Tranexamic Acid (often abbreviated as TXA or TA) is a synthesized amino acid that is used to treat moderate to severe melasma, especially in patients that have not had success with other treatments like lasers, skincare (sunscreen), and other prescription medication.
This is a new and promising treatment for melasma that’s been slowly gaining support for almost a decade now as an off-label use of this FDA-Approved drug, and now has some really good science behind its use in adults with melasma.
- 1 Tranexamic Acid in Melasma
- 2 BEFORE & AFTER PHOTOS
- 3 Topical Tranexamic Acid
- 4 Oral Tranexamic Acid
- 5 Frequently Asked Questions about Treatment of Melasma with TXA
- 5.1 How long can you take tranexamic acid for melasma?
- 5.2 How long does tranexamic acid take to work for melasma?
- 5.3 How effective is tranexamic acid for melasma?
- 5.4 Is tranexamic acid safe for dark skin?
- 5.5 Is tranexamic acid good for sensitive skin?
- 5.6 Is tranexamic acid prescription only?
- 5.7 Is tranexamic acid prescription only?
- 5.8 Does melasma come back after tranexamic acid?
- 5.9 Will Tranexamic Acid Work for My Melasma? Who Should Not Take Tranexamic Acid for Melasma?
Tranexamic Acid in Melasma
Tranexamic acid is the only therapeutic agent that can prevent the activation of the pigment cells (melanocytes) by ultraviolet light, hormones, and injury to the skin. It acts by inhibition of the activation of a protein called plasminogen. Besides reducing the formation of melasma, Tranexamic acid is suggested to reduce the probability of recurrence upon discontinuation of other treatment modalities.
TA significantly reduces the recurrence rate of melasma upon discontinuation of the medicine. A good skin care regimen with carefully prescribed topical agents and laser technologies should be continued to be performed for maintenance.
In addition, strict avoidance of sun exposure is suggested as well as year round full spectrum sunblock.
Most patients respond to the combination of oral tranexamic acid, topical hydroquinone and either Q switched Nd:Yag or clear and brilliant laser treatments within 3-4 weeks. Normally a total of 3-4 laser treatments are provided approximately 2-4 weeks apart (Q switched Yag interval is 2-3 weeks apart and Clear and Brilliant interval is 3-4 weeks) apart.
Tranexamic acid has to reach to the bottom layers of the skin to interact with the melanocytes, the cells responsible for creating melanin and darker coloration in the skin, in order to be effective.
Tranexamic acid can reach to the proper skin depth 1 of 4 ways currently:
- Oral prescription medication: doctor prescribes you a pill to take daily. The problem with this is that tranexamic acid then interacts with and impacts the entire body, not just the skin, and this medication can have real side effects. Patients should not take Tranexamic acid pills if they have a history of venous or arterial clots, actively smoke, or are taking oral contraceptive pills.
- Microneedling the Skin and Applying Topically (rubbing into the skin through puncture channels) this method is problematic because the dosage is not precise: the channels close very quickly and at an uneven rate – and you never really know how deeply the product you’re rubbing in is penetrating, or how evenly it’s entering those channels.
- Skincare serums and creams containing tranexamic acid: claim to to able to deliver the molecules of TA through the skin to the required depths, but the science is lacking, and because this is a non-prescription strength, its weaker than the other options. We’ve seen many patients try a variety of products with little to no success and there is no science to say this method is viable.
- tranexamic acid microinjections were tedious and incredibly difficult using individual handheld syringes – it’s nearly impossible to precisely inject at the same depth, the same tiny amount, for hundreds of injections – so this method was untenable for both doctor and patient (due to discomfort and length of that method), until we created a computer-controlled precision micro-injection technique called TXA Restore.
BEFORE & AFTER PHOTOS
Tranexamic Acid (TXA) is a particular version of the amino acid Lysine, which works within the skin to prevent melanocytes from fully forming new melanin. This is a harmless effect, but by inhibiting the skin from forming new melanin, we can stop the forming of new dark spots in patients with melasma.
No, tranexamic acid prevents your skin from laying down new pigment (or darkening) for a short period of time. Generally, this 3-6 month application of this drug allows those with melasma to calm down the overactive melanocytes that are causing this skin disorder, and its often paired with laser treatments that remove the existing dark patches, to create skin that’s even with your natural complexion tone.
No, tranexamic acid has not been FDA-Approved for melasma specifically, but here’s why that doesn’t matter all that much.
TXA has been FDA-Approved for patients with blood and clotting disorders. Well, as we have been using tranexamic acid to treat these patients since the early 1960’s, several of them also suffered from melasma, and reported this happy side effect of a clearer complexion.
Since the 1980’s, several clinical studies have shown its safe and effective use in treating melasma (both in the US and internationally, on patients of all types) – but the pharmaceutical companies have decided not to (yet) pursue FDA-Approval (likely because each new FDA-Approval costs several million dollars to go through the process, and because there are a good deal of drugs used off-label in the way tranexamic acid is for melasma, especially when the drug has a long history of safety and efficacy, as is in this case).
Normally a total of 3-4 laser treatments are provided approximately 2-4 weeks apart (Q switched Yag interval is 2-3 weeks apart and Clear and Brilliant interval is 3-4 weeks) apart, while tranexamic acid will be prescribed for a period of 3-6 months, and topical skincare, while the individual products recommended may change over time, will be a lifetime commitment in order to best-manage melasma.
Topical Tranexamic Acid
Historically, we’ve know that topical TA is really the ideal, but it has been a struggle to find a way to get the TXA evenly deposited throughout the skin at the depths it works best. Topical use of medications is almost always preferred, when possible, as it reduces the risk of systemic interference or side effects that are inherent when you take a pill form of any medication.
It’s only been in the last year that we’ve developed a method of precisely depositing the TXA in uniform droplets at a uniform depth, and this is done through our own proprietary treatment, called TXA Restore. This microneedling injection device has 3 important distinctions from traditional microneedling in that 1. the needles are depositing the TXA through hollow tips, 2. the amount of TXA being deposited is controlled through a precision injection tool, and 3. the depth is also precisely controlled by the device. This also means the treatment is much faster and more comfortable for the patient.
Oral Tranexamic Acid
Oral tranexamic acid(TXA prescription pills) have been shown to be an effective way of managing melasma, to decrease the creation of new pigment – so that the effects of laser treatment and hydroquinone to remove existing pigment are long-lasting. However, this pill format means that the TXA is dispersed throughout the entire body, and TA will have some side effects, which make it not a good choice for every patient, especially in pill format, where the effects are much more widespread than in a topical or injected formula.
Frequently Asked Questions about Treatment of Melasma with TXA
It is common to prescribe Tranexamic acid for 3-6 months when used as a treatment for melasma.
In one study, comparing daily topical hydroquinone 2% versus intradermal injections of tranexamic acid performed monthly, the tranexamic acid showed much bigger results at the one-month mark2. However, you will need 3-6 months to see the full results from prescription strength TXA, whether that’s injected or pill format.
When combined with a carefully chosen laser technology, appropriate for the skin type of the individual, tranexamic acid is very effective for melasma in either pill or micro-injected form. Topical tranexamic acid is less effective (remember that skincare strength is also far less potent).
Oral Tranexamic acid is safe for treatment of melasma in skin of color, but one needs to be cautious when it is used in its injectable form due the risk of causing pigment alteration.
In certain individuals with sensitive skin, topical tranexamic acid might be irritating.
There are low potency forms of topical tranexamic acid creams and skincare products available, without a prescription, but these are not very effective.
Treatment of melasma using tranexamic acid(TA) sometimes involves the use of a skincare cream that contains the TA. Generally, these creams are far less effective (and less concentrated) than injected, microneedled, or oral applications. However, tranexamic acid creams are available over-the-counter(OTC) without a prescription, making them affordable and accessible – if not all that effective.
The jury is still out on whether TA significantly reduces the recurrence of melasma after the course of the medication is completed. This is an area of active study in medicine. However, what we do know is that the recurrence rate is at least as good as in those not treated – meaning it doesn’t make you more likely to have a recurrence or flare afterwards. Right now, we know short-term recurrence is around 1/3 of people with melasma in a 3 month period1, and there have been some small studies showing TXA can extend that when used in certain ways, but we need more data to say conclusively.
Good skincare and especially strict avoidance of sun exposure is suggested as well as year round full spectrum sunblock. We know that avoiding sun exposure and limiting hormonal fluctuations are both very helpful in preventing future melasma patches.
There’s no guarantee that tranexamic acid will work for you – and generally it has been thought of as a last resort of sorts for treating the melasma cases that are resistant to laser therapy and other medications, because it does have potential side effects, whereas laser therapy does not.
However, in one review of 560 melasma patients treated with tranexamic acid, 89.7% saw an improvement3. Of those, only 1 experienced a serious complication of deep vein thrombosis, and she was later found to have a rare disease.
Patients should not take Tranexamic acid if they have a history of venous or arterial clots, actively smoke, or are taking oral contraceptive pills (birth control pills with hormones). Physicians at our practice review medical history of the patient prior to prescribing the use of tranexamic acid, whether that’s topical or oral formulations, because this drug is not safe for everyone to use.
- Lajevardi, Vahideh, et al. “Comparison of the Therapeutic Efficacy and Safety of Combined Oral Tranexamic Acid and Topical Hydroquinone 4% Treatment vs. Topical Hydroquinone 4% Alone in Melasma: A Parallel-Group, Assessor- and Analyst-Blinded, Randomized Controlled Trial with a Short-Term Follow-Up.” Journal of Cosmetic Dermatology, vol. 16, no. 2, 2016, pp. 235–42. Crossref, doi:10.1111/jocd.12291.
- Saki, Nasrin, et al. “Comparing the Efficacy of Topical Hydroquinone 2 versus Intradermal Tranexamic Acid Microinjections in Treating Melasma: A Split-Face Controlled Trial.” Journal of Dermatological Treatment, vol. 29, no. 4, 2017, pp. 405–10. Crossref, doi:10.1080/09546634.2017.1392476.
- Lee, Hwee Chyen, et al. “Oral Tranexamic Acid (TA) in the Treatment of Melasma: A Retrospective Analysis.” Journal of the American Academy of Dermatology, vol. 75, no. 2, 2016, pp. 385–92. Crossref, doi:10.1016/j.jaad.2016.03.001.
Dr. Mitchell Chasin founded Reflections Center for skin & body as a place where physicians specializing in cosmetic medicine could focus on helping empower patients to feel their most beautiful. Dr. Chasin believes strongly that the best cosmetic physicians are those who are dedicated to mastering their craft through continuing education and collaboration with the industry’s top doctors.