Optimizing Melasma Management With Topical Tranexamic Acid: An Expert Consensus

April 2023 | Volume 22 | Issue 4 | 386 | Copyright © April 2023


Published online March 23, 2023

Seemal R. Desai MD FAADa,b, Lee Chin Chan MD MIntMedc, Evangeline Handog MD FPDS FAADd, Lanny Juniarti Djojoseputro MDe, Joyce Teng-Ee Lim FRCPI FAMS Dermatologyf, Ruth Hee Ninh Ling MRCP AdvM DERM SCEg, Hao Trong Nguyen MDh, Elias Tam MBBS GDFM GD (FP) Dermatologyi, Jyh Jong Tang MD MRCPj, Steven Thng MBBS MRCP FRCPk, Hau Khang Tran MD PhD FRCPl

aDepartment of Dermatology, The University of Texas Southwestern Medical Center, TX;
bInnovative Dermatology, Plano, TX;
cNorthern Skin Specialist Clinic, Penang, Malaysia;
dAsian Hospital and Medical Center, Manila, Philippines;
eMiracle Aesthetic Clinic & Anti-Aging Group, Surabaya, East Java, Indonesia;
fJoyce Lim Skin and Laser Clinic, Singapore;
gBorneo Skin Specialist Clinic, Borneo Medical Centre, Kuching, Sarawak, Malaysia;
hHo Chi Minh City Hospital of Dermato-Venereology, Ho Chi Minh City, Vietnam;
iEHA Aesthetic Clinic, Singapore;
jHospital Raja Permaisuri Bainun, Ipoh, Malaysia;
kNational Skin Centre, Singapore;
lHanoi Medical University, Hanoi, Vietnam

Abstract
Because of its complex pathogenesis, chronicity, and high rates of recurrence, melasma is regarded as a challenging skin disorder. Topical treatments are often offered as first-line therapy. However, many patients are unaware that melasma is recurrent and requires long-term management. Hydroquinone is effective for controlling relapses and has become the standard of care for melasma in many countries. Nonetheless, it is limited by its side effect profile. Certain patient profiles who have had prior therapy and/or are refractory to treatment may be offered an alternative, that is topical tranexamic acid (TXA) alone or in combination with other modalities. This review provides a summary of current evidence on topical TXA as a treatment for certain case profiles. This paper aims to fill knowledge gaps in terms of currently available options, highlighting the role of topical TXA alone or in combination with other active ingredients (ie, topical TXA 2% with patented delivery technology).

J Drugs Dermatol. 2023;22(4): doi:10.36849/JDD.7104

Citation: Desai SR, Chan LC, Handog E, et al. Optimizing melasma management with topical tranexamic acid: An expert consensus. J Drugs Dermatol. 2023;22(4):386-392. doi:10.36849/JDD.7104

INTRODUCTION

The Burden of Melasma 
Melasma is a clinically diagnosed benign acquired pigmentary disorder that typically presents as symmetric, reticulated hypermelanosis with irregular borders. It appears on the centrofacial region (ie, forehead, nose, and upper lip), malar, and mandibular areas of the face. Rarely, it can involve the neck, sternum, and upper extremities.1  The etiology of melasma is multifactorial. Ultraviolet (UV) light is recognized as a pathogenetic factor for this condition. Studies have reported a positive family history in about 55% to 64% of patients with melasma, suggesting a potential genetic link. Hormonal influences are also known to play a role in the pathogenesis of melasma as it is often associated with pregnancy, oral contraceptive use, and other hormonal therapies.1 

Histologically, melasma manifests as increased epidermal and dermal melanin. The number of melanocytes does not appear increased, but they are seen to be enlarged with prominent and elongated dendrites and have more abundant melanosomes. The involved skin also has features of solar elastosis and increased mast cells, dermal blood vessels, and expression of vascular endothelial growth factor (VEGF).2,3
Melasma occurs in most races and ethnicities, but it is more prevalent among women of darker skin types (Fitzpatrick skin phototypes IV-VI), particularly Asians, Hispanics, and individuals of African descent.4,5 Because of its location and severe discoloration, melasma can cause tremendous emotional and psychosocial distress in patients and plays a major role in adversely affecting patients' quality of life (QoL).5,6

Current Gaps in the Treatment of Melasma
The management of melasma is challenging due to its complex pathogenesis, chronicity, and high recurrence rates.1 Studies suggest that, for most cases, combination therapy may provide the best outcomes; hence, many clinicians opt for a multimodal therapeutic course.2 Because melanogenesis is a complex, multi-stage process, combination treatment has the advantage of addressing multiple concerns and it can be tailored to address deeper (ie, dermal) melasma.7  
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