma is a common disorder of hyperpigmentation that presents a therapeutic challenge for clinical dermatologists. The pathogenesis is complex, but previous studies have demonstrated vascular proliferation is a key factor in the development of the classic hyperpigmented patches. Studies have revealed reduction of erythema by oral tranexamic acid; however, there has been no direct comparison to placebo. This 24-week randomised placebo-controlled trial demonstrates oral tranexamic acid may improve erythema in melasma. This mechanism of action may be the reason for the success of tranexamic acid in complex and difficult to treat melasma.

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.

Postinflammatory and rebound hyperpigmentation as a complication after treatment efficacy of telangiectatic melasma with 585 nanometers Q-switched Nd: YAG laser and 4% hydroquinone cream in skin phototypes III-V

BACKGROUND

The potential efficacy of vascular component-targeted laser has been evaluated for the treatment of melasma, which commonly found with the co-existence of telangiectasia.

AIMS

To evaluate the treatment efficacy and safety of 585-nm QSNYL and 4% HQ cream combination vs 4% HQ cream alone for telangiectatic melasma in the skin phototypes III-V.

PATIENTS/METHODS

Twenty-one Thai female patients with telangiectatic melasma and Fitzpatrick skin phototypes (FPTs) III-V were randomly treated with the 585-nm QSNYL on one side of the face for five sessions at 2-week intervals. All patients were assigned to apply HQ cream daily at night on both sides of the face for 10 weeks and a broad-spectrum sunscreen regularly throughout the study. The treatment efficacy and safety were evaluated using the Modified Melasma Area and Severity Index (mMASI), biometric evaluation, patient assessment, and adverse effects.

RESULTS

The combination-treated side yielded more significant improvement of mMASI than the topical-treated side at weeks 2, 4, and 8, respectively. However, 19% of the patients developed postinflammatory hyperpigmentation (PIH) on the laser-treated side, especially in FPTs IV-V and rebound hyperpigmentation. There was a significant improvement of hemoglobin and melanin index, but without statistical difference between the two treatment groups.

CONCLUSIONS

The combination of 585-nm QSNYL and HQ treatment yields treatment efficacy and skin rejuvenation effects for telangiectatic melasma. Nonetheless, a high incidence of PIH and rebound hyperpigmentation is adversely developed in dark FPT. Thus, this laser treatment should be cautiously applied in those with dark FPTs IV-V to avoid laser-induced pigment alteration.

The influence of topical 5% tranexamic acid at pH 2.38 with and without corundum microdermabrasion on pigmentation and skin surface lipids

Tranexamic acid (TA) has anti-hemorrhagic effects; however, oral administration has been found to decrease hyperpigmentation. The aim of the work was to compare the effects of treatment with 5% tranexamic acid in combination with corundum microdermabrasion on skin pigmentation, redness, pH, transepidermal water loss (TEWL), sebum level and hydration of back surface and dorsal surface of the hand skin. Six treatments were performed every week on the back surface and both dorsal surfaces of the hands of 12 subjects. The entire back/both hands were treated with 5% tranexamic acid at pH 2.38; left side of the back or left hand were also subjected to corundum microdermabrasion. Skin parameters were measured using the Courage & Khazaka 580 Multi Probe Adapter. Clinical photos were taken using the Fotomedicus system. Significant differences between treatment methods were observed for melanin, erythema and pH. In addition, the two methods differed significantly with regard to the amount of sebum, TEWL and the level of moisture in the skin. Both methods gave similar acidic pH. Summing up tranexamic acid causes a significant reduction in epidermal melanogenesis, has a significant impact on the level of skin hydration, lipids of the epidermis and maintaining the proper TEWL. TA has a significant effect on reducing skin redness.

Micro-needling versus fractional carbon dioxide laser for delivery of tranexamic acid in the treatment of melasma: A split-face study

BACKGROUND

Tranexamic acid (TXA) in oral, topical, and intra-dermal injection routes showed efficacy in melasma treatment. Micro-needling and fractional carbon dioxide (CO₂ ) laser were reported to enhance the drug delivery of TXA.

AIMS

This study aimed at comparing the use of micro-needling and fractional CO₂ laser for drug delivery of TXA in the treatment of facial melasma.

PATIENTS/METHODS

Thirty female patients with bilateral symmetrical facial melasma were subjected to micro-needling, for one side of the face, and fractional CO₂ laser, for the other, followed by an immediate topical application of TXA solution 4 mg/mL. Patients received six biweekly sessions.

RESULTS

Two weeks after the last session, a significant reduction in baseline modified melasma area and severity index (mMASI) score was observed on both sides. The mean ± SD baseline mMASI dropped from 3.43 ± 1.84 to 1.59 ± 1.51 (mean reduction 57.73%, P < .001) and from 3.51 ± 1.84 to 1.78 ± 1.51 (mean reduction 55.82%, P < .001) in the micro-needling-treated side and in the fractional CO₂ laser-treated side, respectively. However, no statistically significant differences were found between the two sides (P = .81).

CONCLUSIONS

Micro-needling and fractional CO₂ laser are equally safe and effective for the delivery of TXA in the treatment of facial melasma.

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.