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  Table of Contents  
LETTER TO THE EDITOR
Year : 2020  |  Volume : 11  |  Issue : 6  |  Page : 1024-1026  

Topical 10% tranexamic acid for recalcitrant topical steroid-dependent face


Department of Dermatology and STD, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India

Date of Submission21-Feb-2020
Date of Decision23-Mar-2020
Date of Acceptance17-Apr-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Ishmeet Kaur
Department of Dermatology and STD, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi - 110 007
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_97_20

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How to cite this article:
Jakhar D, Kaur I, Yadav S. Topical 10% tranexamic acid for recalcitrant topical steroid-dependent face. Indian Dermatol Online J 2020;11:1024-6

How to cite this URL:
Jakhar D, Kaur I, Yadav S. Topical 10% tranexamic acid for recalcitrant topical steroid-dependent face. Indian Dermatol Online J [serial online] 2020 [cited 2020 Nov 26];11:1024-6. Available from: https://www.idoj.in/text.asp?2020/11/6/1024/295487



Sir,

Topical steroid dependent/damaged face (TSDF) is defined as a semi-permanent or permanent damage to the skin of the face precipitated by the irrational, indiscriminate, unsupervised, or prolonged use of topical corticosteroids (TC) resulting in a plethora of cutaneous signs and symptoms and psychological dependence on the drug.[1] Once damaged, the management becomes challenging as the treatment options are very limited and results are unpredictable. We present a case of recalcitrant TSDF with excellent response to topical 10% tranexamic acid (TXA).

A 21-year-old girl (Fitzpatrick type IV-V) presented with persistent erythema of the face with associated itching and burning sensation [Figure 1]a and [Figure 1]b. On enquiring, she gave history of application of betamethasone dipropionate cream twice daily for past 5 months. She was advised by a local pharmacist to apply betamethasone dipropionate cream for her freckles. Since last 1 month, she has been experiencing a burning sensation on face and a persistent erythema. Patient was asked to stop the topical steroid application and was advised strict photoprotection. Topical tacrolimus 0.1% was prescribed at nighttime but was discontinued after 8 weeks due to minimal improvement of symptoms. Topical brimonidine 0.33% was given later, which showed initial improvement. The lesions, however, reappeared on discontinuation of therapy. Patient was then started on topical 10% TXA, which was prepared from injection TXA (100 mg/ml). The solution was dispensed in an ethylene/propylene copolymer plastic container and patient was educated to apply it with a cotton bud once daily at night. In addition, a physical sunscreen was also advised. Burning sensation decreased within 2 weeks. Erythema was assessed using a clinician erythema assessment scale[2] [Table 1] and it showed a 2-grade reduction (baseline grade-4) after 4 weeks [Figure 2]a and [Figure 2]b. Treatment was continued till 8 weeks, after which it was stopped and patient was asked to continue using the sunscreen. There was no relapse in the next 4 weeks, after which the patient was lost to follow up.
Figure 1: Dusky erythema over the face of a young girl (a); lateral view showing topical steroid induced erythema (b)

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Table 1: Clinician erythema assessment scale description

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Figure 2: Improvement of the erythema after 4 weeks of topical 10% tranexamic acid application (a); lateral view showing improvement in erythema (b)

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The clinical picture of TSDF appears due to a combination of factors: dermal atrophy (TC inhibit collagen and hyaluronic acid synthesis by fibroblasts),[3] local immunosuppression, and inhibition of action of nitric oxide (NO).[4],[5] On withdrawal of TC, endothelial NO is released causing vasodilation and erythema.[4],[5]

TXA is a synthetic lysine-like molecule, which competitively inhibits the conversion of plasminogen into plasmin, thereby inhibiting the plasmin mediated angiogenesis.[2] In addition, it is known to inhibit vascular endothelial growth factor. Topical TXA has been used in the management of rosacea.[2],[3] Tranexamic acid decreases the clinical signs of rosacea via inhibition of PAR-2 activation by serine protease and calcium influx in keratinocytes.[2] Additionally, it decreases erythema by decreasing pro-inflammatory cytokines (interleukin 6 and tumor necrosis factor alpha).[3]

Treatment of TSDF includes withdrawal of the topical corticosteroid, which itself can lead to the increased flushing and erythema due to released nitric oxide from the endothelia.[4],[5] Oral anti-inflammatory antibiotics, topical metronidazole, topical tacrolimus/pimecrolimus, topical brimonidine, and topical xylometazoline has been used in past with variable results [Table 2].[2] Increasing evidence of TXA in the reduction of erythema prompted us to start the patient on 10% TXA.[6],[7],[8],[9] Commercially, TXA preparation as solo therapeutic agent is not available and hence has to be prepared from the injectable form. The preparation has to be stored in an ethylene/propylene plastic bottle. The preparation should be stored away from light and at room temperature.[8],[9]
Table 2: Topical therapeutic modalities for topical steroid dependent face

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Dryness was the only side-effect reported by our patient during the therapy. A moisturizer was prescribed to deal with dryness. A long-term follow-up could not be done in our patient, which is the limitation of this report. Our report shows a promising role of TXA in TSDF. However, further studies with increased sample size and long-term follow-up is needed to conclude the role of TXA in the management of TSDF.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lahiri K, Coondoo A. Topical steroid damaged/dependent face (TSDF): An entity of cutaneous pharmaco dependence. Indian J Dermatol 2016;61:265-72.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Draelos ZD, Gold MH, Weiss RA, Baumann L, Grekin SK, Robinson DM, et al. Efficacy and safety of oxymetazoline cream 1.0% for treatment of persistent facial erythema associated with rosacea: Findings from the 52-week open label REVEAL trial. J Am Acad Dermatol 2018;78:1156-63.  Back to cited text no. 2
    
3.
Barnes L, Kaya G, Rollason V. Topical corticosteroid-induced skin atrophy: A comprehensive review. Drug Saf 2015;38:493-509.  Back to cited text no. 3
    
4.
Jakhar D, Kaur I. Dermoscopy of topical steroid Damaged/Dependent face. Indian Dermatol Online J 2018;9:286-7.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Rapaport MJ, Rapaport V. The red skin syndromes: Corticosteroid addiction and withdrawal. Expert Rev Dermatol 2006;1:547-61.  Back to cited text no. 5
    
6.
Bageorgou F, Vasalou V, Tzanetakou V, Kontochristopoulos G. The new therapeutic choice of tranexamic acid solution in treatment of erythematotelangiectatic rosacea. J Cosmet Dermatol 2019;18:563-7.  Back to cited text no. 6
    
7.
Li Y, Xie H, Deng Z, Wang B, Tang Y, Zhao Z, et al. Tranexamic acid ameliorates rosacea symptoms through regulating immune response and angiogenesis. Int Immunopharmacol 2019;67:326-34.  Back to cited text no. 7
    
8.
Jakhar D, Kaur I. Topical 5% Tranexamic acid for acne-related postinflammatory erythema. J Am Acad Dermatol 2019. doi: 10.1016/j.jaad.2019.09.074.  Back to cited text no. 8
    
9.
Jakhar D, Kaur I, Misri R. Topical 10% Tranexamic acid for erythematotelangiectatic steriod induced rosacea. J Am Acad Dermatol 2020. doi: 10.1016/j.jaad.2019.12.067.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 1], [Table 2]



 

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