The Use of Tranexamic Acid to Prevent and Treat Post-Inflammatory Hyperpigmentation

March 2021 | Volume 20 | Issue 3 | Editorials | 344 | Copyright © March 2021


Published online February 8, 2021

Aleksandra L Lindgren a, Andrea H Austin MD FAADb, Kathleen M Welsh MD FAADb

aUniversity of Queensland – Ochsner School of Medicine, New Orleans, LA
bBay Area Cosmetic Dermatology, San Francisco, CA

Abstract
The risk of post-inflammatory hyperpigmentation (PIH) in patients undergoing dermatologic procedures is well known. It is especially common after laser procedures and chemical peels but can be seen with any procedure. PIH is also a sequela of acne, burns, and other trauma. High-risk patients are thought to have excessive production and abnormal distribution of melanin within the skin that triggers PIH, but the exact pathophysiology is unknown.1 We define high-risk patients as Fitzpatrick skin types 3–5, those with existing PIH, or a history of PIH.1,2

Tranexamic acid (TXA) is an antifibrinolytic medication prescribed to treat bleeding and is also used off-label to treat melasma. TXA is contraindicated in patients with hypercoagulable conditions, renal impairment, vision impairment disorders, pregnancy, breast-feeding, or on hormone therapies.3,4,5

From 2015–2020, we have used TXA off-label to successfully treat and/or prevent PIH in approximately 82 high-risk patients after injuries or prior to procedures that disrupt the epidermis. We also have used TXA to prevent PIH after acute injuries such as irritant dermatitis, thermal burns, and abrasions. We now consider TXA treatment for all at risk patients prophylactically before undergoing microneedling, cryotherapy, cryolipolysis, chemical peels, and laser treatments.

J Drugs Dermatol. 2021;20(3) doi:344-345. 10.36849/JDD.2021.5622

CASE 1

A 38-year-old woman with Fitzpatrick skin type 3 complained of a burning 20 minutes after the application of topical anesthetic cream: benzocaine 20%, lidocaine 8%, and tetracaine 4% (BTL cream, Sincerus Pharmaceuticals, Pompano Beach, FL). Removal of BTL cream showed evidence of significant inflammation (Figure 1). Past medical history was significant for severe PIH in the same location after irritation from a chemical peel.
The patient had no contraindications for oral TXA. Given the high concern for PIH, she was prescribed TXA 650 mg daily and clobetasol 0.05% cream twice daily. The clobetasol cream was discontinued after one week and TXA was discontinued after eight weeks. Sixteen weeks later, she presented with normal-appearing skin. Her previous similar episode of PIH had been treated with clobetasol 0.05% cream for 2 weeks followed by hydroquinone 4% and monthly light chemical peels, leading to resolution only after six months. We believe the addition of TXA was responsible for her quick recovery without PIH, and without multiple chemical peels or prolonged use of hydroquinone (Figure 2).

CASE 2

A 20-year-old woman with Fitzpatrick skin type 4, presented with acne, acne excorie, and PIH (Figure 3, left side). She was treated with topicals (sunscreen and tretinoin 0.05%) and daily spironolactone 100 mg. A series of light chemical peels was planned. She was prophylactically prescribed oral TXA 650 mg daily for her ongoing excoriation and concern that the peels would exacerbate her current PIH. Over a period of 2.5 years, she completed nine exfoliative chemical peels (Vitalize peels, Allergan, Irvine, CA) without any complications (Figure 3, right side). She did not develop any new PIH during this time despite continued excoriation.