Efficacy and Safety of Tranexamic Acid in Melasma: A Meta-analysis and Systematic Review

Tranexamic acid as a therapeutic option for melasma management: meta-analysis and systematic review of randomized controlled trials

Purpose: This study aimed to evaluate the efficacy of tranexamic acid (TXA) in treating melasma through a meta-analysis and systematic review of randomized controlled trials (RCTs). The study focused on identifying associated adverse effects and comparing TXA's effectiveness with other melasma treatments.Materials and methods: Following PROSPERO and PRISMA guidelines, an extensive electronic search was conducted across four databases for RCTs on TXA use in melasma. Inclusion criteria encompassed full-text English articles with specific outcome measures, while studies with high bias risk or non-English publications were excluded. Data were extracted from 22 relevant studies and analyzed using the RevMan software, with heterogeneity identified using I² statistics and forest plots.Results: A total of 22 studies with 1280 patients were included. TXA was administered orally, topically, or via injection, with treatment durations ranging from 8 weeks to nearly 2 years. TXA significantly reduced melasma severity, evidenced by reductions in MASI, mMASI, MI, and hemi-MASI scores. Oral TXA showed the most substantial decrease in MASI scores, followed by injections and topical applications. However, studies exhibited high heterogeneity, particularly in combined treatments. Adverse effects included gastrointestinal discomfort, skin irritation, and menstrual irregularities.Conclusions: TXA is effective in treating melasma, either alone or combined with other treatments. Despite significant reductions in melasma severity, further research is necessary to standardize TXA administration methods and address long-term effects. The high heterogeneity observed suggests a need for more consistent treatment protocols.

Efficacy, safety, tolerability and treatment durability of microneedling plus topical tranexamic acid in combination with topical modified Kligman lightening formula for melasma: A four-arm assessor and analyst blinded randomized controlled clinical trial

BACKGROUND

The challenging management of melasma highlights the inadequacies of conventional therapies and their high risk of recurrence. Integrating microneedling for device-assisted drug delivery with tranexamic acid (TA), recognized for its melanin synthesis inhibition, presents a novel approach that warrants further investigation to fully assess its potential in enhancing melasma treatment efficacy.

METHODS

Fifty moderate to severe melasma patients participated in this randomized outcome-assessor-blinded controlled trial. Patients were randomly allocated into two main groups. Group A received a modified Kligman formula on one hemi-face on alternate nights for 2 months (A1) and three sessions of microneedling with 10% topical TA on the other hemi-face at 1-month intervals (A2). Group B used the same modified Kligman formula on both sides of the face, with one side additionally receiving three sessions of microneedling with 4% TA (B1) and the opposite side with 10% TA (B2). Primary outcomes were % Modified Melasma Area and Severity Index (mMASI) and % visual analogue scale (VAS) change during 6 month follow-up. Adverse events including post-inflammatory hyperpigmentation (PIH) and treatment tolerability were recorded.

RESULTS

Compared to baseline, the mean mMASI reduction immediately after the final session was higher in A1, B1, and B2 (56.84%, 50.88%, and 55.87%, respectively) than in A2, which saw only a 13.16% reduction. Efficacy notably declined after the cessation of treatment across all groups. While the efficacy within groups A1, B1, and B2 was comparable, microneedling with 4% or 10% TA combined with the topical modified Kligman formula proved more potent in patients at a lower risk of PIH. Overall, 22% of patients reported PIH, particularly in the A2 group (28% of hemi-faces), with its occurrence significantly associated with treatment during warmer seasons and in darker skin phototypes. Other adverse events were not observed in any patient. Patient satisfaction was highest in groups B1 and B2, where approximately 72% reported 'excellent' satisfaction. The lowest durability rate (16%) was observed in group A2, while the highest (72%) was seen in group B2, comparable with groups A1 and B1. Treatment tolerability was reported 100% in all groups.

CONCLUSION

It was found that the modified Kligman formula outperformed microneedling-TA alone. However, with optimal patient selection, particularly targeting those at lower risk for PIH with lighter skin phototypes and scheduling treatments during less-sunny seasons, combining microneedling with 4% or 10% TA and the modified Kligman formula significantly enhanced efficacy and satisfaction rates compared to conventional topical treatment.

Expert consensus on perioperative integrated skincare for noninvasive energy-based device aesthetic procedures in clinical practice in China

BACKGROUND

Noninvasive energy-based device (NI-EBD) aesthetic procedures has recently gained widespread usage for treating various skin conditions, enhancing skin texture and performing rejuvenation-related procedures. However, practically all NI-EBD procedures result in variable degrees of damage to the skin barrier, inducing pathological and physiological processes such as oxidative stress and inflammation, and only a small percentage of individuals possess the innate ability to restore it.

OBJECTIVE

To introduce the concept of integrated skincare and establish standardized operational procedures for perioperative integrated skincare, and furnish a theoretical basis for clinical diagnosis and treatment performed by professional medical aestheticians.

METHODS

The author leveraged domestic and international guidelines, clinical practice expertise and evidence-based research, adapting them to suit the specific circumstances in China.

RESULTS

The consensus were provided four parts, including concept and essence of integrated skincare, integrated skincare significance during the perioperative phase of NI-EBD procedures, active ingredients and functions of effective skincare products, standardized perioperative skincare procedure for NI-EBD procedures and precautions. For the standardized perioperative skincare procedure, four recommendations were listed according to different stages during NI-EBD procedures.

CONCLUSION

These recommendations create the 'Expert Consensus on Perioperative Integrated Skincare for Noninvasive Energy-Based Device Aesthetic Procedures in Clinical Practice in China'.

Melasma: A Step-by-Step Approach Towards a Multimodal Combination Therapy

Melasma is a common challenge in the field of pigmentary skin disorders, exerting a significant emotional and psychosocial burden on patients. The persistent and recurring nature of melasma complicates its management in routine clinical practice. This comprehensive review outlines a stepwise, practical approach encompassing diagnostic, preventive and therapeutic strategies for the management of melasma. A thorough exploration of aggravating and exacerbating factors, including sun exposure, hormonal imbalances, photosensitizing medication and cosmetics, is essential for a holistic assessment of the disease. With an emphasis on consistent and effective photoprotection, initial topical treatment modalities target the melanin production and/or the transfer of melanosomes to keratinocytes. Topical tyrosine inhibitors emerge as the first choice for reducing and preventing hyperpigmentation, with compounds such as thiamidol or tranexamic acid (TXA) being preferred for their safety profile over hydroquinone (HQ), kojic acid and arbutin. Combination with chemical peels can further enhance the therapeutic efficacy, even in cases with resistant melasma. In more severe cases, laser- and light-based interventions may be considered, but with the caveat of the likelihood of recurrence within 3-6 months. Assisted TXA delivery, via either fractional non-ablative laser or microneedling techniques, can further improve clinical outcomes. In conclusion, an optimal melasma management strategy is a multimodal approach, which includes effective photoprotection and a mix of different topical treatments targeting melanin synthesis, the anti-inflammatory environment, senescence and vascularity. Complementary procedures, such as chemical peels, and laser, light-based or microneedling procedures, with or without TXA, can further expedite melanin clearance in more severely affected instances. Individual discussions with patients regarding treatment expectations, recurrence likelihood and potential side effects are paramount to a comprehensive and successful therapeutic journey.

Oral tranexamic acid treats papulopustular rosacea by improving the skin barrier

BACKGROUND

Papulopustular rosacea (PPR) is a chronic inflammatory disease with a significant impact on facial aesthetics. An impaired skin barrier is an important factor in the development and exacerbation of PPR. Tranexamic acid (TXA) has immune regulatory and anti-inflammatory effects, inhibits angiogenesis and endothelial hyperplasia, and promotes skin barrier repair.

AIMS

We investigated the efficacy and safety of oral TXA for PPR treatment.

PATIENTS/METHODS

In total, 70 patients were randomly assigned to receive traditional therapy plus oral TXA or traditional therapy alone for 8 weeks, with a 4-week follow-up period. The subjective improvement in rosacea was assessed using the clinical erythema assessment (CEA), investigator's global assessment (IGA), patient self-assessment (PSA) score, rosacea-specific quality of life (RQoL) score, and global aesthetic improvement score (GAIS). An objective improvement in rosacea was assessed using skin hydration, trans-epidermal water loss (TEWL), clinical photography, and an eight spectrum facial imager.

RESULTS

CEA/IGA/PSA, dryness, and RQoL scores were significantly lower and GAIS was higher in the TXA group than in the traditional therapy group. Furthermore, oral TXA significantly improved skin barrier function, increased skin hydration, and decreased TEWL, with no significant side effects. Notably, we observed better outcomes and a greater improvement in skin barrier function with TXA treatment in patients with dry-type rosacea than in patients with oily skin.

CONCLUSIONS

The addition of oral TXA to traditional therapy can lead to rapid and effective improvements in PPR, which may be attributed to improvements in skin barrier function.

Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study

PURPOSE

To compare the effects of preoperative tranexamic acid (TXA) administered intravenously (IV) versus subcutaneously on postoperative ecchymosis and edema in patients undergoing bilateral upper eyelid blepharoplasty.

METHODS

A prospective, double-blinded, placebo-controlled study of patients undergoing bilateral upper eyelid blepharoplasty at a single-center. Eligible participants were randomized to preoperatively receive either (1) 1 g of TXA in 100 ml normal saline IV, (2) 50 µl/ml of TXA in local anesthesia, or (3) no TXA. Primary outcomes included ecchymosis and edema at postoperative day 1 (POD1) and 7 (POD7). Secondary outcomes included operative time, pain, time until resuming activities of daily living, patient satisfaction, and adverse events.

RESULTS

By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), ecchymosis scores were significantly lower on POD1 (1.31 vs. 1.56 vs. 2.09, p = 0.02) and on POD7 (0.51 vs. 0.66 vs. 0.98, p = 0.04) among those that received TXA. By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), significant reductions in edema scores occurred in those that received TXA on POD1 (1.59 vs. 1.43 vs. 1.91, p = 0.005) and on POD7 (0.85 vs. 0.60 vs. 0.99, p = 0.04). By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA) patients treated with intravenous and local subcutaneous TXA preoperatively were more likely to experience shorter operative times (10.8 vs. 11.8 vs. 12.9 minutes, p = 0.01), reduced time to resuming activities of daily livings (1.6 vs. 1.6 vs. 2.3 days, p < 0.0001), and higher satisfaction scores at POD1 (8.8 vs. 8.7 vs. 7.9, p = 0.0002). No adverse events occurred were reported.

CONCLUSION

In an analysis of 106 patients, preoperative TXA administered either IV or subcutaneously safely reduced postoperative ecchymosis and edema in patients undergoing upper eyelid blepharoplasty. While statistical superiority between intravenous versus local subcutaneous TXA treatment was not definitively identified, our results suggest clinical superiority with IV dosing.

Different therapeutic approaches in melasma: advances and limitations

Melasma is a chronic hyperpigmentation skin disorder that is more common in the female gender. Although melasma is a multifactorial skin disorder, however, sun-exposure and genetic predisposition are considered as the main etiologic factors in melasma occurrence. Although numerous topical and systemic therapeutic agents and also non-pharmacologic procedural treatments have been considered in melasma management, however, the commonly available therapeutic options have several limitations including the lack of sufficient clinical effectiveness, risk of relapse, and high rate of unwanted adverse drug reactions. Recruitment of nanotechnology for topical drug delivery in melasma management can lead to enhanced skin penetration, targeted drug delivery to the site of action, longer deposition at the targeted area, and limit systemic absorption and therefore systemic availability and adverse drug reactions. In the current review, first of all, the etiology, pathophysiology, and severity classification of melasma have been considered. Then, various pharmacologic and procedural therapeutic options in melasma treatment have been discussed. Afterward, the usage of various types of nanoparticles for the purpose of topical drug delivery for melasma management was considered. In the end, numerous clinical studies and controlled clinical trials on the assessment of the effectiveness of these novel topical formulations in melasma management are summarized.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Photobiomodulation for melasma treatment: Integrative review and state of the art

PURPOSE

Photobiomodulation therapy (PBM) is a versatile technique for treating skin diseases. Melasma, a chronic hyperpigmentation condition, has recently been associated with vascular features and dermal photoaging and poses significant management challenges. We review the recent literature on melasma etiology and the evidence supporting PBM as a therapeutic modality for melasma treatment.

METHODS

We conducted a comprehensive literature search in three different databases from May to August 2023, focusing on studies published in the past 10 years. The inclusion criteria comprised full-text studies investigating low-power lasers and/or light-emitting diodes (LEDs) in in vitro or in vivo models, as well as clinical trials. We excluded studies discussing alternative melasma therapies or lacking experimental data. We identified additional studies by searching the reference lists of the selected articles.

RESULTS

We identified nine relevant studies. Clinical studies, in agreement with in vitro experiments and animal models, suggest that PBM effectively reduces melasma-associated hyperpigmentation. Specific wavelengths (red: 630 nm; amber: 585 and 590 nm; infrared: 830 and 850 nm) at radiant exposures between 1 and 20 J/cm2 exert modulatory effects on tyrosinase activity, gene expression, and protein synthesis of melanocytic pathway components, and thus significantly reduce the melanin content. Additionally, PBM is effective in improving the dermal structure and reducing erythema and neovascularization, features recently identified as pathological components of melasma.

CONCLUSION

PBM emerges as a promising, contemporary, and non-invasive procedure for treating melasma. Beyond its role in inhibiting melanogenesis, PBM shows potential in reducing erythema and vascularization and improving dermal conditions. However, robust and well-designed clinical trials are needed to determine optimal light parameters and to evaluate the effects of PBM on melasma thoroughly.

Effectiveness of Tranexamic Acid in the Postoperative Period in Body Contour Surgery: Randomized Clinical Trial

Background

Tranexamic acid (TXA) is used to reduce bleeding in body contouring procedures; however, there are no studies that show the effectiveness of TXA when it is also used in the immediate postoperative period.

Methods

A controlled, randomized, parallel, and open-label clinical trial was carried out in adult patients undergoing liposculpture and/or abdominoplasty. A control group administering presurgical TXA and a study group with presurgical and postsurgical TXA were formed. The decrease in hemoglobin and the incidence of blood transfusions between both groups were compared as well as the possible adverse effects of TXA.

Results

Four hundred twenty-seven subjects were included, 208 (48.7%) in the control group and 219 (51.3%) in the study group. The median age was 34 years (interquartile range 28-42). Median postoperative hemoglobin levels at 24 hours were similar in both groups (study 11.3 g/dL versus control 11.1 g/dL, P = 0.07); however, at 72 hours, postoperative hemoglobin was higher in the study group versus control (10.8 versus 10.0 g/dL, P ≤ 0.001). The incidence of transfusions at 72 hours was 1.8% in the study group and 8.6% in the control group, for a risk ratio of 0.21 (95% confidence interval 0.07-0.61). There were no adverse or thromboembolic events.

Conclusion

TXA proved to be more effective in reducing intra- and postsurgical bleeding and the need for transfusions, when used preoperatively and continued for 48 hours after surgery, than when used only preoperatively, without reporting adverse or thromboembolic effects.

Tranexamic acid for haemostasis and beyond: does dose matter?

Tranexamic acid (TXA) is a widely used antifibrinolytic agent that has been used since the 1960's to reduce blood loss in various conditions. TXA is a lysine analogue that competes for the lysine binding sites in plasminogen and tissue-type plasminogen activator impairing its interaction with the exposed lysine residues on the fibrin surface. The presence of TXA therefore, impairs the plasminogen and tPA engagement and subsequent plasmin generation on the fibrin surface, protecting fibrin clot from proteolytic degradation. However, critical lysine binding sites for plasmin(ogen) also exist on other proteins and on various cell-surface receptors allowing plasmin to exert potent effects on other targets that are unrelated to classical fibrinolysis, notably in relation to immunity and inflammation. Indeed, TXA was reported to significantly reduce post-surgical infection rates in patients after cardiac surgery unrelated to its haemostatic effects. This has provided an impetus to consider TXA in other indications beyond inhibition of fibrinolysis. While there is extensive literature on the optimal dosage of TXA to reduce bleeding rates and transfusion needs, it remains to be determined if these dosages also apply to blocking the non-canonical effects of plasmin.

Efficacy and safety of the combination of tranexamic acid injection and electro-optical synergy (ELOS) versus tranexamic acid injection alone in the treatment of melasma

Melasma is a common, relapsing, multifactorial disease for which the treatment decision remains extremely difficult. This study was designed to compare the efficacy and safety of the combination of tranexamic acid (TA) injection and electro-optical synergy (ELOS) versus TA injection alone in treating melasma. A retrospective study was undertaken for patients with facial epidermal or mixed-type melasma to compare clinical data between 15 patients receiving a combination regimen and 15 patients with TA injection only. The study administered TA through intravenous injection to the combination group (twice weekly for 12 weeks) followed by ELOS therapy (once a month for three times). The TA group, on the other hand, received only TA injection (twice weekly for 12 weeks). The evaluation of clinical effectiveness was based on comparing the Melasma Area Severity Index (MASI) scores before and one month after treatment (at 4 months). The Physician Global Assessment (PGA) and Patient satisfaction were documented, and adverse reactions were recorded. All patients were followed up for one year to observe the relapse. After treatment, the MASI scores and melasma severity were significantly reduced in both groups. The combination group showed better efficacy than the TA only group (P < 0.05). The Physician Global Assessment (PGA) and Patient satisfaction showed superior efficacies of the combination group. No significant difference was observed between the two groups in terms of treatment-related side effects. Both groups experienced a certain degree of recurrence during the one-year follow-up, but the TA only group had a significantly higher recurrence rate than the combination group (P < 0.01). Together, the combination of TA injection and ELOS is a safe and effective treatment strategy for melasma and should be promoted.

Amber photobiomodulation versus tranexamic acid for the treatment of melasma: protocol for a double-blind, randomised controlled trial

INTRODUCTION

Photobiomodulation (PBM) has been suggested as an alternative treatment for melasma. In vitro studies have shown PBM with amber light inhibits the tyrosinase enzyme, induces autophagy and reduces the melanin content, but randomised controlled clinical trials are still needed. This study aims to evaluate the efficacy of amber PBM (590 nm) in the treatment of melasma compared with liposomal tranexamic acid.

METHODS AND ANALYSIS

This study is a controlled, randomised, double-blind, non-inferiority trial. This study will be performed in two centres (Universidade Nove de Julho Facility, Campus Vergueiro, and Galache Odontology Clinic, São Caetano do Sul, both in São Paulo State, Brazil). The sample (54 participants) will be divided into two groups in a 1:1 ratio; one group will receive active PBM and a placebo cosmetic and the other will receive sham PBM and liposomal tranexamic acid. Women presenting facial melasma, aged 35-50 years, with skin phototypes II-IV, will be eligible for inclusion. Women who use oral contraceptives, intrauterine devices, hormone replacement or photosensitive drugs, those with autoimmune disease and those who have undergone facial treatments in the last 3 months will be excluded from the study. The participants will receive PBM weekly for 12 weeks and will use the cosmetic two times per day at home during this period. The severity of melasma will be evaluated through the Melasma Area and Severity Index (MASI) as the primary outcome; pigmentation of the epidermis evaluated by corneomelametry, the photographic records, the global diagnosis of the face and the quality-of-life questionnaire (Brazilian Portuguese version of the Melasma Quality of Life Questionnaire) will assessed as secondary outcomes. All assessments will be made before starting the study (week 0), mid-study at 6 weeks and at the completion of treatment (week 12). MASI will also be evaluated during follow-up (weeks 16 and 20). The data will be analysed based on the intention-to-treat analysis using a generalised mixed model, and α <0.05 will be considered statistically significant.

ETHICS AND DISSEMINATION

The protocol was approved by the Research Ethics Committee of Universidade Nove de Julho (5 332 384). All participants will fill out the patient informed consent form. The results obtained in this trial will be presented at conferences and submitted for publication.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05326997).

Efficacy and Safety of Topical Tranexamic Acid Alone or in Combination with Either Fractional Carbon Dioxide Laser or Microneedling for the Treatment of Melasma

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.

Comparative Study of Combination of Oral Tranexamic Acid With Modified Kligman's Formula Versus Oral Tranexamic Acid With Azelaic Acid 15% in the Treatment of Melasma

Background Melasma is a persistent skin condition affecting individuals of Asian, African, and Hispanic backgrounds. It causes dark patches on sun-exposed areas of the face. The exact causes are unclear, but UV light and hormonal factors play a role. Melasma significantly impacts physical appearance and quality of life, causing emotional and social distress. Objective The objective was to compare the efficacy of a combination of oral tranexamic acid and modified Kligman's formula vs. oral tranexamic acid and 15% azelaic acid. Material and methods This two-year interventional study occurred at the Outpatient Department of Dermatology, Venereology, and Leprosy in Sawangi, Maharashtra. It included male and female patients aged 18-50 with melasma seeking treatment. Ethical approval was obtained, and data collection involved medical histories, skin examinations, and calculating the Melasma Area and Severity Index (MASI). Results The study found no significant association between age groups and subject distribution in Groups A and B. Significant differences were observed in MASI scores within each group over time. There was a significant difference in mean MASI scores between Group A and Group B at the eight-week mark. A burning sensation was significantly associated with the groups, while no significant association was found for erythema. Conclusion This study concludes that combining oral tranexamic acid with a modified Kligman's formula is more effective in treating melasma than combining oral tranexamic acid with azelaic acid 15%.

Mesotherapy-Induced Cutaneous Foreign Body-Type Granulomatous Reaction in the Face Treated with Minocycline: Case Report and Literature Review

Mesotherapy is a popular treatment that delivers substances deep into the skin but induces foreign body-type granulomatous reactions. However, such reactions caused by unauthorized use of topical tranexamic acid products in mesotherapy have never been reported before. We herein demonstrated a case of a 33-year-old woman with multiple mesotherapy-induced foreign body-type granulomas disseminated across her face. The patient was diagnosed with echo-color Doppler (ECD) and successfully treated with medications including minocycline hydrochloride. Then, we reviewed the differential diagnosis and current treatment for foreign body-type granulomatous reaction.

Oral Supplementation and Systemic Drugs for Skin Aging: A Narrative Review

Skin aging is influenced by intrinsic and extrinsic factors and involves multiple pathogenic mechanisms. The most widely used treatments are topical products and minimally invasive procedures. Evidence on the benefits of systemic therapy is limited for several reasons: Reliance on mostly small and predominantly female samples, short study durations, methodologic heterogeneity, and a lack of consensus on which outcome measures are clinically relevant. Furthermore, systemic drugs and oral supplements are not without adverse effects. Oral hydrolyzed collagen and oral hyaluronic acid are well tolerated, and numerous clinical trials show they can mitigate some signs of skin aging. Low-dose oral isotretinoin is another option, but it has a higher risk of adverse effects. Evidence is lacking on the effects of the many dietary supplements on offer, such as vitamins, flavonoids, plant extracts, and trace elements. The future of skin aging management would appear to lie in the use of senolytic and senomorphic agents targeting senescent cells in the skin.

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.

[Translated article] Oral Supplementation and Systemic Drugs for Skin Aging: A Narrative Review

Skin aging is influenced by intrinsic and extrinsic factors and involves multiple pathogenic mechanisms. The most widely used treatments are topical products and minimally invasive procedures. Evidence on the benefits of systemic therapy is limited for several reasons: reliance on mostly small and predominantly female samples, short study durations, methodologic heterogeneity, and a lack of consensus on which outcome measures are clinically relevant. Furthermore, systemic drugs and oral supplements are not without adverse effects. Oral hydrolyzed collagen and oral hyaluronic acid are well tolerated, and numerous clinical trials show they can mitigate some signs of skin aging. Low-dose oral isotretinoin is another option, but it has a higher risk of adverse effects. Evidence is lacking on the effects of the many dietary supplements on offer, such as vitamins, flavonoids, plant extracts, and trace elements. The future of skin aging management would appear to lie in the use of senolytic and senomorphic agents targeting senescent cells in the skin.

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.

Understanding Melasma-How Can Pharmacology and Cosmetology Procedures and Prevention Help to Achieve Optimal Treatment Results? A Narrative Review

Melasma is a chronic skin condition that involves the overproduction of melanin in areas exposed to ultraviolet radiation. Melasma treatment is long-term and complicated with recurrence and resistance to treatment. The pathogenesis of melasma is highly complex with multiple pathologies occurring outside of the skin pigment cells. It includes photoaging, excessive melanogenesis, an increased number of mast cells, increased vascularization, and basement membrane damage. In addition, skin lesions related to melasma and their surrounding skin have nearly 300 genes differentially expressed from healthy skin. Traditionally, melasma was treated with topical agents, including hydroquinone, tretinoin, glucocorticosteroids and various formulations; however, the current approach includes the topical application of a variety of substances, chemical peels, laser and light treatments, mesotherapy, microneedling and/or the use of systemic therapy. The treatment plan for patients with melasma begins with the elimination of risk factors, strict protection against ultraviolet radiation, and the topical use of lightening agents. Hyperpigmentation treatment alone can be ineffective unless combined with regenerative methods and photoprotection. In this review, we show that in-depth knowledge associated with proper communication and the establishment of a relationship with the patient help to achieve good adherence and compliance in this long-term, time-consuming and difficult procedure.

Treatment of melasma by a combination of intense pulsed light with advanced optimal pulse technology and human-like collagen repair dressing: A case series study

To observe the efficacy and safety of a combination of intense pulsed light (IPL) with advanced optimal pulse technology (AOPT) and human-like collagen repair dressing in the treatment of melasma. Ten patients with melasma were treated using IPL with AOPT once a month for a total of 8 times, and received the treatment of external human-like collagen repair dressing after each operation. The efficacy was evaluated with the modified Melasma Area Severity Index (mMASI) score and satisfaction score, respectively, before treatment, after each treatment and at 4 months after the end of the whole treatment course. The melasma was significantly lightened in all 10 patients after 8 times of treatments. The mMASI score before treatment was (8.6 ± 3.8) points, which decreased significantly to (5.1 ± 2.7) points after 8 times of treatments, and there was a significant difference in mMASI score between before and after 8 times of treatments (P = .001). The mMASI score was (3.3 ± 2.2) points at 4 months after the end of whole treatment course, and there was no significant difference in mMASI score between after 8 times of treatments and 4 months after the end of whole treatment course (P > .05). The satisfaction score was (7.2 ± 1.4) points after 8 times of treatments and (7.1 ± 1.4) points at 4 months after the end of whole treatment course, there was no significant difference in satisfaction score between after 8 times of treatments and 4 months after the end of whole treatment course (P > .05). A combination of IPL with AOPT and human-like collagen repair dressing can effectively decrease the severity of melasma, and is associated with a higher patient satisfaction score and a lower risk of relapse after discontinuation of treatment.

Efficacy and Safety of Tranexamic Acid in Cancer Surgery. An Update of Clinical Findings and Ongoing Research

In cancer patients undergoing surgery, tumor biology and anticancer treatments can increase the risk of perioperative bleeding and blood transfusions. Notably, blood transfusions can be potentially associated with an increased risk of life-threatening immune responses, acute lung injury, postoperative infections, and thromboembolism. Moreover, the link between perioperative transfusion and increased risk of cancer recurrence cannot be excluded. On the other hand, cancer patients have an increased risk of thromboembolism due to cancer itself and antineoplastic systemic treatments including chemotherapy and anti-angiogenic drugs. In this complex scenario, effective and safe strategies aimed at the prevention of blood transfusions are warranted. This narrative review addresses the efficacy, and the safety of the synthetic antifibrinolytic agent tranexamic acid (TXA) when used perioperatively in cancer surgery. Although in not oncologic surgery the use of TXA has been extensively studied, in the setting of cancer patients requiring surgery, the evidence is scarce. An overview of the ongoing clinical research is also provided.

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.

Application of PRP in Chloasma: A Meta-Analysis and Systematic Review

Background

Chloasma is a common skin pigment disorder. Treatment of chloasma has been challenging, often unsatisfactory, and difficult to avoid recurrence. PRP is a new treatment for chloasma, but there is no consensus on its use. Lingyun Zhao's team recently reported a systematic evaluation and meta-analysis of the efficacy and safety of PRP in the treatment of chloasma, which is consistent with our ideas, but we will elaborate on the application of PRP in chloasma from a deeper and more comprehensive perspective. Before we started this study, we had registered with Prospero as CRD42021233721.

Methods

The authors searched the public medical network, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ScienceDirect, Scopus, and Science Network. The clinical trials registry ClinicalTrials.gov databases were searched for relevant publications to June 2021. The results showed the area and severity of chloasma (MASI) or revised MASI (mMASI) score.

Results

Three RCTs, one nonrandomized controlled study, and four were prospective before and after self-controlled studies met the inclusive criteria. Intradermal PRP injections significantly improved chloasma as indicated by the significant decrease MASI (average balance -6.71, 95% CI -8.99 to -4.33) and mMASI scores (average balance -2.94, 95% CI -4.81 to -1.07). The adverse reactions were mild, and there were no significant long-term adverse events. Conclusive. The data can reflect the effectiveness and safety of PRP therapy for chloasma. RCTs are needed to determine effective treatment parameters, and long-term follow-up should be included to better clarify the efficacy and side effects of PRP in treating chloasma.

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

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

Efficacy and Safety of Oral Herbal Drugs Used as Adjunctive Therapy for Melasma: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Background

Melasma is an acquired disorder of facial pigmentation. Its etiology is multifactorial; thus, the management is usually challenging. As a complementary therapy, herbal drugs are often used in the management of melasma. This work was aimed to investigate the efficacy and safety of herbal drugs on melasma in female patients.

Methods

This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted, and all randomised controlled trials (RCTs) on the use of oral herbal drugs as complementary therapy for melasma in female patients were included. A meta-analysis was conducted according to the guidelines of the Cochrane Collaboration using Review Manager 5.4.

Results

Ten eligible trials, with 1015 female melasma patients, were included. All of the included RCTs had some concerns for risk of bias for different reasons, especially for that most of included trials were unblinded. Pooled data suggested phytotherapy plus routine therapy had significantly better efficacy on melasma than routine therapy, in terms of response rate (OR: 4.49, 95% CI: 3.25 to 6.20, p < 0.00001), reduction of skin lesion score (SMD: −0.56, 95% CI: −0.79 to −0.33, p < 0.00001), and improvement of serum E2 levels (SMD: −1.58, 95% CI: −2.62 to −0.55, p 0.003). In addition, there was no significant difference in the incidence of AEs between phytotherapy plus routine therapy and routine therapy (OR: 0.92, 95% CI: 0.53 to 1.58; p 0.76). Overall, herbal drugs used as an adjunct to routine therapy significantly enhanced the efficacy for the treatment of melasma but with a comparable safety profile.

Conclusion

These findings have implications for recommending herbal drugs as a viable complementary treatment option for melasma.

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

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

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

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

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

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

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

Comparison of the efficacy and safety of intralesional injection of tranexamic acid and the topical application of Kligman combination drug in the treatment of macular amyloidosis

Macular amyloidosis (MA) is a common form of cutaneous amyloidosis that manifests as dark spots consisting of brown pigments with a rippled pattern on the skin, and the treatment of this condition is highly challenging. The aim of this study was to compare the efficacy and safety of intralesional injection of tranexamic acid (TXA) and topical application of Kligman combination drug in the treatment of macular amyloidosis. In this double-blind clinical trial, a total of 43 patients, who were diagnosed with MA, were treated with two different methods of intralesional injection of tranexamic acid and topical application of Kligman combination drug. Both therapeutic methods were effective in improving MA and significantly reduced hyperpigmentation of the treated areas, but tranexamic acid was significantly more effective than the Kligman combination drug. Significantly, greater improvements were observed in the group of patients treated with tranexamic acid. In the tranexamic acid treatment group, ΔE was reduced from 11.39 in the first session to 8.53 in the third session, and in the Kligman treatment group, it was reduced from 8.79 in the first session to 6.32 in the third session (p < 0.05). In addition, the pruritus score in patients treated with topical tranexamic acid injection was lower compared to the patients treated with the topical application of the Kligman combination drug. The results of this study demonstrated the significant positive effects of both treatment methods, but in terms of reducing melanin content, intralesional injection of tranexamic acid was a more effective method. Both treatments considered safe for MA. In tranexamic acid group, patients logically experienced a tolerable pain during injection but they significantly had significantly lower local pruritic discomfort during study. So, based on the positive findings of this study we suggest to use tranexamic acid in combination with other effective therapeutic methods for treatment of MA especially use of its topically applied form in combination with non-aggressive needling that results in better drug delivery without the experience of injection pain. Selection of the best administration route of tranexamic acid for hyperpigmented lesions depends on the each patient characteristic and their previous theraputic results that may vary case by case.

Tranexamic acid in non-traumatic intracranial bleeding: a systematic review and meta-analysis

Non-traumatic intracranial bleeding (NTIB), comprising subarachnoid hemorrhage (SAH) and intra-cranial bleeding (ICH) is a significant public health concern. Tranexamic acid (TXA) is a promising treatment with benefits yet to be fully demonstrated. We conducted a systematic review and meta-analysis on the impact of TXA on mortality in NTIB. We searched the PubMed, Cochrane Library, Google Scholar and ScienceDirect databases for studies reporting mortality data following the use of TXA in NTIB for comparisons with a control group. We computed random-effect meta-analysis on estimates of risk and sensitivity analyses. We computed meta-regression to examine the putative effects of the severity of NTIB, sociodemographic data (age, sex), and publication date. Among potentially 10,008 articles, we included 15 studies representing a total of 4883 patients: 2455 receiving TXA and 2428 controls; 1110 died (23%) during the follow-up. The meta-analysis demonstrated a potential of 22% decrease in mortality for patients treated by TXA (RR = 0.78, 95%CI 0.58-0.98, p = 0.002). Meta-regression did not demonstrate any influence of the severity of NTIB, age, sex, length of treatment or date of publication. Sensitivity analyses confirmed benefits of TXA on mortality. TXA appears to be a therapeutic option to reduce non-traumatic intracranial bleeding mortality, particularly in patients with SAH.

Tranexamic acid evidence and controversies: An illustrated review

Tranexamic acid (TXA) is an antifibrinolytic agent commonly used for the treatment or prevention of bleeding. Indications for TXA are diverse, including heavy menstrual bleeding, trauma, postpartum hemorrhage, traumatic brain injury, and surgical site bleeding. Despite decades of use and a robust body of evidence, hesitancy using TXA persists in many clinical settings. This illustrated review describes the history, pharmacology, and practical considerations of TXA use. We also describe the major landmark randomized controlled trials of TXA and their implications. Finally, we review the evidence around common controversies surrounding TXA such as the risk of thrombosis, prescription along with combined hormonal contraceptives, and use in patients with gross hematuria.

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.

A Systematic Review of Tranexamic Acid in Plastic Surgery: What's New?

BACKGROUND

Blood loss associated with surgical interventions can lead to several complications. Therefore, minimizing perioperative bleeding is critical to improve overall survival. Several interventions have been found to successfully reduce surgical bleeding, including the antifibrinolytic agent. After aprotinin was withdrawn from the market in 2008, TXA remained the most commonly used medication. The safety and efficacy of TXA has been well studied in other specialties. TXA has been rarely used in plastic surgery, except in craniofacial procedures. Since the last review, the number of articles examining the use of TXA has doubled; so the aim of this systematic review is to update the readers on the current knowledge and clinical recommendations regarding the efficacy of TXA in plastic surgical procedures.

METHODS

A systematic literature search was conducted in Medline, SciELO, Cochrane, and Google Scholar to evaluate all articles that discussed the use of TXA in plastic surgery in the fields of aesthetic surgery, burn care, and reconstructive microsurgery.

RESULTS

A total of 233 publications were identified using the search criteria defined above. After examination of titles and abstracts, and exclusion of duplicates, a total of 23 articles were selected for analysis.

CONCLUSIONS

The literature shows a clear benefit of using TXA to decrease blood loss regardless of the administration route, with no risk of thrombosis events. Also, TXA elicits a potent anti-inflammatory response with a decrease in postoperative edema and ecchymosis, which improves recovery time. Further investigations are needed to standardize the optimal administration route and dosage of TXA.

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.

Efficacy of microneedling plus topical 4% tranexamic acid solution vs 4% hydroquinone in the treatment of melasma: A single-blind randomized clinical trial

BACKGROUND

There are various treatment modalities for melasma, but none of them are effective on dermal component of melasma.

AIMS

In this study, we decided to evaluate the efficacy of microneedling plus tranexamic acid in comparison with 4% hydroquinone in the treatment of melasma.

METHODS

This is a single-blind randomized clinical trial on 70 participants with 14% dropout, and therefore, 60 patients with melasma completed the study. Patients were randomized based on simple randomization in 2 groups of A (microneedling plus topical 4% tranexamic acid, monthly) and B (topical 4% hydroquinone, nightly). Evaluation of mean MASI score, patient and physician assessments was performed at 4th, 8th and12th weeks of the treatment. Statistical analysis was performed by paired t test, chi-square test and Fisher's exact test, respectively.

RESULTS

Sixty women (30 patients in each group) were completed the study. Mean MASI score in group A was significantly lower at the end of the treatment (6.84 ± 4.31) than at the baseline (12.89 ± 5.16) (P < .01). Mean MASI score in group B was significantly lower at the end of the treatment (7.16 ± 4.38) than at the baseline (13.56 ± 4.88) (P < .01). There was no statistical difference between 2 groups regarding MASI score, physician and patient assessments during the treatment. Percentage of patient satisfaction was significantly higher than physician satisfaction in both treatment groups (P < .01).

CONCLUSION

In our study, the combination of microneedling with tranexamic acid did not differ from 4% hydroquinone in the treatment of melasma.

Melasma Treatment: An Evidence-Based Review

BACKGROUND

Melasma is an acquired, chronic pigmentary disorder predominantly affecting women. It may significantly affect quality of life and self-esteem due to its disfiguring appearance. Multiple treatments for melasma are available, with mixed results.

OBJECTIVE

The aim of this article was to conduct an evidence-based review of all available interventions for melasma.

METHODS

A systematic literature search of the PubMed electronic database was performed using the keywords 'melasma' and/or 'chloasma' in the title, through October 2018. The search was then limited to 'randomized controlled trial' and 'controlled clinical trial' in English-language journals. The Cochrane database was also searched for systematic reviews.

RESULTS

The electronic search yielded a total of 212 citations. Overall, 113 studies met the inclusion criteria and were included in this review, with a total of 6897 participants. Interventions included topical agents, chemical peels, laser- and light-based devices, and oral agents. Triple combination cream (hydroquinone, tretinoin, and corticosteroid) remains the most effective treatment for melasma, as well as hydroquinone alone. Chemical peels and laser- and light-based devices have mixed results. Oral tranexamic acid is a promising new treatment for moderate and severe recurrent melasma. Adverse events from all treatments tend to be mild, and mainly consist of skin irritation, dryness, burning, erythema, and post-inflammatory hyperpigmentation.

CONCLUSIONS

Hydroquinone monotherapy and triple combination cream are the most effective and well-studied treatments for melasma, whereas chemical peels and laser- and light-based therapies are equal or inferior to topicals, but offer a higher risk of adverse effects. Oral tranexamic acid may be a safe, systemic adjunctive treatment for melasma, but more studies are needed to determine its long-term safety and efficacy. Limitations of the current evidence are heterogeneity of study design, small sample size, and lack of long-term follow-up, highlighting the need for larger, more rigorous studies in the treatment of this recalcitrant disorder.

The color of skin: brown diseases of the skin, nails, and mucosa

Brown diseases comprise disorders leading to hyperpigmentation in skin and nails. Melasma is an acquired skin disorder that is characterized by brownish macules that typically occur on the face. Schamberg disease, also known as progressive pigmented purpura, is characterized by brown pigmentation with pepper spots on their edges. We summarize the epidemiology, pathogenesis, histologic features, and treatment choices for additional brown diseases, including melasma, pigmented purpuric dermatoses, postinflammatory hyperpigmentation, drug-induced hyperpigmentation, and pigmentations due to systemic or physiologic conditions.

The many roles of tranexamic acid: An overview of the clinical indications for TXA in medical and surgical patients

Clinically significant bleeding can occur as a consequence of surgery, trauma, obstetric complications, anticoagulation, and a wide variety of disorders of hemostasis. As the causes of bleeding are diverse and not always immediately apparent, the availability of a safe, effective, and non-specific hemostatic agent is vital in a wide range of clinical settings, with antifibrinolytic agents often utilized for this purpose. Tranexamic acid (TXA) is one of the most commonly used and widely researched antifibrinolytic agents; its role in postpartum hemorrhage, menorrhagia, trauma-associated hemorrhage, and surgical bleeding has been well defined. However, the utility of TXA goes beyond these common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk. Herein, we review the literature and provide practical suggestions for clinical use of TXA across a broad spectrum of bleeding disorders.

Randomized control trial outcomes of tranexamic acid combination serum as a depigmenting agent for the use in healthy individuals

To compare the effectiveness of tranexamic acid (TA) combination serum with hydroquinone, the gold standard in whitening agents for healthy populations. This was a three-arm randomized controlled trial. The subjects were divided into three groups: the first group received 3% TA combination serum (3% TA, 4% galactomyces ferment filtrate, 2% niacinamide, and 4% alpha arbutin), the second group received 2% TA combination serum, and the third group received 4% hydroquinone. One milliliter of each serum was applied on three holes: Hole A, which was located 4 cm from the left cubital fossa, Hole B, which was located 4 cm from the first hole, and Hole C, which was located 4 cm from the right cubital fossa. The skin brightness and pigmentation intensity were evaluated each week for 4 weeks using a chromameter. A total of 44 subjects were recruited for this study. All groups showed a significant improvement in skin brightness and pigmentation intensity after 4 weeks (p < .001). There were no differences between the treatment groups and hydroquinone (p > .05). TA serum (2 and 3%) combined with 4% galactomyces ferment filtrate, niacinamide, and alpha arbutin is an effective depigmenting agent.

Preoperative Tranexamic Acid for Treatment of Bleeding, Edema, and Ecchymosis in Patients Undergoing Rhinoplasty: A Systematic Review and Meta-analysis

Importance

Evidence has emerged on the efficacy of tranexamic acid to control blood loss and postoperative complications after rhinoplasty.

Objective

To investigate the results of tranexamic acid use to reduce intraoperative bleeding, postoperative eyelid edema, and periorbital ecchymosis in rhinoplasty.

Data Sources and Study Selection

For this systematic review of randomized clinical trials, searches were performed in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, Science Direct, Google Scholar, OpenThesis, and ClinicalTrials.gov from inception to December 23, 2017. Key words included tranexamic acid, rhinoplasty, and nasal surgical procedures. The following elements were used to define eligibility criteria: (1) population: patients undergoing rhinoplasty surgery; (2) intervention and controls: tranexamic acid vs placebo solution or no-treatment control group; (3) outcomes: intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis, and thromboembolic events; and (4) study type: randomized clinical trials.

Data Extraction and Synthesis

Two reviewers extracted data and assessed study quality according to the Cochrane guidelines for randomized clinical trials. Treatment effects were defined as weighted mean difference (WMD) and 95% CIs. The strength of evidence was analyzed using the Grading of Recommendations Assessment, Development, and Evaluation rating system.

Main Outcomes and Measures

Intraoperative bleeding, postoperative eyelid edema and periorbital ecchymosis. To calculate the effect sizes, means and SDs were obtained for each study group and outcome of interest.

Results

Five studies comprising 276 patients were included in the systematic review: 177 patients (64.1%) were women, and mean age was 26.8 (range, 16-42) years. Four studies comprising 246 patients estimated the amount in intraoperative bleeding as a primary outcome and were included in the meta-analysis. Eyelid edema and ecchymosis were evaluated as outcomes in 2 studies. Tranexamic acid was associated with reduced bleeding during rhinoplasty was found (WMD, -42.28 mL; 95% CI, -70.36 to -14.21 mL), with differences (P = .01) between oral (WMD, -61.70 mL; 95% CI, -83.02 to -40.39 mL; I2 = 0%) and intravenous (WMD, -23.88 mL; 95% CI, -45.19 to -2.58 mL; I2 = 56%) administration. Eyelid edema and ecchymosis scores in patients receiving tranexamic acid were significantly lower compared with the control group within the first postoperative week: lower eyelid edema, WMD, -0.76; 95% CI, -1.04 to -0.49 and lower eyelid ecchymosis, WMD, -0.94; 95% CI, -1.80 to -0.08. No cases of thromboembolic events were reported.

Conclusions and Relevance

Current available evidence suggests that preoperative administration of tranexamic acid is safe and may reduce intraoperative bleeding as well as postoperative eyelid edema and ecchymosis in patients undergoing rhinoplasty.