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Panchal VS, Patel YS, Dalal YD, Parikh AP, Dalal AD, Rana DA. Efficacy of Oral, Topical, and Intradermal Tranexamic Acid in Patients with Melasma - A Meta-Analysis. Indian Dermatol Online J 2024; 15:55-63. [PMID: 38283017 PMCID: PMC10810386 DOI: 10.4103/idoj.idoj_495_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 01/30/2024] Open
Abstract
Background and Objective Tranexamic acid (TXA) has recently shown promising results in the treatment of melasma. The objective of this study was to generate statistical evidence on the efficacy of TXA with different routes. Materials and Methods We searched studies in PubMed, Cochrane, ClinicalTrials.gov, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A change in melasma area and severity index (MASI)/modified MASI score from the baseline at the end of 8 and 12 weeks was seen. Inverse variance method was used for continuous data to measure standard mean difference (SMD) at a 95% confidence interval (CI). RevMan version 5.4 was used for analysis, and statistical heterogeneity across studies was reported using I2 statistics. P < 0.05 was considered significant. Results Totally, 28 randomized control trials were included. At 8 weeks, oral TXA showed a significant change in SMD of 1.61, 95% CI 0.44-2.79, P = 0.007; at 12 weeks, oral TXA showed SMD of 2.39, 95% CI 1.42-3.35, P < 0.00001 compared to adjuvant treatment. At 8 weeks, topical TXA did not show a significant change with SMD of -0.05, 95% CI -1.08-0.97, P = 0.92; at 12 weeks, topical TXA did not show a significant change with SMD of 0.66, 95% CI -0.10-1.42, P = 0.09 compared to adjuvant treatment. Similarly, for intradermal TXA at 8 weeks, results were not significant with SMD of 1.21, 95% CI -0.41-2.83, P = 0.14, and at 12 weeks, SMD was -0.55, 95% CI -2.27-1.18, P = 0.54 compared to adjuvant treatment. Conclusion Tranexamic acid in an oral formulation can be used along with adjuvant treatment for the management of melasma. Data are still required for topical and intradermal routes. Owing to the fact that our included studies had a lot of heterogeneity, more research is needed along with addressing the adverse effects of tranexamic acid as well as its variation in different skin colors.
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Affiliation(s)
- Viraj S. Panchal
- Department of Medicine, Smt. N.H.L. Municipal Medical College, Ahmedabad, Gujarat, India
| | - Yatri S. Patel
- Department of Medicine, Smt. N.H.L. Municipal Medical College, Ahmedabad, Gujarat, India
| | - Yagnya D. Dalal
- Department of Medicine, G.C.S. Medical College, Ahmedabad, Gujarat, India
| | - Amrita P. Parikh
- Department of Medicine, Smt. N.H.L. Municipal Medical College, Ahmedabad, Gujarat, India
| | - Archana D. Dalal
- Department of Surgery, Smt. N.H.L. Municipal Medical College and SVPIMSR Hospital, Ahmedabad, Gujarat, India
| | - Devang A. Rana
- Department of Pharmacology, Smt. N.H.L. Municipal Medical College, Ahmedabad, Gujarat, India
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Sarkar R, Handog EB, Das A, Bansal A, Macarayo MJ, Keshavmurthy V, Narayan V, Jagadeesan S, Pipo E, Ibaviosa GM, Podder I, Bansal S. Topical and Systemic Therapies in Melasma: A Systematic Review. Indian Dermatol Online J 2023; 14:769-781. [PMID: 38099013 PMCID: PMC10718129 DOI: 10.4103/idoj.idoj_490_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 03/13/2023] [Accepted: 03/21/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Melasma is an acquired disorder, which presents with well-demarcated, brown-colored hyperpigmented macules, commonly involving the sun-exposed areas such as the face. It is a chronic and distressing condition, affecting the patients' quality of life, and has been conventionally treated with "first-line" agents including hydroquinone (HQ) alone or as a part of a triple combination cream (TCC), while "second-line" options include chemical peels, and third line options include laser therapy. Materials and Methods A systematic search was performed for all topical and systemic treatments for melasma up till May 4, 2021, using the PubMed and EMBASE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The search terms "melasma" and "treatment" were used to search for the relevant articles on both these databases, and a total of 4020 articles were identified. After removing the duplicate entries and screening the titles, abstracts, and full-text articles, we identified 174 randomized controlled trials (RCTs) or controlled clinical trials. Results Based on our review, HQ, TCCs, sunscreens, kojic acid (KA), and azelaic acid receive grade A recommendation. Further large-scale studies are required to clearly establish the efficacy of topical vitamin C, resorcinol, and topical tranexamic acid (TXA). Several newer topical agents may play a role only as an add-on or second-line drugs or as maintenance therapy. Oral TXA has a strong recommendation, provided there are no contraindications. Procyanidins, Polypodium leucotomos (PL), and even synbiotics may be taken as adjuncts. Discussion Several newer topical and systemic agents with multimodal mechanisms of action have now become available, and the balance seems to be tipping in favor of these innovative modalities. However, it is worth mentioning that the choice of agent should be individualized and subject to availability in a particular country.
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Affiliation(s)
- Rashmi Sarkar
- Department of Dermatology, Lady Hardinge Medical College, New Delhi, India
| | - Evangeline B. Handog
- Department of Dermatology, Asian Hospital and Medical Center, Muntinlupa City, Metro Manila
| | - Anupam Das
- Department of Dermatology, KPC Medical College and Hospital, Kolkata, India
| | - Anuva Bansal
- Department of Dermatology, BLK-MAX Super Speciality Hospital, New Delhi, Delhi, India
| | - Ma. Juliet Macarayo
- Department of Dermatology, Angeles University Foundation Medical Center, Angeles, Pampanga
| | | | | | - Soumya Jagadeesan
- Department of Dermatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Eugenio Pipo
- Department of Dermatology, Northside Doctors Hospital, Ilocos Sur, Philippines
| | | | - Indrashis Podder
- Department of Dermatology, College of Medicine and Sagore Dutta Hospital, Kamarhati, Kolkata, West Bengal, India
| | - Shivani Bansal
- Department of Dermatology, All India Institute of Medical Sciences, Bathinda, Punjab, India
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Mamdouh Kamal Dawaud S, Hegab DS, Mohamed El Maghraby G, Ahmad El-Ashmawy A. Efficacy and Safety of Topical Tranexamic Acid Alone or in Combination with Either Fractional Carbon Dioxide Laser or Microneedling for the Treatment of Melasma. Dermatol Pract Concept 2023; 13:e2023195. [PMID: 37557109 PMCID: PMC10412040 DOI: 10.5826/dpc.1303a195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) is a promising treatment modality for melasma. Microneedling (MN) and fractional carbon dioxide (CO2) laser were reported to enhance TXA transepidermal delivery. OBJECTIVES To compare efficacy and safety of topical TXA alone or in combination with either fractional CO2 laser or MN for treatment of melasma. METHODS Thirty females with facial melasma were divided randomly into 3 equal groups after excluding pregnant and lactating women and those using oral contraceptives or other hormonal therapy. Patients of group A were treated with fractional CO2 laser and those of group B were treated with MN (4 sessions, 3 weeks apart for both) with immediate topical application of TXA 5% solution after sessions and daily application of 5% TXA cream for both groups. Patients of group C were treated by topical daily application of TXA 5% cream. Evaluation was done by modified melasma area and severity index scores (mMASI), patient satisfaction and dermoscopy. RESULTS Statistically significant improvement of mMASI was reported in all studied groups with a significantly better improvement in patients of groups A and B than those of group C, meanwhile the difference between groups A and B was statistically insignificant. CONCLUSIONS Topical TXA is a safe and fairly effective treatment modality for facial melasma. Combining TXA with either fractional CO2 laser or MN yielded significantly better improvement than when used alone. Fractional CO2 laser carries the risk of post-inflammatory hyperpigmentation in patients with skin types III and IV and requires meticulous patient selection.
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Affiliation(s)
| | - Doaa Salah Hegab
- Faculty of Medicine, Dermatology and Venereology Department, Tanta University, Tanta, Egypt
| | | | - Amal Ahmad El-Ashmawy
- Faculty of Medicine, Dermatology and Venereology Department, Tanta University, Tanta, Egypt
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Konisky H, Balazic E, Jaller JA, Khanna U, Kobets K. Tranexamic acid in melasma: A focused review on drug administration routes. J Cosmet Dermatol 2023; 22:1197-1206. [PMID: 36606378 DOI: 10.1111/jocd.15589] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/30/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Melasma is a disorder of hyperpigmentation and vascularization often found in women between the ages of 20 and 40. The pathogenesis is unknown, but melasma often occurs in sun-exposed areas of the face, forearms, and back. Risk factors include family history, increased estrogen/progesterone, certain medications, and UV exposure. Melasma is typically treated with topical hydroquinone (HQ); however, it is often refractory to treatment. Tranexamic acid (TXA) is a plasmin inhibitor used off-label in the treatment of melasma. TXA can be administered orally, topically, or intralesionally. AIMS The purpose of this review is to characterize the wide variety of TXA delivery methods for melasma treatment and the efficacy of these methods compared with traditional treatments. PATIENTS/METHODS A comprehensive PubMed and Embase search was conducted in May 2022 using the phrases tranexamic acid and melasma. Forty-six articles were included in this review. RESULTS Oral, intralesional, and topical TXA is safe and effective treatments for melasma. They have been studied in a variety of randomized controlled trials and have been compared with several traditional treatments. Overall, MASI scores in patients using TXA in any form improved. CONCLUSIONS Oral TXA was found to be the most effective, especially in cases of refractory melasma; however, it caused GI upset and menstrual irregularities in many patients. The pro-thrombotic nature of this drug must be considered before safely prescribing to patients. Intralesional injections and microneedling with topical TXA were found to be effective alternatives to oral treatment. Lastly, topical TXA alone was found to be the least effective method but can be combined with other cosmeceuticals to improve outcomes. Topical TXA was also found to be better tolerated than hydroquinone, a traditional topical melasma treatment.
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Affiliation(s)
- Hailey Konisky
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Eliza Balazic
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Jose A Jaller
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Urmi Khanna
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Kseniya Kobets
- Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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Pazyar N, Dezfuly MB, Hadibarhaghtalab M, Parvar SY, Molavi SN, Mapar MA, Zeinali M. Intradermal Injection of 100mg Tranexamic Acid Versus Topical 4% Hydroquinone for the Treatment of Melasma: A Randomized, Controlled Trial. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2023; 16:35-40. [PMID: 36743976 PMCID: PMC9891212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective Melasma is an acquired and chronic hyperpigmentation disorder associated with a negative impact on patients' quality of life. This study compares the efficacy of 100mg/mL intradermal TA with 4% topical HQ on female patients presenting with melasma lesions. Methods In this randomized double-blind controlled trial, 48 women with melasma were allocated into two groups, treated with either 100mg/mL intradermal TA or topical 4% HQ. The MASI (Melasma Area and Severity Index) score was assessed by paired t-tests and repeated measured ANOVAs. The Dynamic Physician General Assessment (PGA) was also performed by taking photographs with a digital camera. Results The average MASI score for the HQ and TA groups was 7.7 (3.0 SD) and 5.9 (2.5 SD), respectively. In both groups, the MASI decreased significantly after three months of treatment; however, the decrease was not significant between the two groups (P=0.1). All participants developed mild degrees of burning pain in the injection site without serious adverse effects. Limitations First, we only used the MASI score to measure melasma degree. Second, this is a single-center study with a small sample size. Third, the before-after photos were not taken with a high-quality camera. Conclusion The results of our study showed that both TA and continuous HQ significantly reduced the MASI score of patients without any significant differences and serious side effects. Although many treatment modalities are available for melasma, this condition is still challenging for dermatologists with a high recurrence rate after treatment.
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Affiliation(s)
- Nader Pazyar
- Dr. Pazyar is an Assistant Professor with the Department of Dermatology at Imam Khomeini Hospital at Ahvaz Jundishapur University of Medical Sciences in Ahvaz, Iran
| | - Motahareh Babazadeh Dezfuly
- Drs. Dezfuly and Molavi are Assistants of Dermatology with the Department of Dermatology at Imam Khomeini Hospital at Ahvaz Jundishapur University of Medical Sciences in Ahvaz, Iran
| | - Maryam Hadibarhaghtalab
- Dr. Hadibarhaghtalab and Ms. Parvar are with the Molecular Dermatology Research Center at Shiraz University of Medical Sciences in Shiraz, Iran
| | - Seyedeh Yasamin Parvar
- Dr. Hadibarhaghtalab and Ms. Parvar are with the Molecular Dermatology Research Center at Shiraz University of Medical Sciences in Shiraz, Iran.,Ms. Pavar is additionally with the Student Research Committee at Shiraz University of Medical Sciences in Shiraz, Iran
| | - Seyedeh Nasrin Molavi
- Drs. Dezfuly and Molavi are Assistants of Dermatology with the Department of Dermatology at Imam Khomeini Hospital at Ahvaz Jundishapur University of Medical Sciences in Ahvaz, Iran
| | - Mohammad Ali Mapar
- Drs. Mapar and Zeinali are with the Department of Dermatology at Ahvaz Jundishapur University of Medical Sciences in Ahvaz, Iran
| | - Maryam Zeinali
- Drs. Mapar and Zeinali are with the Department of Dermatology at Ahvaz Jundishapur University of Medical Sciences in Ahvaz, Iran
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Sangha AM. Dermatological Conditions in SKIN OF COLOR-Melasma: Topical and Systemic Management. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2022; 15:S17-S19. [PMID: 35382438 PMCID: PMC8970209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Archana M Sangha
- Ms. Sangha is a medical science liaison for Incyte in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also Immediate Past President of the Society of Dermatology Physician Assistants
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Khalili M, Amiri R, Iranmanesh B, Zartab H, Aflatoonian M. Safety and efficacy of mesotherapy in the treatment of melasma: A review article. J Cosmet Dermatol 2021; 21:118-129. [PMID: 34846788 DOI: 10.1111/jocd.14644] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 11/15/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Mesotherapy is a popular novel therapeutic modality that is defined as intradermal or subcutaneous microinjection of pharmaceutical compounds. Although this novel treatment method is used commonly in aesthetic dermatology, there is little information about details of injections, efficacy, and side effects of mesotherapy in melasma. AIM In this review, we evaluated efficacy and safety of various types of mesotherapy in the treatment of melasma. METHOD We searched Google Scholar, Medline, and PubMed for related articles with keywords "melasma" OR "chloasma" AND "mesotherapy" OR "injection." Inclusion criteria were articles that evaluated intradermal injection of lightening drugs and published dates between January 2000 and September 2021. Exclusion criteria were articles in languages other than English or non-human studies. RESULTS Thirty-three articles evaluated efficacy of mesotherapy in melasma, including 28 articles about tranexamic acid, 4 articles about vitamin C, 2 articles about glutathione, and 2 articles about triamcinolone. CONCLUSION Mesotherapy is a good alternative or adjunctive choice in patients who are refractory to first-line therapy, patients with low compliance with everyday use of topical therapy, patients with contraindication to oral tranexamic acid therapy, or who wish short downtime and fast recovery period. Further studies with large sample sizes are required to determine ideal concentrations of mesotherapy substances and intervals between sessions and to evaluate the efficacy of different substances for mesotherapy as monotherapy compared to combination therapy and other treatment modalities for melasma.
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Affiliation(s)
- Maryam Khalili
- Department of Dermatology, Kerman University of Medical Sciences, Kerman, Iran
| | - Rezvan Amiri
- Department of Dermatology, Afzalipour Hospital, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Behzad Iranmanesh
- Department of Dermatology, Afzalipour Hospital, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamed Zartab
- Department of Dermatology, Afzalipour Hospital, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mahin Aflatoonian
- Department of Dermatology, Afzalipour Hospital, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
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Neagu N, Conforti C, Agozzino M, Marangi GF, Morariu SH, Pellacani G, Persichetti P, Piccolo D, Segreto F, Zalaudek I, Dianzani C. Melasma treatment: a systematic review. J DERMATOL TREAT 2021; 33:1816-1837. [PMID: 33849384 DOI: 10.1080/09546634.2021.1914313] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Melasma is a common chronic refractory disorder of pigmentation affecting people with darker skin types. Overall prevalence varies between 8.8% and 40%, depending on the ethnicity of the population and the geographical area. Therapeutic management of melasma is challenging, with high recurrence rates which significant impacts on the quality of life. No single treatment is universally efficacious. Systemic treatments with tranexamic acid and polypodium leucotmatous had promising results, although the former was related to systemic side effects. Microneedling and peeling were also efficacious, although their superiority to topical hydroquinone, the gold standard in melasma treatment, remains to be established. Similarly, laser and light devices have been beneficial. However, recurrence rates remain high in all treatment groups. Combination therapies, either in double or triple combinations yielded the best results when compared to single terapies. Treatment choice should be made after Wood's lamp examination, as well as dermatoscopic evaluation, in order to select the best treatment option, targeted at each melasma subtype.
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Affiliation(s)
- Nicoleta Neagu
- State Clinic of Dermatology, Mureș County Hospital, Tîrgu Mureș, Romania
| | - Claudio Conforti
- Dermatology Clinic, Maggiore Hospital of Trieste, Trieste, Italy
| | - Marina Agozzino
- Dermatology Clinic, Maggiore Hospital of Trieste, Trieste, Italy
| | | | | | - Giovanni Pellacani
- Dermatology Clinic, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Persichetti
- Plastic and Reconstructive Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Francesco Segreto
- Plastic and Reconstructive Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy
| | - Iris Zalaudek
- Dermatology Clinic, Maggiore Hospital of Trieste, Trieste, Italy
| | - Caterina Dianzani
- Plastic and Reconstructive Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy
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Batory M, Wołowiec-Korecka E, Rotsztejn H. The influence of topical 5% tranexamic acid at pH 2.38 with and without corundum microdermabrasion on pigmentation and skin surface lipids. Dermatol Ther 2020; 33:e14391. [PMID: 33034937 DOI: 10.1111/dth.14391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/17/2020] [Accepted: 10/03/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Mirella Batory
- Faculty of Pharmacy, Department of Cosmetology and Aesthetic Dermatology, Medical University of Lodz, Lodz, Poland
| | | | - Helena Rotsztejn
- Faculty of Pharmacy, Department of Cosmetology and Aesthetic Dermatology, Medical University of Lodz, Lodz, Poland
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