|LETTER TO THE EDITOR
|Ahead of print publication
Topical 10% tranexamic acid for recalcitrant topical steroid-dependent face
Deepak Jakhar, Ishmeet Kaur, Sachin Yadav
Department of Dermatology and STD, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India
|Date of Submission||21-Feb-2020|
|Date of Decision||23-Mar-2020|
|Date of Acceptance||17-Apr-2020|
|Date of Web Publication||19-Sep-2020|
Department of Dermatology and STD, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi - 110 007
Source of Support: None, Conflict of Interest: None
|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 [Epub ahead of print] [cited 2020 Oct 20]. Available from: https://www.idoj.in/preprintarticle.asp?id=295487
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. 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 [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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|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), local immunosuppression, and inhibition of action of nitric oxide (NO)., On withdrawal of TC, endothelial NO is released causing vasodilation and erythema.,
TXA is a synthetic lysine-like molecule, which competitively inhibits the conversion of plasminogen into plasmin, thereby inhibiting the plasmin mediated angiogenesis. In addition, it is known to inhibit vascular endothelial growth factor. Topical TXA has been used in the management of rosacea., Tranexamic acid decreases the clinical signs of rosacea via inhibition of PAR-2 activation by serine protease and calcium influx in keratinocytes. Additionally, it decreases erythema by decreasing pro-inflammatory cytokines (interleukin 6 and tumor necrosis factor alpha).
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., Oral anti-inflammatory antibiotics, topical metronidazole, topical tacrolimus/pimecrolimus, topical brimonidine, and topical xylometazoline has been used in past with variable results [Table 2]. Increasing evidence of TXA in the reduction of erythema prompted us to start the patient on 10% TXA.,,, 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.,
|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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]