Topical 5% tranexamic acid for the treatment of melasma in Asians: a double-blind randomized controlled clinical trial

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An Update on New and Existing Treatments for the Management of Melasma

Melasma is a chronic, acquired disorder of focal hypermelanosis that carries significant psychosocial impact and is challenging for both the patient and the treating practitioner to manage in the medium to long term. Multiple treatments have been explored, often in combination given the many aetiological factors involved in its pathogenesis. Therapeutic discoveries to treat melasma are a focal topic in the literature and include a range of modalities, with recent developments including updates on visible light photoprotection, non-hydroquinone depigmenting agents, oral tranexamic acid, chemical peels, and laser and energy-based device therapy for melasma. It is increasingly important yet challenging to remain up-to-date on the arsenal of treatments available for melasma to find an efficacious and well-tolerated option for our patients.

Update on Melasma Treatments

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

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.

Topical and Systemic Therapies in Melasma: A Systematic Review

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.

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

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

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%.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

This study was no control group.

CONCLUSION

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

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

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

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

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

Update on Melasma-Part II: Treatment

Melasma is a prevalent chronic relapsing pigmentary disorder that affects photoexposed areas, especially in women of childbearing age. Although there is currently no curative treatment available for melasma, this manuscript critically reviews the knowledge regarding photoprotection, topical and oral therapies, and procedures such as peelings, laser, and microneedling that represent the main strategies for control and prevention of this disease. As the pathogenesis of melasma is not entirely understood, there are prospects for the development of new therapeutic strategies that might act on the pathways that promote sustained pigmentation rather than merely decreasing melanin synthesis and removing melanin from the epidermis.

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

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

Medical therapies for Melasma

Melasma is a common malady affecting all races with a higher incidence in Hispanics, Middle Eastern, Asians and African origin females (Fitzpatrick skin phototypes III-V). Women are affected much more often than men. Melasma remains a significant cause of cosmetic morbidity and psychosocial embarrassment affecting quality of life necessitating effective and reliable treatment. Unfortunately, treatment remains unsatisfactory due to limited efficacy, adverse effects and relapses after stopping treatment. Although chemical peels, laser and light therapies and dermabrasion may have utility, the evidence available for their efficacy is limited and they often cause post inflammatory hyperpigmentation particularly in individuals with darker skin types. Medical therapies remain mainstay in the management of melasma. The triple combination, hydroquinone 4%, tretinoin 0.05% and fluocinolone acetonide 0.01% (Triluma, Galderma, Ft. Worth Texas, often modified incorporating different corticosteroids) remains the only US FDA approved treatment for melasma and is the gold standard due its demonstrated efficacy across ethnicities. Oral tranexamic acid alone or in combination with other modalities has also shown significant efficacy. Several cosmeceuticals and botanical extracts used as skin lightening agents have been demonstrated to be useful. Physical sunscreens containing zinc oxide, iron oxide, titanium dioxide, and silicones provide photoprotective and camouflage effect. We propose that a multimodality approach to the treatment of melasma is the most effective treatment approach. This review is focused on the medical therapies for melasma.

Adjunctive Treatment for Acne Vulgaris by Tranexamic Acid

BACKGROUND

Acne is a chronic, inflammatory skin disorder of pilosebaceous units. Tranexamic acid (TXA) acts as a plasmin inhibitor to reduce blood loss, and is also used to treat rosacea due to its anti-inflammatory effects. Some parts of the pathogenesis of rosacea are similar to inflammatory acne.

OBJECTIVES

The study aimed to evaluate the efficacy of 10% TXA serum in treating acne and its adverse effects.

METHODS

A randomized, double-blind, placebo-controlled, split-face study was performed on 18 mild to moderate acne patients. Patients applied 10% TXA serum on one side of the face and placebo on another side twice daily for 8 weeks. Acne lesion counts and adverse effects were evaluated every 2 weeks.

RESULTS

Significant differences in total inflammatory acne counts were observed between TXA and placebo since week 4 (p = 0.008). TXA mainly reduced papules and pustules, as papule counts significantly decreased since the 8^th week (p = 0.046) and pustule counts significantly reduced since week 8 (p = 0.033). Moreover, physicians also found that TXA serum reduced the redness of the skin, corresponding with the imaging from VISIA^® Skin Analysis. The anti-inflammatory effect of TXA resulted in less PIE and PIH. Adverse effects, including erythema and scaling, were treated by applying any moisturizing cream.

CONCLUSION

Topical 10% TXA can reduce inflammatory acne effectively. Adverse effects were minor and treat easily.

The uses of tranexamic acid in dermatology: a review

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

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.

Topical 5% tranexamic acid with 30% glycolic acid peel: An useful combination for accelerating the improvement in melasma

Recently, topical Tranexamic acid (TXA) has been used in melasma management. On detail search of literature, this may be the first study-assessing efficacy on combining of Topical TXA with GA peel in melasma. The aim of this study is to assess efficacy, safety, and improvement in quality of life index on combining 30% GA peel with 5% TXA solution topically in melasma of epidermal type. Sixty patients of epidermal melasma were included in the study and were categorized into two groups: Combination group was treated with 30% GA peel at 2 weekly intervals with 5% TXA solution applied twice daily and Control group was treated with only 30% GA peel every 2 weeks for 12 weeks. Melasma area severity index (MASI) was used for assessing clinical improvement. Hi-MELASQOL and HRQOL scales were used to measure Melasma related quality of life and were compared between both groups. At each visit, adverse effects were noted. A significantly decreasing trend was seen regarding the MASI score when compared within the group, but the difference was statistically not significant between the two groups at 12 weeks. However, significant reduction in MASI score was attained earlier in the combination group than the control group. Similarly, there was significant improvement in Hi-MELASQOL and HRQOL in both the groups, but the difference between them was statistically not significant. Side effects experienced by patients in both groups were trivial and did not require stoppage of therapy. This study concluded that topical TXA with GA peel has comparable result with GA peel alone, but the therapeutic response was achieved in patients of combination group earlier in comparison to control group patients.

The pathogenesis of melasma and implications for treatment

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review

OBJECTIVES

We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications.

METHODS

An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles.

FINDINGS

TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma.

CONCLUSIONS

TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.

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.

Novel dissolving microneedles preparation for synergistic melasma therapy: Combined effects of tranexamic acid and licorice extract

The aim of this study was to prepare dissolving microneedles (DMNs) patches containing tranexamic acid (TA) for the treatment of melasma. Polyvinyl alcohol (PVA) and polyvinylpyrrolidone (PVP) were preferred as matrix materials through the compatibility experiment. In the in vitro permeation study, the transdermal amount of TA was significantly promoted through dissolving microneedles with the cumulative release was 44.43 ± 6.55%. By comparison, the release of TA solution assisted with solid microneedles (SMNs) was merely 11.31 ± 2.30% (p < 0.05). Pharmacokinetics study indicated the bioavailability of dissolving microneedles was more than 1.3 times compared with oral administration. In pharmacodynamics investigation, TA dissolving microneedles obviously reduced melanin deposition in the skin of melasma guinea pigs after 8 consecutive administrations. In particular, the combination of tranexamic acid and licorice extract (LIC) dissolving microneedles worked better than tranexamic acid alone. Accelerated stress conditions including high temperature, high humidity, as well as photostability were designed to prove that TA microneedles maintained good pharmaceutical stability. In conclusion, tranexamic acid dissolving microneedles showed reliable quality and remarkable effect. Moreover, the combination of tranexamic acid and licorice extract had a synergistic therapy in melasma.

Dermoscopic evaluation of tranexamic acid versus Vitamin C, with microneedling in the treatment of melasma: a comparative, split-face, single-blinded study

BACKGROUND

Melasma is a complex pigmentary disorder with challenging management.

OBJECTIVES

Evaluation of efficacy of topical tranexamic acid (TXA) versus Vitamin C (Vit C) with microneedling (MN) in melasma therapy.

MATERIALS AND METHODS

In 30 females with melasma, after 4 weeks of using Modified Kligman's formula, the right side of the face was treated with MN + TXA and the left with MN + Vit C for five biweekly sessions. Wood's light, dermoscopy, Melasma Area and Severity Index (MASI), MASI malar right and malar left (MASI_MR and MASI_ML), Visual Analogue Score (VAS), and Dermatology Life Quality Index (DLQI) were evaluated at weeks 0, 4, 12, and 16.

RESULTS

Both MASI_MR and MASI_ML decreased significantly (p < .001). Both sides exhibited significant diminution in dark fine granules (p-value < .001), homogeneous pigmentation (p-value = .005) and pseudoreticular brown network (p-value = .028). However, telangiectasia significantly improved only on the TXA treated side (p = .002). DLQI improved significantly on both sides (p < .001). In some patients transformation of mixed to dermal melasma was depicted.

CONCLUSION

MN followed by Vit C or TXA is successful in melasma management, the latter being advantageous vis-a-vis dermal vascularity and epidermal pigmentation. Dermoscopic evaluation appears crucial in choosing optimum treatment in each patient.

Most worthwhile superficial chemical peel for melasma of skin of color: Authors' experience of glycolic, trichloroacetic acid, and lactic peel

Glycolic acid (GA), lactic acid (LA) and trichloroacetic acid (TCA) peels have been used in various combinations for treating melasma patients, but none of the studies have compared their therapeutic efficacy and improvement in quality of life (QOL) index with these three peeling agents in melasma. Our study aims to compare the clinical efficacy, safety, tolerability and improvement in QOL index between 30% GA, 92% LA, and 15% TCA peeling in epidermal melasma. Ninety patients were divided into three groups with 30 in each. First group was treated with 30% GA peel, second with 92% LA peel, and third with 15% TCA peel at every 2 weeks interval for 12 weeks. Melasma area severity index (MASI) and QOL index (Melasma quality of life and Health related quality of life index) were used for clinical evaluation. Patients were observed for side effects and tolerability. The mean MASI score after therapy was significantly lower in patients treated with GA and TCA peels as compared with the group receiving LA peel. However, there was no significant difference in the mean MASI scoring at 12 weeks between GA peel and TCA peel groups. The improvement in QOL index was higher among patients undergoing GA peel followed by TCA and LA peel. Adverse effects were noted mostly with TCA peels followed by GA and LA peel. Thus, GA and TCA peels were equally efficacious and more effective than LA peels. LA peel had minimum side effects and better tolerability than GA and TCA peels.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Therapeutic efficacy and safety of oral tranexamic acid 250 mg once a day versus 500 mg twice a day: a comparative study

Oral tranexamic acid (TXA) 250 mg twice daily has been used effectively for 4 weeks to 6 months to treat melasma. As relapses are frequent on discontinuation, a minimum effective dose of TXA that can be used safely for long time remains unknown. We compared the efficacy of oral TXA 250 mg once daily and 500 mg twice daily given for 16 weeks in 132 (m:f 23:109) adults with melasma. 42 patients in Group-A (TXA 250 mg/d) and 46 patients in Group-B (TXA 500 mg twice/d) completed the study. They were followed up at 4-week interval for percentage reduction in baseline Melasma Area Severity Index (MASI) and at 24 and 28 weeks for relapse. Therapeutic response, for both as per-protocol and intention-to-treat analysis, was scored as very good (> 75% reduction), good (51-75% reduction), moderate (25-50% reduction), mild (< 25% reduction) or no improvement. Reduction in mean MASI score at 4 weeks was not statistically significant in Group-A but it decreased significantly 8 weeks onwards and was comparable with that in Group-B. The relapse rate was higher in Group-B (10.8%) than Group-A (4.7%) at the end of 28 weeks. Oligomenorrhoea and abdominal discomfort in few patients did not necessitate treatment discontinuation. TXA 500 mg twice daily showed early reduction in mean MASI score compared to 250 mg given once daily with comparable safety and therapeutic efficacy at 16 weeks. Open-label cross-sectional design, no control arm, small number of patients in each group, MASI score being subjective assessment tool, short duration of treatment and follow-up are study limitations.

Elaboration of Charged Poly(Lactic-co-Glycolic Acid) Microparticles for Effective Release of Tranexamic Acid

In this study, tranexamic acid (TA) was used as a model compound to study the charge effect on the physicochemical properties of poly(lactic-co-glycolic acid) (PLGA) microparticles (MPs). Charged PLGA MPs were elaborated by the incorporation of a quaternary ammonium, cetyltrimethylammonium bromide (CTAB), during the double emulsion solvent evaporation process. Three TA-CTAB-carrying modes of PLGA MPs were designed in the CTAB-free (TA-MP), adsorption (TA-CTAB_AD), or encapsulation (TA-CTAB_EN) form. The obtained MPs were characterized by morphology and TA-MP affinity. The experiment revealed that the three prepared MPs were spherical and smooth, with pores on their surfaces. TA-CTAB_AD had a relatively narrow size distribution, compared with that of TA-MP and TA-CTAB_EN. The particle sizes of TA-MP, TA-CTAB_EN, TA-CTAB_AD were measured as 59 ± 17, 54 ± 20, and 19 ± 8 μm, respectively. The zeta potential of the three MPs was found to be in the order: TA-CTAB_AD > TA-CTAB_EN > TA-MP. Differential scanning calorimetry (DSC) indicated that the manufacturing process had no influence on the glass transition temperature of the MPs, which was close to 48 °C. Thermogravimetric analysis illustrated that the presence of CTAB slightly changed the thermal stability of PLGA MPs. In vitro release showed that TA-CTAB_AD exhibited faster TA release than TA-MP and TA-CTAB_EN in a basic environment (pH of 13), probably because of electrostatic attraction. At pH = 1, the release of TA from TA-CTAB_EN was faster than those from TA-MP and TA-CTAB_AD, probably because of electrostatic repulsion. However, the effect of electrostatic interaction was not significant at pH = 7.4.

Towards Boosting Power by Encapsulating Tranexamic Acid into Emulsified Particles

In aesthetic medicine, during a course of skin whitening treatment, injections must be frequently administered to achieve a strong curative effect. To develop a method to prevent long-term harm due to injections, this study applied a novel technology for the delivery of whitening agents that achieved long-term slow release of agents, thereby reducing the danger of frequent injections. We utilized biodegradable poly(ethylene glycol)-poly(lactide-co-ε-caprolactone) and Span 85 as surfactants and squalene as the core oil to encapsulate and adsorb tranexamic acid in emulsified particles, respectively. The conductivity test determined that the continuous phase of the obtained emulsified particles was aqueous; tranexamic acid did not play a critical role because of its low content. The controlled release experiment demonstrated that the release rate of tranexamic acid from the emulsified matrix was in the sequence of (1) adsorption, (2) encapsulation plus adsorption, and (3) encapsulation. Encapsulating tranexamic acid can efficiently halt the behavior of sudden release and potentially boost the efficacy of whitening.

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

Introduction

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

Material and Methods

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

Results

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

Conclusion

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

Postinflammatory hyperpigmentation: A comprehensive overview: Treatment options and prevention

Postinflammatory hyperpigmentation (PIH) occurs after various dermatoses, exogenous stimuli, and dermatologic procedures. The clinical course of PIH is chronic and unpredictable, although the probability of resolution of epidermal hyperpigmentation is better than those of dermal hyperpigmentation. PIH can be prevented or alleviated. When it does occur, the underlying inflammatory conditions should be sought and treated as the first step to reduce the progression of inflammation and PIH (which is an inflammatory consequence). If the inflammatory conditions subsides or there is no evidence of inflammation at the time of diagnosis, the treatments of PIH should be considered as the next step. Understanding the available treatment options helps the physician choose the appropriate treatment for each patient. Having a reproducible model for PIH is essential for the development of treatment modalities. The second article in this 2-part continuing medical education series on PIH specifically addresses the evidence that supports medical and procedural treatments of PIH and other forms of acquired hyperpigmentation. It also describes a PIH model and provides an algorithm for clinical practice along with discussion about the prevention of PIH.

Therapeutic Effects of Topical Tranexamic Acid in Comparison with Hydroquinone in Treatment of Women with Melasma

Introduction

Few studies have focused on therapeutic as well as side effects of tranexamic acid (TXA) as a topical drug compared to other topical drugs in treating melasma. The present study aimed to assess and compare the beneficial therapeutic effects and also side effects of local TXA in comparison with hydroquinone in treating women with melasma.

Methods

This randomized double-blinded clinical trial was performed on 60 women who suffered from melasma and were referred to the skin disorders clinic at the Rasoul-e-Akram hospital in Tehran in 2015. The patients were then randomly assigned via computerized randomization to two groups: group A received TXA%5 (topically twice a day for 12 weeks in the location of the melasma) and group B (received hydroquinone 2% with the same treatment order). Prior to intervention and at 12 weeks after intervention, the intensity and extension of melasma were assessed based on the Melasma Area and Severity Index (MASI) scoring method.

Results

The mean MASI score in both treatment groups decreased considerably after completion of treatment and was not significant between the two groups. No side effects were detected in group A, but 10% of those in group B complained of drug-related side effects including erythema and skin irritation (p = 0.131). Regarding the level of patient satisfaction, the patients in group A had a significantly higher level of satisfaction level of 33.3% compared with 6.7% in group B (p = 0.015) (Fig. 9). Multivariate linear regression modeling with the presence of age, history of systemic disorder, drug history, and family history of melasma demonstrated no difference in the mean MASI between the two groups.

Conclusion

Topical use of TXA significantly reduced both melanin level and MASI score. Given its high efficiency and low drug side effects, this regimen results in high patient satisfaction compared with topical hydroquinone. IRCT code: IRCT2016040627220N2.

Melasma: an Up-to-Date Comprehensive Review

Melasma is a common acquired condition of symmetric hyperpigmentation, typically occurring on the face, with higher prevalence in females and darker skin types. Multiple etiologies, including light exposure, hormonal influences, and family history, have been implicated in the pathogenesis of this disorder. Overall prevalence ranges widely at 1-50%, since values are typically calculated within a specific ethnic population within a geographic region. Histologically, melasma can display increased epidermal and/or dermal pigmentation, enlarged melanocytes, increased melanosomes, solar elastosis, dermal blood vessels, and, occasionally, perivascular lymphohistiocytic infiltrates. Various topical, oral, and procedural therapies have been successfully used to treat melasma. Traditional topical therapies including hydroquinone, tretinoin, corticosteroids, and triple combination creams; however, other synthetic and natural topical compounds have also shown varying efficacies. Promising oral therapies for melasma include tranexamic acid, Polypodium leucotomos, and glutathione. Procedures, including chemical peels, microneedling, radiofrequency, and lasers, are also often used as primary or adjunctive treatments for melasma. Notably, combination therapies within or across treatment modalities generally result in better efficacies than monotherapies. This review serves as a comprehensive update on the current understanding of the epidemiology, pathogenesis, clinical and histologic features of melasma, as well as treatments for this common, yet therapeutically challenging, condition.

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

Melasma is a common acquired pigmentary disorder marked by irregular hyperpigmented macules or patches and most commonly occurs in women of darker skin color. It is a chronic often-relapsing condition that causes negative psychosocial effects in those affected. Current treatments such as hydroquinone, kojic acid, and retinoids, among others, demonstrate variable efficacy and side-effect profiles. We conducted a comprehensive literature review examining the use of tranexamic acid (TA), a well-known anti-fibrinolytic agent, in the treatment of melasma. TA delivered orally, topically, and through physical methods works via the inhibition of ultraviolet (UV)-induced plasmin activity in keratinocytes. Predefined search terms were entered into PubMed. Articles were then independently screened by two authors to include only those written in the English language and relating to human subjects with at least mild melasma. The search identified 28 articles, 15 of which met the criteria for full review. The review revealed that TA treatment for melasma is equally effective or more effective than other standard therapies and may induce fewer side effects. Our comprehensive review suggests that TA may be a promising treatment option for melasma because of its demonstrated effectiveness alone and in combination with other modalities as well as its limited side-effect profile.

Efficacy of functional microarray of microneedles combined with topical tranexamic acid for melasma: A randomized, self-controlled, split-face study

To evaluate the efficacy of a functional microarray of microneedles (MNs) plus topical tranexamic acid (TA) for melasma in middle-aged women in China.Thirty female subjects with melasma were enrolled in this study. The left or right side of the face was chosen randomly to be pretreated with a functional microarray of MNs, followed by topical 0.5% TA solution once per week for 12 weeks. The other half-face was the control, treated with a sham device plus topical 0.5% TA solution. At baseline and at weeks 4, 8, and 12 of treatment, clinical (photographic) evaluations and parameters determined by Visia were recorded. At baseline and week 12, patient satisfaction scores and the biophysical parameters measured by Mexameter were also recorded. Side effects were evaluated at baseline and at the end of the 12 weeks.In total, 28 women (93.3%) completed the study. The brown spots' scores measured by Visia were significantly lower on the combined therapy side than on the control side at 12 weeks after starting treatment; there was no significant difference between sides at 4 or 8 weeks. After 12 weeks, melanin index (MI) decreased significantly in both 2 groups, and the MI was significantly less on the combined side at week 12. Transepidermal water loss, roughness, skin hydration, skin elasticity, and erythema index showed no significant differences between 2 sides at baseline, 4, 8, and 12 weeks after treatment. Physicians' evaluations of photographs showed better results at week 12 with combined therapy: >25% improvement was observed in the MNs plus TA side in 25 patients, and in the TA side in only 10 patients. Subjective satisfaction scores on both sides increased significantly. The participants were more satisfied with the results of the combined therapy side than the control side. No obvious adverse reactions were observed throughout the study.Combined therapy with a functional microarray of MNs and topical TA solution is a promising treatment for melasma.