comparative study of localized intradermal microinjection of...
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COMPARATIVE STUDY OF LOCALIZED
INTRADERMAL MICROINJECTION OF TRANEXAMIC
ACID IN DIFFERENT DOSES FOR TREATMENT OF
MELASMA IN THAI PATIENTS
BY
MISS PRAPALPITCH WONGWICHARN
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE (DERMATOLOGY)
CHULABHORN INTERNATIONAL COLLEGE OF MEDICINE
THAMMASAT UNIVERSITY
ACADEMIC YEAR 2017
COPYRIGHT OF THAMMASAT UNIVERSITY
Ref. code: 25605929040458YKT
COMPARATIVE STUDY OF LOCALIZED
INTRADERMAL MICROINJECTION OF TRANEXAMIC
ACID IN DIFFERENT DOSES FOR TREATMENT OF
MELASMA IN THAI PATIENTS
BY
MISS PRAPALPITCH WONGWICHARN
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE (DERMATOLOGY)
CHULABHORN INTERNATIONAL COLLEGE OF MEDICINE
THAMMASAT UNIVERSITY
ACADEMIC YEAR 2017
COPYRIGHT OF THAMMASAT UNIVERSITY
Ref. code: 25605929040458YKT
(1)
Thesis Title COMPARATIVE STUDY OF LOCALIZED
INTRADERMAL MICROINJECTION OF
TRANEXAMIC ACID IN DIFFERENT DOSES
FOR TREATMENT OF MELASMA IN THAI
PATIENTS
Author
Degree Master of science
Major Field/Faculty/University Dermatology
Chulabhorn International College of Medicine
Thammasat University
Thesis Advisor
Thesis Co-Advisor
goyggrrdnnatnatnPun Punyaphat Sirithanabadeekul, M.D.
-
Academic Years 2017
ABSTRACT
Introduction: Nowadays, there are numerous treatment modalities for
melasma. However, the results still vary and have not been able to reach satisfactory
outcomes. Intradermal microinjection of tranexamic acid (TA) has been reported as an
alternative treatment for melasma.
Objective: To evaluate the efficacy and safety of tranexamic acid (TA)
intradermal microinjection in treatment of melasma, between 50 mg/ml TA versus 4
mg/ml TA in reducing melanin level and modified Malasma Area Severity Index
scoring (mMASI score).
Method: Thirty four patients with melasma were enrolled a prospective,
randomized, triple-blinded, split-faced trial. TA 50 mg/ml was randomly intradermal
microinjection to one side of the face and 4 mg/ml TA was injected to the other side
every 2 weeks for 12 weeks and follow up 1-month after the last treatment. All
patients were instructed to applying the SPF 50 sunscreen to both side of the face in
every morning. Clinical images were taken monthly including melanin level and
hemoglobin level by using the skin analysis camera (Antera3D®), mMASI score
Miss Prapalpitch Wongwicharn
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which evaluated by two dermatologists, side effects to assess the clinical response.
Patients’ self-assessment score was assessed at 1-month follow up after the complete
treatment protocol.
Results: Although, the significant decreased in mMASI score and
melanin level was observed in both concentrations but the side treated with 50 mg/ml
TA could achieve the better result in shorter period comparing to the other side of
face which treated with 4 mg/ml TA. Furthermore, in the sided treated with 50 mg/ml,
there was 34 % improvement in mMASI score and 13 % improvement in melanin
level comparing to 25 % and 5 %, respectively in the side treated with 4 mg/ml. At 1-
month follow up, there was significant decrease in mMASI score and melanin level in
both sides of the face. No any serious adverse effect was observed. Majority of the
patients preferred 50 mg/ml TA intradermal microinjection than 4 mg/ml. 85% of the
patients scored as excellent improvement on the side treated with 50 mg/ml
comparing to 4 mg/ml which was scored 35% as excellent improvement.
Conclusion: Intralesional microinjection of 50 mg/ml TA showed a
statistically significant decrease in melasma without any serious side effects.
Moreover, 50 mg/ml of TA showed superior to 4 mg/ml in term of improvement in
melasma and also can reach the better result in the shorter period of time. Therefore,
50 mg/ml TA appeared to be a therapeutic option or adjunctive treatment for
melasma.
Keywords: Melasma, Melasma pathogenesis, Melasma treatment, tranexamic acid
(TA), intradermal microinjection
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ACKNOWLEDGEMENTS
First of all, I would like to extend my special thanks to Dr. Punyaphat
Sirithanabadeekul, M.D., my advisor, for her understanding, consultation, patience,
encouragement and especially for pushing me farther than I thought I could go. She is
such a very good role model for me. AS well my sincere gratefulness and respect
would be conveyed to Dr. Salinee Rojhirunsakool, M.D. and Dr. Suparuj Lueangarun,
M.D., the committee members, for such wonderful pieces of advice and kindly
suggestions to the modification of my research study towards the best and highest
quality. Moreover thank you so much to my family and Mr. Kevin Choe for their
valuable time for helping and giving me words of encouragement thoughout this
research study.
In particular, my appreciation is devoted to Tobacco Monopoly Hospital
for their willingness to me to use the study site, and distinctively the graciousness of
all staffs which always facilitates and comforts me well. Moreover, I owe my deepest
gratitude to all of my colleagues, especially Mr. Zaw Hla oo who help me survive the
stress time as always.
Finally, I would like to express my sincere gratitude to chulabhorn
international college of medicine, Thammasat University for letting me fulfill my
dream of being a student here and the opportunity to write an honors thesis.
Miss Prapalpitch Wongwicharn
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TABLE OF CONTENTS
Page
ABSTRACT (1)
ACKNOWLEDGEMENTS (3)
LIST OF TABLES (7)
LIST OF FIGURES (8)
LIST OF ABBREVIATIONS (10)
CHAPTER 1 INTRODUCTION 1
1.1 Background and rationale 1
1.2 Research question 2
1.3 Specific Objective 2
1.4 Hypothesis 3
1.5 Keywords 3
1.6 Ethic consideration 3
1.7 Limitation 4
1.8 Expected benefits and application 4
CHAPTER 2 REVIEW OF LITERATURE 6
2.1 Review of literature 6
CHAPTER 3 RESEARCH METHODOLOGY 26
3.1 Study design 26
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3.2 Study sample or study population 26
3.2.1 Target population 26
3.2.2 Sampling method 26
3.2.3 Discontinuation criteria 28
3.2.4 Sample size 28
3.3 Research grouping 28
3.4 Material and Methods 29
3.4.1 Informed consent process 29
3.4.2 History taking 29
3.4.3 Physical examination and evaluation 30
3.4.4 Intervention 30
3.4.5 Tranexamic acid preparation 31
3.4.6 Follow up 32
3.5 Outcome measurement 34
3.5.1Objectiveassessment 35
3.5.1.1 Skin analysis camera (Antera 3D®) 35
3.5.1.2 Side effects 36
3.5.2 Subjective assessment 36
3.5.2.1 modified MASI score (mMASI score) 36
3.5.2.2 Patients’ self-assessment of the 37
improvement of melasma
3.5.2.3 Dermatological Quality of Life Index 37
3.5.2.4 Pain score 38
3.6 Data analysis 38
CHAPTER 4 RESULTS AND DISCUSSION 39
4.1 Patients demographic data 39
4.2 Objective assessment 41
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4.2.1 Skin analysis camera (Antera 3D®) 41
4.2.1.1 Antera 3D® melanin level 41
4.2.1.2 Antera 3D® hemoglobin level 43
4.3 Subjective assessment 45
4.3.1 mMASIscore 45
4.3.2 Patients’self-assessment 45
4.3.3Side effect 49
4.3.4 Dermatologic Quality of Life Index 51
4.4 Discussion 52
CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS 60
5.1 Conclusion 60
5.2 Recommendation 61
5.3 Limitation 61
REFERENCES 62
APPENDICES 68
APPENDIX A 69
APPENDIX B 71
APPENDIX C 73
APPENDIX D 75
APPENDIX E 79
BIOGRAPHY 86
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LIST OF TABLES
Tables Page
1.1 Administration and time schedule 5
2.1 Classification of melasma based on the depth of melasma 8
2.2 Clinical trials of tranexamic acid in the treatment of melasmax 22
3.1 Inclusion and exclusion criteria 26
3.3 Outcome measurement 34
4.1 Patients demographic data 39
4.2 Antera 3D® Melanin level 42
4.3 Antera 3D® Hemogloin level 44
4.4 MASI score 46
4.5 Patients’ self-assessment score 47
4.6 Local Side effect 49
4.7 Systemic side effect 50
4.8 Dermatologic Quality of Life Index 52
4.9 The studies of the injection of tranexamic acid for the 56
treatment of melasma
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LIST OF FIGURES
Figures Page
2.1 Schematic view of melanogenesis induced by UV radiation in 7
direct and in direct pathway
2.2 Chemical structure of tranexamic acid 11
2.3 Pathogenesis of melasma and role of tranexamic acid 12
2.4 Pathology of normal skin and damaged skin stained with 14
Fontana- Masson
2.5 Pronounced telaniectatic erythema noticed on the melasma 15
lesion
2.6 Immunohistochemistry for factor VIIa-related antigen 15
enlarge and elongated blood vessels in the upper dermis
versus perilesional normal skin
2.7 Computer assisted morphometric analysis of factor VIIIa- 16
related Antigen stained section in vessel size, vessel density
and the related area covered by blood vessels
3.1 Demonstrate the injection site of tranexamic acid 29
3.2 Fitzpatrick skin type and characteristics 30
3.3 Interdermal injection technique 31
3.4 Tranexamic acid 32
3.5 Study methodology 33
3.6 Skin analysis camera (Antera3D®) 35
3.7 Pictures from the skin analysis camera 35
3.8 Modified MASI score and Calculation of mMASI score 37
3.9 Visual analogue scale 38
4.1 Previous treatment 40
4.2 Aggravating factor 40
4.3 Antera 3D® Melanin level 41
4.4 Antera 3D® hemoglobin level 43
4.5 mMASI score 45
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4.6 Patients’ self-assessment score 48
4.7 Local side effect 49
4.8 Dermatologic Quality of Life Index 51
5.1 Photograph and melanin level of subject 1 75
showing intradermal microinjection of 4 mg/ml TA
5.2 Photograph and melanin level of subject 1 75
showing intradermal microinjection of 50 mg/ml TA
5.3 Photograph and melanin level of subject 2 76
showing intradermal microinjection of 4 mg/ml TA
5.4 Photograph and melanin level of subject 2 76
showing intradermal microinjection of 50 mg/ml TA
5.5 Photograph and melanin level of subject 3 77
showing intradermal microinjection of 4 mg/ml TA
5.6 Photograph and melanin level of subject 3 77
showing intradermal microinjection of 50 mg/ml TA
5.7 Photograph and melanin level of subject 4 78
showing intradermal microinjection of 50 mg/ml TA
5.8 Photograph and melanin level of subject 4 78
showing intradermal microinjection of 4 mg/ml TA
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LIST OF ABBREVIATIONS
Symbols/Abbreviations Terms
α Alpha
β Beta
AA Arachidonic acid
AE Adverse effect
bFGF Basic fibroblast growth factor
CI Confidence interval
DIC Disseminated intravascular coagulation
DNA Deoxyribonucleic acid
EI Erythema index
ET-1 Endothelin-1
FbDP Fibrin degradation product
FGF
FA
fibroblast growth factor
Fluocinolone Acetonide
F/U Follow up
GA Glycolic acid
Hb level Hemoglobin level
HQ Hydroquinone
iNOS Nitric oxide synthase
IPL Intense pulse light
MSH Melanocyte-stimulating hormone
LK Leukotriene
Mg Milligram
MI Melanin index
Ml milliliter
ML Melanin level
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Symbols/Abbreviations
mMASI
NGF
Terms
Modified Melasma Area and Severity
Index
Nerve growth factor
OCP Oral contraceptive pill
PA Plasminogen activatior
PAI-1 Plasminogen activator inhibitor-1
PASI Psoriasis Area and Severity Index
PDL Pulsed dye laser
PGA Physician global assessment
PGE2 Prostaglandin E2
POMC Proopiomelanocortin
PIH Postinflammatory hyperpigmentation
PtGA Patient global assessment
QS Nd: YAG 1064 nm Q switched neodymium: Yttrium garnet-
1064 nm
Er: YAG 2940 nm Erbium: Yttrium aluminium gernet 2940
nm
RNA Ribonucleic acid
SCF Stem cell factor
Sc-uPA Sigle-chain Urokinase-type plasminogen
activator
SD Standard deviations
TA Tranexamic acid
TAT Thrombin-antithrombin III complexs
level
TCA Trichloroacetic acid
TRP-1 Tyrosinase-relaed protein 1
TRP-2 Tyrosinase-related protein 2
uPA Urokinase-type plasminogen activator
U Unit
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UV Ultraviolet
VAS Visual analog scale
VEGF Vascular endothelial growth factor
WHO World Health Organization
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CHAPTER 1
INTRODUCTION
1.1 Background and rationale
Melasma is a common cosmetic problem with facial hyperpigmentation
among Asians. It is a chronic acquired pigmentary disorder. The characteristics are
symmetrically distributed light to dark brown macules and patches in the sun
exposure areas, mostly on the face (e.g. forehead, cheeks, temple, upper-lips and
nose)(1). Three different types of melasma exist depending on the location of pigment
deposits: epidermal, dermal and mixed type(2). The exact prevalence of melasma is
still unknown. Women are more susceptible than men, particularly those at
reproductive ages and mainly affects darker skin types (Fitzpatrick skin type IV-
VI)(3). Although there is no definite pathogenesis, multiple studies have found that
common predisposing factors include genetic predisposition, ultraviolet radiation,
pregnancy, oral contraceptives, thyroid disease, cosmetic, nutrition and drugs(4).
Many studies have found that the affected skin will result in an increase in vascularity
and angiogenic factors in the epidermis. These may play a role in pathogenesis (5)(6).
UV radiation is the most aggravating factor for melasma (7).
There are many treatment modalities for melasma including whitening
agents such as hydroquinione, retinoic acid, azelaic acid, kojic acid, Chemical
peeling. Laser and light therapy are now effectively used in the treatment of
melasma. It is helpful in refractory cases. However, many researchers reported
adverse effects such as mottled hypopigmentation, irritation, acneiform eruption and
rebound hyperpigmentation(8).
Although many treatment modalities have been tried, no treatment has
been proven to be consistently satisfactory. Treating melasma remains a challenge for
dermatologists, as no gold standard exists and recurrence is common.
There are studies which revealed that tranexamic acid, a plasmin inhibitor,
is commonly used as a hemostatic agent due to its anti-fibrinolysis action. Tranexamic
acid also has recently obtained in popularity in melasma treatment. It can reduce
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hyperpigmentation effect. Interestingly, there are many studies about topical and oral
tranexamic acid in melasma treatment but the outcome of the topical treatment is still
not satisfactory while the oral tranexamic acid is quite dangerous due to the systemic
side effect of the drugs when given in high dosage. The most noteworthy side effects
include Thromboembolism, myocardial infarction and pulmonary embolism. While
the thrombotic risk may be considered low, there are factors such as old age, high
dosage, prolonged usage of TA and concomitant doses of other prothrombotic drugs
which can still lead to an increased risk (9).
There was a clinical trial study using localized intradermal microinjection
of tranexamic acid (TA). The result of this study showed a significant decrease in
pigmentation. The intralesional microinjection shows little systemic absorption and no
systemic side effects but the drawback of this study is the frequency of the treatment
(once/week)(7). In this study, we would like to evaluate the efficacy and side effects
of intradermal microinjection of 50 mg/ml TA versus 4 mg/ml, the same
concentration of TA of previous study.
This study would help the patients to save the cost and time for going to
visits to the dermatologists to do the treatment while lower frequency the intradermal
microinjections made patients feel more comfortable with the same or more effective
outcome of the treatment comparing to the previous study(10)
1.2 Research question
Our research question is whether the 50 mg/ml TA intradermal
microinjection could be more effective and superior to 4 mg/ml TA in term of
reducing melanin level and modified Melasma Area and Severity Index (mMASI
score).
1.3 Specific Objective
Primary objective
- To evaluate the efficacy of tranexamic acid (TA) intradermal
microinjection between 50 mg/ml and 4 mg/ml to reduce the melanin level of
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melasma by using skin analysis camera (Antera3D®)
Secondary objectives
- To demonstrate the efficacy of 50 mg/ml versus 4 mg/ml
tranexamic acid intradermal microinjection in treatment of melasma which is
measured by modified MASI score and hemoglobin
- To evaluate the local side effects of intradermal microinjection of
tranexamic acid in both concentrations.
- To evaluate the systemic side effects of intradermal microinjection
of tranexamic acid
- To analyzed Patients’ self-improvement score.
1.4 Hypothesis
Fifty mg/ml TA could be more effective and superior than 4 mg/ml in
melasma treatment including decrease melanin level, mMASI score. Moreover 50
mg/ml TA could achieve the better result within shorter period of time comparing to 4
mg/ml TA
1.5 Keywords
Melasma, Melasma pathogenesis, Melasma treatment, tranexamic acid
(TA), intradermal microinjection
1.6 Ethic consideration
- The study protocol was approved by Thammasat University’s Ethical
review Committee
- The objectives, methods and expected benefits of this study together
with general information about Melasma were briefed to all patients. The possible
adverse events were also clearly explained to all patients.
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- Patients were also informed that they can withdraw from the study
without any bias from the physicians to continue the standard treatment.
- The patient's data would be strictly confidential.
1.7 Limitation
The limitations of this study are the sunlight and patients’ activities,
patient compliance and sunscreen applying habit.
1.8 Expected benefits and application
Melasma is a common hyperpigmention disorder. It causes suffering to
patients as it can lead to deep psychological and social stress. The treatment is very
challenging. There are numerous melasma treatment modalities such as topical agents,
chemical peeling, laser and light therapy. However, the results still vary and have not
been able to reach satisfactory outcomes. Thus, this study was expected that 50 mg/ml
TA intradermal microinjection could be a potentially effective treatment modality for
melasma.
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Table 1.1 Administration and time schedule
Schedule
of Events
2017 2018
JAN-
MAY
JUN JUL AUG-DEC JAN-
MARCH
APRIL-
MAY
JUN-
JUL
Research
proposal
Research
ethics
Data
collection
Data analysis
Manuscript
Preparation
&Presentation
Thesis
paperwork
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CHAPTER 2
REVIEW OF LITERATURE
Melasma is a common localized, chronic acquired hyperpigmented skin
disorder. It appears on sun-exposed areas such as the face, neck and occasionally
forearms with symmetrical light to dark brown macule to patches (9). For
epidemiology, it is commonly found in darker skin women (Fitzpatrick skin type IV-
VI). The reported prevalence of melasma varies from 8.8% in Latino women in the
southern United States to 40% of women in Southeast Asia (5). Even though its
pathogenesis remains a mystery, the cell in human skin which play an important role
in regulating pigmentation and hemostasis of the epidermis is epidermal melanin unit
which compose of melanocytes and keratinocytes. Some studies confirmed that
increased numbers and activity of melanocyte as well as increased in melanin
production (melanogenesis) play a role in the hyperpigmentation in melasma. As for
the number and quality of melanins, they depend on number of melanocytes, degree
of melanogenesis, dendriticity and surrounding factor such as surrounding tissue
environment, blood supply and UV radiation, etc. Genes that encoded tyrosinase is a
key enzyme in melanin synthesis. Tyrosinase-related protein 1 (TRP-1) and
tyrosinase- related protein 2 (TRP-2) are the protein that stabilize and stimulate
melanocyte activity. Therefore, these enzymes relate in melanin production too
(11)(12). In addition, there are many studies showed that various vascular growth
factors, keratinocyte-derived melanogenic factors such as basic fibroblast growth
factor (bFGF), nerve growth factor (NGF), engothelin-1 (ET-1), the
proopiomelanocortin (POMC)- derived peptides such as melanocyte-stimulating
hormone (MSH) and adrenocorticotrophic hormone (ACTH) have been reported in
UV-induced melanogenesis via keratinocytes melanocytes interaction (13). Other
factor such as genetic factors, inducible nitric oxide synthase (iNOS) and Wnt
pathway modulator genes could also play a role in melasma pathogenesis (14).
Several etiological factors implicated in the pathogenesis including genetic
susceptibility which is reported in many studies to show high incidence in family
members. A study in Singapore reported that 10.2% of study subjects with melasma
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have a family history of melasma (15) while a survey study in Iran shows 54.7% of
pregnant women with melasma have a family history of melasma (16). Ultraviolet
(UV) light exposure induced melanocytosis (the presence of an excessive number of
melanocytes) and melanogenesis (the production of melanin) through directly and
indirectly pathway. For the directly pathway, UV light has directly effect on
melanocyte. This effect caused TYR, TYR-1 and TYR-2 up regulate in melanocytes
which lead to increase melanin production. Another pathway, indirectly pathway, the
UV irradiation has indirectly effects on keratinocytes releasing melanogenic factors
such as nitric oxide (NO), nerve growth factor, basic fibroblast growth factor (bFGF),
MSH, ACTH, ET-1stem cell factor (SCF), all of these are keratinocyte-derived
paracrine factors which have a role in melanogenic effect through keratinocyte
melanocytes interaction (13) (figure 2.1).
Figure 2.1 Schematic view of melanogenesis induced by UV radiation in direct and
indect pathway (13)
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While the relationship between hormones and melasma is still unknown
(5), numerous studies accepted that the onset of melasma begins with using oral
contraceptive pills. Actually oral contraceptive pills and pregnancy have been shown
to increase serum plasminogen activator (PA) which is produced by keratinocyte. The
keratinocyte-PA system can induce the melanogenesis which can explain the
pathogenesis of melasma. In the Resnick study, 29% of the 212 female patients in
obstetrics and gynecology clinics suffered from melasma due to the use of oral
contraceptive pills and 87% of this group of patients have melasma related
pregnancies (15). Another recent study by the Ortonne, et al., (6) global survey which
studied 324 women with melasma from dermatology clinics in many countries
revealed that 25% of this group had the onset of melasma triggered by oral
contraceptive use. The rates were higher in patients who did not have a family history
of melasma. Even if the definition of hormones associated with melasma is still
uncertain, the suggestion for this group of patients is to cease taking oral
contraceptive pills and avoid using such drugs in the future if possible (6). Other less
common risk factors included thyroids disease, cosmetic usage, and phototoxic drugs
(e.g., antiseizure medication) (1). Histopathology of melasma shows that melanin and
epidermal melanocyte were significantly increased in the epidermis as well as an
increase in the number of melanosomes.
There are three types of melasma consisting of epidermal, dermal and
mixed-type.
Table 2.1 Classification of melasma based on the depth of melanin
Type Clinical feature Histopathology Wood’s light
examination
Response
Epidermal Well-defined
with light
brownish color
Increase Melanin deposit in
basal and suprabasal of
epidermis
Enhancement of
color contrast
Good
Dermal Ill-defined
margin, blue-
gray/ashen color
Increase melanophage seen in
superficial and mid-dermis
No enhancement Poor
Mixed Dark brown Melanin deposition is found in
epidermis and dermis
Contrast Enhance
show in some area
Partial
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Table 2.1 shows the traditional classifications based on the depth of
melanin pigment in the histopathology. The wood’s lamp examination can distinguish
the type of melasma by characterizing the extent of involvement of melanin.
Nonetheless, this examination may not be exactly in determining how deep the
melanin deposition is in the skin. The association between the classification based on
wood’s light examination and histopathology is low (14).
Nowadays, there are several treatments for melasma including topical and
systemic treatment, chemical peeling, laser and light therapy. All of the treatment
modalities need to include the use a broad spectrum sunscreen and patients are to
avoid sun light.
Topical treatments such as whitening agents which contain hydroquinone
(HQ), a hydroxyphenolic chemical, inhibits the tyrosinase enzyme that prevents
DOPA from converting to melanin. Deoxyribonucleic acid (DNA) and Ribonucleic
acid (RNA) which synthesizes melanocyte, degrades the melanosomes and also
destructs the melanocytes also inhibited by HQ (17),(18). Hydroquinone is considered
as the gold standard in the treatment of melasma. Commercially available
hydroquinone concentrations vary from 2-4%. It is found to be more effective when
combined with other agents. These combinations include the Kligman’s modified
Kligman’s formula, Pathak’s formula and Westerhof’s formula(14). However there
are many side effects following the use of hydroquinone and combination topical
therapy as previously mentioned such as erythema, dryness, and desquamation,
burning, pruritus, allergic contact dermatitis, nail discoloration, postinflammatory
hypo and hyperpigmentation (PIH) (19),(20). Torok et al (21) conducted the study to
evaluate the efficacy of the combination therapy (HQ 4%, tretinoin 0.05%, FA 0.01%)
to facial melasma. The cream was applied daily at night. For the clinical assessment,
the Follow up held in every month until they achieved a satisfactory result. Fifty
seven percentages of the participants experienced related adverse effect (AE) for
example, erythema and desquamation on the site where the cream was applied. The
greater number of the course of the treatments the higher the incidence of application-
site AEs.
Chemical peeling works by eradicating melanin rather than inhibiting
melanocyte. Several agents such as glycolic acid (GA), salicylic acid, trichloroacetic
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acid (TCA), tretinoin, and resorcinol have been studied but GA peels remains the
most popular. Many studies have characterized them as easy to use, safe, low
occurrence of downtime and some post-peel hyperpigmentation. However,
dermatologists should be careful when prescribing these peeling agents in patients of
darker skin types to avoid incidences of PIH and worsening of melasma itself (22).
Several observations have been made in the study of laser therapy for the
treatment of pigmentary disorders: melanin possesses a wide absorption spectrum
which allows for a large range of laser and light sources; melanosomes have a short
thermal relaxation time; and wavelengths which are longer are able to penetrate
deeper to pinpoint dermal pigment even though the absorption of melanin is optimal
with shorter wavelengths (23).
The laser types currently used in the treatment of melasma are Q switched
neodymium: Yttrium aluminium garnet- 1064 nm (QS Nd: YAG 1064 nm), Erbium:
Yttrium aluminium gernet 2940 nm (Er: YAG 2940 nm), Q switched ruby ( 694 nm),
Intense pulsed light (IPL), Pulsed dye laser (PDL) 585 nm, Fractional laser 1550 nm
(14). The most popularly used laser is QS Nd: YAG with laser toning technique.
However, the laser treatment itself can damage surrounding tissues with an
inflammation process that can lead to post inflammatory hyperpigmentation (PIH).
This may be long lasting and even delayed at the onset (24).
Tranexamic acid (Trans-4-Aminomethylcyclohexane-carboxylic acid, TA)
(Figure 1.1) is a plasmin inhibitor. It is a synthetic derivative of the amino acid lysine
and works by reversibly blocking lysine binding sites on plasminogen molecules.
Thus TA inhibits the plasminogen activator (PA) from converting plasminogen to
plasmin (25),(26). TA is used to prevent abnormal fibrinolysis to prevent abnormal
blood loss (22),(24)-(28). It has been widely used clinically for over 30 years to
prevent and provide therapy for hemorrhage and also primary and secondary
hyperfibrinolysis (29).
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Figure 2.2 Chemical structure of tranexamic acid(26)
TA has been used for the treatment of menorrhagia which has been
approved since the 1970s. The dosages for menorrhagia are 2.0-4.5 g/day during the
cycle (32). However no serious side effects were observed even when the dosages
were increased to 4-4.5 g/day. TA is also successful in treating prophylaxis of
hereditary angioedema for durations of 8 to 34 months without any serious side
effects or abnormal fibrinolytic activity (33). As an antifibrinolytic drug, TA can be
administered in both oral and intravenous form. The concentration of TA which has
antifibrinolytic effect is 5-10 µg/ml. The maximum concentration of oral TA is 13.83-
16.41 µg/ml (TA 1,300-3900 mg). The maximum concentration of TA in IV form is
81-86 mg after injection of TA 1 gram via intravenous route. Its oral bioavailability
ranges from 30-50 % with plasma protein binding of 3%. It can completely cross the
placenta. Its clearance via renal amount 95% and 90% of the drug is eliminated
mostly in 1 day and the half-life in adults is approximately 2.3 hours (29). Varying
dosages are recommended for various bleeding conditions. For systemic fibrinolysis,
10 mg/kg of TA is administered intravenously followed by 30-50 mg/kg of TA in oral
form every 3-4 hours will give adequate inhibitory plasma concentration. For local
fibrinolytic bleeding, 10-20 mg/kg of TA in oral form is to be taken three to four
times a day. In the case of menorrhagia, the recommended oral dosage is 1-1.5 g
every 6-8 hours a day for 3-4 days with the total oral dosage dose not exceeding 4
grams/day (32),(34). The data for the pharmacokinetics of topical TA applied on the
epidermis and TA in the tissue has not been reported yet.
It was first reported in 1979 by Nijo Sadako that TA has a role in the
treatment of melasma. The significant improvement of melasma severity was
accidentally found on the patient 2-3 weeks after using TA for treatment of chronic
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urticarial (26). After that he did the first study of TA in melasma treatment. The study
reported that among 12 patients with 30-69 years, most of them had a good clinical
response in melasma after taking 1.5 g TA plus with vitamin supplement ( B, C and
E) once daily for 20 weeks. However, the mechanism of TA affecting the severity of
melasma remains unknown (26).
However the exact pathogenesis of melasma is unknown. Many studies
reported that UV light exposure plays a major role in melasma pathogenesis. After
UV irradiation, the plasminogen activator synthesis resulted in an increase in
keratinocyte as well as plasmin activity (35)(36). Plasmin can also induce arachidonic
acid (AA) production by activated precursors of secretory phospholipid A2. Free AA
stimulates melanogenesis via its metabolite, Prostaglandin E2 (PGE2), and
leukotrienes (LK) (37),(38). In addition, the plasmin can induce AA to be released in
endothelial cells also. Increased plasmin elevates the α-MSH and bFGF which
induces melanocyte activity to synthesize melanin (9),(39). All of these are the
melanin production process in the skin (Figure 2.3).
Figure 2.3 Pathogenesis of melasma and role of tranexamic acid(9)
Other than the effect on melanocytes, Plasmin activation participates in
one of the processes of angiogenesis. It changes extracellular matrix-bound vascular
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endothelial growth factor (VEGF) into freely diffusible forms. TA, a plasmin
inhibitor, can suppress angiogenesis and the bFGF inducing neovascularization
(Figure 2.3).
Human keratinocyte contains both urokinase-type PA (uPA) and tissue-
type PA (tPA) but secretes only single-chain uPA (Sc-uPA). The Sc-uPA which
deposits in keratinocyte, results in upregulation of melanocytes, tyrosinase activity,
cell parameter and increased dendrite in a dose dependent manner. Moreover, Sc-uPA
can induce the growing of keratinocyte, differentiation, and migration. Hence, in-vitro
studies show that Sc-uPA-generated keratinocyte increases the activity of
melanocytes (40). The amount of Sc-uPA can be increased by plasmin activity.
Repeating UV exposure increases the number of mast cells and mast cell
tryptase. Tryptase deteriorates type IV collagen. This increases the number of mast
cells and typtase both of which might be a result of basement membrane weakness
which is observed in melasma. Mast cells also induced the solar elastosis
development in the skin, which is one of the characteristic features of melasma. In the
UV exposed skin, the elastin contents are related with the mast cell.(9)
Another important consideration in the pathogenesis of melasma is that
the use of contraceptive pills and pregnancy can induce serum PA increasingly, which
as mentioned earlier can stimulate the melanin production.
In addition to melasma histology, there is increased epidermal
pigmentation as a result of more active epidermal melanocytes in melasma when
compared with normal skin (Figure 2.4). From the electron microscopy, the enlarged
melanocytes with marked dendrite were observed. Furthermore, the indicators of
increased melanocytic activity are more expressed such as mitochondria, Golgi
apparatus, rough endoplasmic reticulum and ribosomes which result in increased
eumelanin synthesis. Besides this, various changes are also observed: the basement
membrane of the melasma is thinned and disrupted, prominent solar elastosis is
observed. The raising in the intensity of blood vessels and vascular endothelial growth
factor (VEGF) is noted also.
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Figure 2.4 Normal skin (A) and damage skin (B) stained with Fontana-Masson
(40x)(41)
As explained previously, TA is a lysine analogue. It prevents the binding
of plasminogen to the lysine binding on the keratinocyte so it can be implied that TA
inhibits UV-induced plasmin activity in keratinocytes. This results in less free AA
and reduced the ability to produce PGs, and consequently reduced melanogenesis in
melanocytes (26),(42). TA has no effect on non-sun exposed healthy skin (42). TA
can suppress angiogenesis by inhibiting the process of plasmin converting to VEGF
which could play a contributory role in its action on melasma. Plus, inhibition of the
Sc-uPA pathway may be another mechanism through which TA diminishes
hyperpigmentation. The structure of TA looks like the tyrosinase enzyme molecule
structure so TA can completely degrade the activity of tyrosinase enzyme.
As a result of physical examination, patients who suffered from melasma
notice the exhibited telangiectatic erythema within the melasma lesion (Figure 2.5). In
2006, kim, et al.(43), reported about the vascular characteristic of melasma and the
expression of VEGF, a major angiogenic factor of the skin. The study noticed that an
increase of vascularity in melasma showed not only in histopathology but also in the
dermoscopy and reflectance confocal microscopy. The results noted that the erythema
intensity was higher in melasma lesion because of both number and size of dermal
blood vessel were increase significantly by measuring with computer-asissted image
analysed of factor VIIIa-related antigen-stained sections (figure 2.6, 2.7). Thus, there
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was a relationship between the intensity of vessels and pigmentation in melasma.
Concerning for the VEGF, there was also increase significantly in melasma. As a
result of the increasing VEGF, this study suggested that VEGF could be an important
angiogenic factor for transformed vessels in melasma.
Figure 2.5 Pronounced telaniectatic erythema noticed on the malasma lesion (43)
Figure 2.6 Immunohistochemistry for factor VIIIa-related antigen revealed enlarged
and enlongated blood vessels in the upper dermis ( B), as compare with perilesional
normal skin (A) (43)
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Figure 2.7 Computer assisted morphometric analysis of factor VIIIa-related antigen
stained sections revealed a significant increase in vessel size (C), vessel density (D),
and the relative area covered by blood vessels (E ), as compared with perilesional
normal skin.(43)
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After many forms of TA, including oral, topical application, localized
intradermal microinjection and localized microneedling have been treated in melasma.
TA can be combined with other modalities such as intense pulse light or Nd-YAG
laser.
As mentioned previously, Nijo's study in 1797 in Japan made public the
positive effect of TA on melasma (26). Following that the effectiveness of TA for
melasma has been improved in numerous studies and in vivo studies. Maeda and
Tomitab (44) suggest that TA works by interfering in the process between
melanocytes and keratinocytes at the plasminogen/plasmin system. As a result of this
function of TA, it can prevent melanin production.
In 2007, Seong, et al.(12), used neonatal fore skin cultured melanocytes
to show the effects of TA on morphogenesis and melanogenesis and activity of
melanocytes after 20 mJ/cm2
UVB irradiation. There was a significant lower in
melanin synthesis, melanocytes activities and melanocyte viability after treated with
TA in a dose dependent manner. However, for the number and length of melanocyte
dendrites no any change was observed. In addition, not only decreased in melanin
production but also reduced expression of tyrosinase, TRP-1, TRP-2 mRNA which
play a role in melanogenesis in a dose dependent of TA manner
Topical TA in liposome formulation was developed in 2002. (45)
Kondou, et al. (53), demonstrated the efficacy of topical 2% TA emulsion in the
treatment of melasma. The 2% TA emulsion was applied for 5-18 weeks to 25
volunteers who had been diagnosed with melasma. The result showed improvement of
the pigmentation in 20 subjects (80%) without side effects. The improvement was
observed within 8 weeks. On the other hand, there is a split face study for topical 5%
TA versus vehicle for 12 weeks. The study was done in Thailand in 2012(46).
Twenty three melasma women were recruited in the study for 12 weeks. At the end of
the study, the result showed no significant difference between these two regimens.
Moreover, 5% TA caused more irritation to the applied area.
Zhu, et al. (26), in 2001, used 250 mg TA, 0.2 g vitamin C and 0.02 g
vitamin E orally three times a day to treat 128 melasma patients, compared to 30
control cases (only vitamin C and E in the same dosage) in one course of treatment
lasting 6-8 weeks. Authors found that increasing the treatment duration was more
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effective than increasing the dose of TA. Without changing the coagulation
parameters only a few cases reported side effects such as gastrointestinal upset.
Na et al.(47), in their study clarified the effects of oral TA form and
topical TA form on melasma lesions. The patients were prescribed Oral TA three
times daily along with topical TA which required application 2 times a day in the
morning and at night for 8 weeks. After finishing the study, the result showed
significant decrease in mean lesional melanin index (MI) scores. On the other hand,
for the perilesional skin the MI scores were increased. As for the erythema index
scores, no significant difference was observed between lesion and perilesion skin.
According to histological analysis, the intensity of Epidermal pigmentation, vessel
numbers and mast cell counts were markedly decreased. Thus, TA can decrease
epidermal pigmentation in melasma and also prevent melasma related dermal
changes, such as decreased vessel numbers and decreased numbers of mast cells. This
showed the efficacy of TA on melasma pathogenic mechanism.
In 2010, li, et al. (48), performed an experimental study of intradermal
TA on guinea pig skins, which had been exposed to UVB for 1 month. Intradermal
injection of TA was performed every day for another month. Finally they found out
that the melanin content at the basal layer of the epidermis was significantly lessened,
although melanocytes were not reduced. Thus, they suggested that TA had a benefit
on melanin expression but not the number of melanocytes.
Wu et al. (49), 74 Chinese women aged 21-52 years with symmetrical
facial melasma were recruited in the study. TA 250 mg tablet was prescribed orally 2
times/ day to the patients for 6 months. The melasma responded well with the TA but
surprisingly, for other pigmented lesions, such as freckles and senile lentigo they
remained unchanged. As for the result of this study, it might be due to the
differentiation of the pathogenic mechanisms. The improvement of the lesion was
seen at the end of 4 weeks whereas for some patients the improvement was noticed
only at the end of 8 weeks. Overall, 94.6 % of the patients observed noticeable fading
of melasma.
Cho et al. (50), they clarified the effectiveness of oral TA as an adjuvant
therapy in melasma treatment with laser and light-based devices in Fitzpatrick type III
and IV skin. Oral TA 500 mg/day was prescribed to the patients followed by
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receiving the IPL procedure simultaneously and three or four times of low fluence Q-
switched (Qs-Nd:YAG laser treatments). The same Oral TA dosage was found to
yield an improvement in clinical efficacy in light or laser based melasma treatment.
This was especially so during the period of relative high sun exposure. No serious
adverse effects were uncovered.
Bahrain’s study revealed that TA is as effective as the combined effect of
hydroquinone and dexamethasone in melasma treatment while being safer than the
standard treatment of melasma, hydroquinone (52).
In 2001, Angchaisuksiri, et al. (66), clarified the safety of using long-term
oral tranexamic acid in treatment of melasma. A prospective double-blind, placebo-
controlled study, they randomized patients in to 3 groups. Group A: placebo for 3
months then switched to 1,500 mg/ml of oral TA for 3 months. Group B: TA for 3
months then switched to placebo for 3 months and Group C: TA 1,500 mg/ml orally
in 6 months. The blood samples were collected from the melasma patients at month 0,
1, 4 and 6.They found that no any patients had clinical evidence of thromboembolism.
For Group A and B, plasminogen levels were significantly lower during the treatment
of TA period when compared with the placebo period. There are no change in
fibrinogen, fibrin degradation product (FbDP), plasmin inhibitor, plasminogen
activator inhibitor-1 (PAI-1), thrombin-antithrombin III complexes level (TAT). In
addition, complete blood count, thrombin time, Prothrombin time, Activated Partial
Thromboplastin time, Creatinine, Phosphokinase, liver and kidney function were in
normal range. They conclude that the systemic side effects such as systemic
fibrinolytic suppression and thrombogenic effect were not observed after taking the
long-term systemic treatment of TA in melasma. Therefore, Long-term oral TA
administration was safe. They also reported that anti-fibrinolyc mechanism of TA is
only happen in tissue.
For intradermal TA injection, there is a pilot study done by Lee et al. (7),
in Korea. To evaluate the effectiveness of intradermal microinjection of TA to the
melasma, they used 4 mg/ml TA intradermal injection weekly for 12 weeks. The
MASI score showed a significant decrease since week 8. Furthermore, at the end of
the study, the MASI score improved 42.74% from the baseline. Addition to the lee, et
al study, the results of the study by Steiner, et al was in the same direction. The study
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evaluated the efficacy and safety of topical TA versus intradermal microinjection of
TA for melasma treatment. Group A: the patients received 4 mg/ml TA intradermal
microinjection weekly for 8 weeks versus Group B: 3% TA topical therapy.The mean
dose of TA injection in patients was 1.5 mg, which is lower than the usual dose used
for anti-fibrinolytic effect, and the concentration of topical cream at 3% has minimal
systemic absorption. There was statistically significant lower in MASI score after
week 12 in both groups but no significant different between these 2 regimens was
observed.
There was a comparative study about the therapeutic efficacy and safety
of TA between microinjection and microneedling in melasma treatments. The study
was done in India by Budamakuntla, et al. (1), in 2011. It was a prospective,
randomized, open-labelled study with 60 melasma patients divided into 2 groups
(1:1). Patients were administrated with localized microinjections of TA in one group,
and the other group with microneedling TA. The treatment was done at monthly
intervals (0, 4, 8 weeks) and follow ups for three months. The result of the study
showed that the MASI scores, Physician global assessment (PGA), and Patient global
assessment (PtGA) were significantly decreased from the baseline to the fourth, eight,
and twelfth week of treatment in both treatment arms. Although no significant
difference was observed in two group but the improvement scores of microneedling
group was slightly better than TA microinjection group. No any serious side effects
were noted.
As mentioned above, the efficacy of microinjection as well as
microneedling of TA seem to be of the same effectiveness for melasma treatment. As
for side effects, no serious side effects were reported apart from mild local
discomfort, burning sensation erythema, and wheal at the site of injection which
mostly appears as transient side effects and this concurs with Lee et al study (7)
Recently, the study of Saki et al(54) in 2017, it was a spilt-face controlled
trial study to compare the efficacy and safety between 20mg/ml TA intradermal
microinjection monthly for 3 months and topical HQ once at night for 3 months. The
result showed that both modalities could reduce melanin value by measuring a
colormeter, Dermacatch® (p value < 0.001). Monthly TA intradermal injection could
achieve the better result in term of reducing melanin value during the first 4 weeks
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when compared with topical HQ. By the way, after 20 weeks no significant difference
was observed between these 2 groups. This study concluded that the onset of action of
TA intradermal injection may be shorter when compared to topical HQ. Also the
longer treatment duration could achieve greater improvement.
The localized intradermal microinjection of tranexamic acid is a new
treatment modality for melasma. In the future, it may be a promising therapeutic
method due to its safety, effectiveness and reduced recurrent rate. Moreover, it is an
office-based procedure with relatively quick results and no significant serious side
effects, and almost downtime.
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Table 2.2 Clinical trials of tranexamic acid in the treatment of melasma
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CHAPTER 3
RESEARCH METHODOLOGY
3.1. Study design
Prospective randomized controlled trial triple-blinded split face study
3.2 Study sample or study population
EC approval from Chulabhorn International College of Medicine,
Thammasat University, Hospital.
This experimental were conducted at Thailand Tobacco Monopoly
Hospital between July 2017 to March 2018.
3.2.1 Target population
Female patients with symmetrical epidermal to mixed-type melasma on the face and
aged 26-60 who achieve the inclusion criteria were included in the study
3.2.2 Sampling method
Table3.1 Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria
- Female patients with
symmetrical epidermal-mixed
type melasma,
- Women who are pregnant or breast
feeding
- Age 26-60 - Women who were taking
contraceptive pills on hormone
therapy during the past 1 year
- Ability and willingness to
comply with the requirement
of the protocol
- History of bleeding disorders or the
concomitant use of anticoagulants
such as warfarin, heparin
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- History of disseminated intravascular
coagulation (DIC) without severe
hemorrhage
- Women who have contraindication
for tranexamic acid such as acute
venous or arterial thrombosis, severe
renal impairment, history of
convulsion, acquired defective color
vision, history of deep vein
thrombosis, hypersensitivity to TA
- Women who are on any concurrent
treatment for melasma and did not
wash out at least a 1 month period
before the start of the study.
- History of drug allergy especially to
the study drug
- Known history or clinically relevant
allergy to components of sunscreen
or topical anaesthetic used in this trial
- Active dermatologic malignancy,
active wart, moderate to severe acne
vulgaris on face
- History skin infection: herpes
infections, impetigo
- Patient who has history receive
chemotherapy, radiotherapy
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3.2.3 Discontinuation criteria
3.2.3.1 Patient’s refusal to participate in the study
3.2.3.2 Patient who has serious adverse effect of TA injection
3.2.3.3 Unreliable and poor compliance patient
3.2.3.4 Patient who are in others type of treatment of melasma
3.2.4 Sample size
A total of 35 females who are aged between 26-60 years old with
melasma on the face are recruited for this study Reference from lee et al, 2006 (7) the
decrease in the mean MASI score is 5.65±2.54
Formula
Reference value (µ0) = 5.65
Mean (µ) = 4.65
Standard deviation (σ) = 2.2
Margin (δ) = 0
Alpha (α) = 0.05
Beta (β) = 0.2
Sample size includes subjects who do not continue follow up sessions: 30 + 5 = 35
3.3 Research grouping
Thirty-five females with bilateral epidermal to mixed- type melasma
were enrolled in a split-faced prospective trial. Thirty-five patients were injected with
tranexamic acid once for 2 weeks, one side of the face was injected with 4 mg/ml of
tranexamic acid and another side was injected with 50 mg/ml (figure 3.1).
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Intradermal injection
4 mg/ml of TA
Figure 3.1Demonstrate the injection site of tranexamic acid
3.4 Materials and Methods
3.4.1 Informed consent process
- Patients were fully informed of melasma general knowledge,
objective, expected benefit outcome, and adverse event of this study.
- The study participants provided informed consent prior to initiation
of any study-related standard conditions.
3.4.2 History taking
The collected data include
- Patients’ personal history; name, age, gender, phone number, skin
type, occupation, smoking and drinking habits, underlying disease, current
medication, menstruation, history of taking oral contraceptive pill (OCP), history
allergy in drug and food.
- Patients’ melasma history; age of melasma onset, duration of
melasma, probably cause of the melasma, history of previous treatment and response,
family history of melasma.
- Patients’ information for exclusion criteria such as pregnant or
breast feeding, taking contraceptive pills or on hormone therapy during the past
1 year, History of bleeding disorders or the concomitant use of anticoagulants such as
warfarin, heparin, Women who have contraindication for tranexamic acid (table 3.1)
Intradermal
injection 50 mg/ml of
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Figure 3.2 Fitzpatrick skin type and characteristics
3.4.3 Physical examination and evaluation
- Subjects will be asked to remove all make up and clean their faces
with make-up remover and water before doing the physical examination
- Five pictures will be taken before the procedure which consists of
both sides of the face at 45, 90 degree and the front of the face with a DSLR digital
camera (Nikon® D7200). The patient’s photographs will be taken again at week 4, 8,
12 and 1-month follow up by using the same camera setting, lighting and patient’s
position.
- Melasma evaluation were evaluated including melanin level,
Hemoglobin level by using skin analysis camera ( Antera 3D®) and mMASI score
which done by two dermatologists at baseline, week 4, 8, 12 and 1-month follow up.
3.4.4 Intervention
- Preoperative, a topical anesthetic cream (EMLA®; 2.5% lidocaine
and 2.5% prilocaine) was applied on the face for 45 minutes under occlusion before
treatment. After that it was washed off to achieve a completely dry skin surface.
- All subjects were treated with tranexamic acid which was repeated
every two weeks for 7 times. Two concentrations of TA were prepared under sterile
condition a 30- gauge, 4 ml/mg and 1 ml and 50 mg/ml. Injection of about 0.05 ml
were applied intradermally on the melasma lesion at a 1 cm interval (0.05 ml/1cm2)
(7). The injection site should form a wheal else it is probably too deep. (Figure 3.3)
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- Randomized the concentration of TA (4 and 50 mg/ml) for split
face study done by the staff who do not participate in this study without any study
participants, the researcher and the dermatologists knowing
- After treatment in every session the patient will be asked about any
pain for their pain score rating. The immediate side effects will be observed 30
minutes after treatment.
- Patients were advised to apply board-spectrum sunscreen with SPF
50 to both side of face in the morning, also avoid excessive sun exposure, and avoid
the use of any topical whitening agents on the lesion during the study period.
Figure 3.3.Intradermal injection technique
3.4.5 Tranexamic acid preparation
- Supplies: 1 ml syringes, 3ml normal saline, 21 gauge and 30 gauge
needle, tranexamic acid 1 ampule (250mg/5ml), (Transamin®, Daiichi Sankyo CO.,
LTD, Tokyo, Japan). (Figure 3.5)
- For 4 mg/ml TA concentration: TA is drawn in a 100 U/ml insulin
syringe about 4 mg and diluted with normal saline up to 1 ml to get a concentration of
4 mg/ml of tranexamic acid(1)
- For 50 mg/ml tranexamic acid concentration: draw TA 1 ml in
a 1 ml syringe without dilution.
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3.4.6 Follow up
- The follow up would be done at 1 month interval; week 4, week 8,
week 12 and week 16
- Patients were asked to score patients self-assessment at the end of
the study (week 16)
Figure 3.4 Tranexamic acid (Transamin®, Daiichi Sankyo CO., LTD, Tokyo, Japan).
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Figure3.5 Study Methodology
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3.5 Outcome measurement
Table 3.3 Outcome measurement
Assessment
Treatment
F/U
Treatment
w
wk 0
w
wk 2
w
wk 4
w
wk 6
w
wk 8
w
wk10
w
wk 12
w
wk 16
Photography
[ ]
[ ]
[ ]
[ ]
[ ]
Antera 3D®
- Melanin
level
- Hemoglobin
level
[ ]
[ ]
[ ]
[ ]
[ ]
mMASI score
[ ]
[ ]
[ ]
[ ]
[ ]
Side effects
[
[ ]
[
[ ]
[
[ ]
[
[ ]
[
[ ]
[
[ ]
[
[ ]
[
[ ]
Pain score
[
[ ]
[
[ ]
[
[ ]
[
[ ]
[
[ ]
[
[ ]
[
[ ]
[
[ ]
Quality of life
index
[
[ ]
[ [ [ [ [ [
[ ]
Patients’ self-
assessment
[
[ ]
[ [ [ [ [ [ [
[ ]
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3.5.1 Objective assessment
3.5.1.1 Skin analysis camera (Antera3D®)
Figure 3.6 Skin analysis camera (Antera 3D®)
Figure3.7 Pictures from the skin analysis camera
Antera 3D® (Miravex Limited, Ireland) (Figure 3.7) is a
skin analysis camera and for image acquisiton. The light reflected from the skin’s
surface was converted into a digital image which shows topography, hemoglobin, and
melanin by using the complex algorithms software. It also has the ability to measure
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skin quality via the use of light emitting diodes and polarizers which illuminates and
captures light reflected an area of 36 cm2 the face. A useful feature of the interface
allows comparisons of skin color, texture, volumes, wrinkles, redness and
pigmentation before and after treatment.
In this study, the melanin level and redness would be measured.
3.5.1.2 Side effects
Side effects such as erythema, swelling, wheal and flare,
irritation were objectively assessed at all visits. Patients were asked to report adverse
effects such as pain which were evaluated by a visual analog scale (VAS), erythema,
irritation, pigmentation change (hypo and hyperpigmentation), purpura. For systemic
side effects, patients were asked about gastrointestinal disturbances, for example,
nausea, vomiting and diarrhea. They were asked about any unusual menstruation
characteristics such as amenorrhea, spotting or intermenstrual bleeding.
3.5.2 Subjective assessment
3.5.2.1 Modified MASI score (mMASI score)
Modified Melasma Area and severity Index (mMASI) was
proposed by Kimbrough-Green et al. in 1994. It has been designed from the pattern of
Psoriasis Area and Severity Index (PASI). For PASI, it uses the whole body to
evaluate the lesions of psoriasis. On the other hand, mMASI is the most widely
applied for assessment of melasma severity at the baseline and any changes during the
treatment(55). The mMASI scoring is determined by three variables based on the
percentage of area involvement (A) and was calculated from 0 to 6. For the area
involvement, the area of the face is splitted into 4 parts: the forehead, right malar, left
malar and chin are 30%, 30%, 30%, and 10%, respectively (figure 3.9). The intensity
of darkness (D) of melasma, D was calculated from the scale 0 (absent) - 4
(maximum). The mMASI was calculated by the following formula
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Figure 3.8 Modified MASI score and Calculation of Modified MASI score
“D” is represent to the darkness of the lesion and “A” is area. The
values 0.3, 0.3, 0.3, and 0.1 are the percentage of the facial area. The maximum score
is 24, with 0 being the minimum(7)
3.5.2.2 Patient’s self-assessment of the improvement of melasma
The improvement score was graded in to five levels
0= no change
1= slightly improvement (0-25%)
2= fair improvement (26-50%)
3= good improvement (51-75%)
4= excellent improvement (>75%)
3.5.2.3 Dermatological quality of life index (DLQI)
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3.5.2.4 Pain score
Pain score were evaluated as Figure 3.10
Figure3.9 Visual analogue scale
0= no pain
1-3= mild pain (annoying, mild interfering little with
activities of daily living)
4-6= moderate pain (interferes significantly with activities of
daily living)
7-10= severe pain (disabling; unable to perform activities of
daily living)
3.6 Data analysis
- All measured values will be expressed in the form of means and standard-
deviations (SD)
- A repeated measure ANOVA will be used to compared the change in
modified MASI between the baseline and final follow-up visits
- All statistical analyses will be performed out using SPSS
- Statistically significant in all case will be considered at the p-value <0.05
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CHAPTER 4
RESULTS AND DISCUSSION
The aim of this study is to evaluate the efficacy of tranexamic acid
intradermal microinjection between 4 mg/ml and 50 mg/ml for treatment of melasma.
The result of the study will be divided into 4 parts:
4.1 Patient demographic data
4.2 Objective assessments
4.3 Subjective assessment
4.4 Patients’ self-assessment and side effect
4.1 Patients demographic data
34 from 35 patients completed the study. One patient dropped out due to
inability to follow up. The data analysis were obtained from these patients.
Table 4.1 Patient demographic data (n=34)
Variables n %
1. Age
- Mean ± SD
- Min-Max
50.71 ± 6.52
32-60
2. Occupation
- Housewife
- Maid
- Office
- Ownbusiness
- Hospital staff
2
2
24
5
1
5.9%
5.9%
70.6%
14.7%
2.9%
3. Smoke 0 0%
4. Alcohol consumption 2 5.9%
5. Family history of melasma 19 55.9%
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Variables n %
6. Type of melasma
- Epidermal-type
- Mixed-type
4
30
11.8%
88.2%
7. Duration of melasma
- <5Y
- 5-10 Y
- >10 Y
12
9
13
35.3%
26.5%
38.2%
8. Skin type
- III
- IV
- V
1
23
10
2.9%
67.6%
29.4%
All patients belonged to the age group ranging from 30-60 years. The
average age of the patients was 50.71 year old. Most of them are officer ( n=24,
70.6%). They had Fitpatrick skin type III-V. 4 (11.8%) patients had epidermal type
and 30 (88.2%) had mixed-type of melasma. As for the duration of melasma, 12
patients (35.3%) were under 5 years. Nine patients (26.5%) were 5-10 years and
Figure4.1 Previous treatment Figure4.2 Aggravating factor
Aggravating factor
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thirteen (38.2%) were greater than 10 years. Nineteen (55.9%) patients had a history
of melasma in family. Sun exposure was a highest risk factor for these patients in 22
patients (64%). The percentage of the number of patients with other risk factor related
to occurrence of melasma such as pregnancy, use of contraceptive pill and cosmetic
was 15%, 9%, and 12% respectively. Regarding the prior treatment, 53% of the
patients had history of prior treatment. Majority of them used topical cream (29%)
followed by laser (18%) and others (6%) such as chemical peeling and PRP (Platelet-
Rich Plasma).
4.2 Objective assessment
4.2.1 Skin analysis camera (Antera 3D®)
4.2.1.1 Antera® melanin level
Figure 4.3 Melanin level results
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Table 4.2 Melanin level results
TA 50 mg/ml P-value1 TA 4 mg/ml P-value2
Mean
difference
(95%CI.)
P-value3
Before 0.695
(0.672, 0.718)
0.665
(0.641, 0.689)
-0.03
(0.009, 0.05)
.075
Week4 0.664
(0.643, 0.685)
0.657
(0.635, 0.679)
-0.006
(-0.009, 0.022)
0.669
Week 8 0.637
(0.616, 0.657)
0.65
(0.629, 0.671)
-0.014
(-0.029, 0.002)
0.346
Week 12 0.608
(0.59, 0.627)
0.639
(0.617, 0.66)
-0.031
(-0.045, -0.016)
.032*
Week 16 0.605
(0.586, 0.623)
0.631
(0.609, 0.653)
-0.026
(-0.043, -0.009)
.072
Difference
at week 4
-0.031
(-0.044, -0.019)
0.001* -0.008
(-0.017, 0.001)
0.085 -0.023
(-0.039, -0.008)
.003*
Difference
at week 8
-0.058
(-0.073, -0.044)
0.001* -0.015
(-0.025,-0.005)
0.005* -0.043
(-0.061, -0.026)
0.001*
Difference
at week 12
-0.087
(-0.101, -0.072)
0.001* -0.026
(-0.037, -0.016)
0.001* -0.06
(-0.078, -0.043)
0.001*
Difference
At week 16
-0.09
(-0.106, -0.075)
0.001* -0.034
(-0.046, -0.022)
0.001* -0.056
(-0.075, -0.037)
0.001*
Values presented as mean (95%CI.). P-value corresponds to Repeated ANOVA test.
P-value1: calculated probability the decrease of melanin level from before to week 4, 8, 12 and 16, respectively for the 50 mg/ml
side.
P-value2: calculated probability the decrease of melanin level from before to week 4, 8, 12 and 16, respectively for the 4 mg/ml
side.
P-value3: calculated probability the difference of melanin level between 4 and 50 mg/ml TA in each visit. Statistically
significant as P<0.05
Regarding the side treated with 50 mg/ml of TA, the melanin level at
baseline was 0.695 (95% CI: 0.672 - 0.718) and reduced to 0.664 (95% CI: 0.643-
0.685), 0.637 (95% CI: 0.616 -0.657), 0.608 (95% CI: 0.059, 0.627) and 0.605 (95%
CI: 0.586-0.623) at week 4, week 8, week 12, and week 16 respectively. As For
another side treated with TA 4 mg/ml, the melanin level started at o.665 and decrease
gradually to 0.657 (95% CI: 0.635 - 0.679), 0.650 (95% CI: 0.629 - 0.671), 0.639
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-0.05
-0.07*
-0.10* -0.09*
0
-0.04
-0.07* -0.10*
-0.06*
-0.14
-0.12
-0.1
-0.08
-0.06
-0.04
-0.02
0
0.02
0.04
Baseline week 4 week 8 week 12 week 16
TA 50mg/ml TA 4 mg/ml
(95% CI: 0.617 - 0.66), 0.631 (95% CI: 0.609 -0.653) at week 4, week 8, week 12and
week 16 respectively.(Table 4.2)
The significant difference between these 2 doses of TA was observed at
week 12. However, the melanin level in both side of the face continuously decreased
till week 16th
even if there was not showed significant different between both
regimens at the end of the study (week 16).
The side treated with TA 50 mg/ml, the result showed significant
decrease in melanin level since week 4 (p-value <0.05), on the other hand, the
significant decrease was observed in week 8 for the side treated with 4 mg/ml TA (p-
value <0.05)
4.1.1.2 Antera® hemoglobin level
Figure 4.4 Antera® hemoglobin level
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Table 4.3 Antera® hemoglobin level (n=34)
TA 50 mg/ml P-value1 TA 4 mg/ml P-value2
Mean
difference
(95%CI.)
P-value3
Before 1.73
(1.67, 1.8)
1.72
(1.65, 1.8)
0.01
(-0.06, 0.08)
.723
Week4 1.69
(1.6, 1.78)
1.69
(1.61, 1.76)
0
(-0.07, 0.07)
.959
Week 8 1.66
(1.6, 1.73)
1.65
(1.58, 1.71)
0.02
(-0.05, 0.09)
.637
Week 12 1.63
(1.57, 1.7)
1.62
(1.56, 1.69)
0.01
(-0.06, 0.08)
.724
Week 16 1.65
(1.58, 1.71)
1.66
(1.59, 1.73)
-0.02
(-0.09, 0.06)
.652
Difference
at week 4
-0.05
(-0.11, 0.02) .135
-0.04
(-0.07, 0) .061
-0.01
(-0.08, 0.06)
.786
Difference
at week 8
-0.07
(-0.13, -0.02)
0
.010*
-0.07
(-0.12, -0.03) 0.003*
0
(-0.06, 0.07)
.887
Difference
at week 12
-0.1
(-0.16, -0.04)
0
.001*
-0.1
(-0.14, -0.05) <0.001*
0
(-0.07, 0.07)
.998
Difference
at week 16
-0.09
(-0.15, -0.03)
0
.007*
-0.06
(-0.1, -0.02) 0.009*
-0.03
(-0.08, 0.03)
.312
Values presented as mean (95%CI.). P-value corresponds to Repeated ANOVA test.
P-value1: calculated probability the decrease of hemoglobin level from before to week 4, 8, 12 and 16, respectively for the 50
mg/ml side.
P-value2: calculated probability the decrease of hemoglobin level from before to week 4, 8, 12 and 16, respectively for the 4
mg/ml side.
P-value3: calculated probability the difference of hemoglobin level between 4 and 50 mg/ml TA in each visit. Statistically
significant as P<0.05
The hemoglobin level (Hb level) of both side of the face showed there was
no significant difference. The side treated with 50 mg/ml TA, the reduction of the Hb
level gradually reduced from 1.73 (95% CI: 1.67, 1.8) to 1.69 (95% CI: 1.6- 1.78),
1.66 (95% CI: 1.6-1.73), 1.63 (95% CI: 1.57- 1.7) at 4th
week, 8th
week, 12th
week
respectively and slightly increased to 1.65 (95%CI; 1.58 -1.71) in 16th
week. On the
contrary, regarding the side treated with TA 4 mg/ml, the Hb level decreased slightly
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from 1.72 ( 95%CI: 1.655-1.8) to 1.69 (95%CI: 1.61-1.76), 1.65 (95%CI: 1.58-1.71),
1.62 (95%CI: 1.56-1.69) respectively and slightly raised up to 1.66 (1.56-1.73) in
week 16. The result showed no significant difference between 2 concentrations of TA
(P>0.05) in term of lowering Hb level. However, the significant reduction in Hb level
was observed at week 8 in both concentrations (p<0.05). For the week 16, even if the
Hb level was slightly increased in both concentrations, the scores were less than the
baseline. Moreover, the statistic revealed significance decrease between baseline and
week 16 (p< 0.05) (Table 4.3)
4.3 Subjective assessment
4.3.1 Modified MASI score (mMASI score)
Figure 4.5 mMASI score
0.00
-0.41*
-0.64*
-0.94* -0.98*
0.00
-0.26*
-0.34*
-0.62*
-0.84*
-1.20
-1.00
-0.80
-0.60
-0.40
-0.20
0.00Baseline week 4 week 8 week 12 week 16
TA 50 mg/ml
TA 4 mg/ml
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Table 4.4 mMASI score (N= 34)
Values presented as mean (95%CI.). P-value corresponds to Repeated ANOVA test.
P-value1: calculated probability the decrease mMASI score from before to week 4, 8, 12 and 16, respectively for the 50 mg/ml
side.
P-value2: calculated probability the decrease of mMASI score from before to week 4, 8, 12 and 16, respectively for the 4 mg/ml
side.
P-value3: calculated probability the difference of mMASI score between 4 and 50 mg/ml TA in each visit
The mMASI score at baseline and individual follow ups are shown in the
figure 4 and table4.3. In the side treated with TA 50 mg/ml, the mMASI was 2.88
(95%CI: 2.53-3.22) at the baseline followed by 2.46 (95%CI: 2.15-2.46), 2.24
(95%CI: 1.98-2.5), 1.94 (95%CI: 1.69-2.2) and 1.9 (95%CI: 1.63-2.17) at week 4,
week 8, week 12, and week 16 correspondingly. In the opposite side that treated with
TA 4 mg/ml, the mMASI revealed the slight decrease from 3.26 (95%CI: 2.9-3.63) at
TA 50
mg/ml
P- value1 TA 4 mg/ml P–value2
V Mean
difference
(95%CI.)
P-value3
Before 2.88
(2.53, 3.22)
3.26
(2.9, 3.63)
-0.388
(-0.88, 0.104)
0.12
Week4 2.46
(2.15, 2.78)
3.01
(2.66, 3.35)
-0.547
(-1.006, -0.088)
0
.02*
week 8 2.24
(1.98, 2.5)
2.92
(2.56, 3.28)
-0.679
(-1.119, -0.239)
0
.003*
Week 12 1.94
(1.69, 2.2)
2.65
(2.27, 3.03)
-0.71
(-1.15, -2.57 )
0
.003*
Week 16 1.9
(1.63, 2.17)
2.43
(2.04, 2.81)
-0.529
(-0.989, -0.07)
0
.025*
Difference
at week 4
-0.41
(-0.6, -0.23)
<
0.001*
-0.26
(-0.41, -0.1)
0
.002*
-0.159
(-0.398, 0.08)
0
.189
Difference
at week 8
-0.64
(-0.91, -0.36)
<
0.001*
-0.34
(-0.55, -0.14)
0
.001*
-0.291
(-0.625, 0.042)
0
.086
Difference
at week 12
-0.94
(-1.22, -0.65)
<
0.001*
-0.62
(-0.8, -0.44)
<
0.001*
-0.318
(-0.648, 0.013)
0
.059
Difference
at week 16
-0.98
(-1.27, -0.69)
<
0.001*
-0.84
(-1.03, -0.64)
<
0.001*
-0.141
(-0.485, 0.203)
0
.415
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the beginning of the treatment to 3.01 (95%CI:2.66-3.35), 2.92 (95%CI:2.56-3.28),
2.65 (95%CI:2.27-3.03), 2.43 (95%CI:2.04-2.81) at week 4, week 8, week 12, week
16, respectively.( Table 4.4)
According to the figure 4.5, lowering of the mMASI score at both sides of
the malar area treated with both concentrations of TA was noted since week 4
(p<0.05). Besides, there was a significant difference in the mMASI score between 50
mg/ml and 4 mg/ml in week 4 with the mean difference of -0.547 (95% CI:-1.006- -
0.088) (p<0.05).
4.3.2 Patients’ self-assessment
Table 4.5 Patients’ self-assessment for TA 50 mg/ml and 4 mg/ml
Melasma
improvement grading
TA 50 mg/ml TA 4 mg/ml
No. % No. %
0
( no improvement) 0 0 0 0
1 (1-25%)
(slightly improvement) 0 0 0 0
2 (26-50)
( Fair improvement ) 1 2.94 3 8.82
3 (51-75%)
(good improvement ) 4 11.76 19 5.88
4 (76-100%)
( excellent improvement)
2
9 85.29 12 5.29
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Figure 4.6 Patients’ self-assessment for TA 50 mg/ml and 4 mg/ml
Figure 4.6 and table 4.5 demonstrated the results of the patients’ self-
assessment which was evaluated by the patients themselves at week 16. The patients’
self-assessment of melasma improvement was graded in five scales: more than 75%
lightening (excellent); 51 to 75% (good); 26 to 50%; (fair); 1 to 25% (minimal); and
0% (no improvement). In the side treated with 50 mg/ml, the result showed that 29
from 34 patients (85.29%) scored the outcome as excellent improvement followed by
4 patients (11.76%) scored as good improvement and 1 (2.94%) scored as fair
improvement. On the other side of face with the intervention of TA 4 mg/ml, more
than half of the patients graded as good improvement (55.88%), 35.29% graded as
excellent improvement and 8.82 % graded as fair improvement.
Majority of the patients could observe the fading of the melasma
noticeably on the 50 mg/ml of TA side (85%) in comparison to the side treated with
4mg/ml (35%).
Ref. code: 25605929040458YKT
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0.00
0.50
1.00
1.50
2.00
2.50
3.00
Pain score Irritation Erythema Bruise Swelling PIH
TA 50 mg/ml TA 4 mg/ml
4.3.3 Side effect
Figure 4.7 Local side effects
Table4.6 Local side effect
TA 50 mg/ml TA 4 mg/ml Mean difference
(95%CI.)
P-value2
Pain score 1.99 (1.67, 2.3) 2.3 (2.03, 2.57) -0.32 (-0.65,
0.02) 0.067
Irritation 0.05 (0, 0.12) 0.04 (0, 0.11) 0.01 (-0.02, 0.05) 0.499
Erythema 1.77 (1.49, 2.06) 1.1 (0.88, 1.32) 0.67 (0.48, 0.87) <0.001*
Bruise 0.45 (0.32, 0.59) 0.53 (0.38, 0.68) -0.08 (-0.2, 0.04) 0.186
Swelling 2.4 (2.15, 2.65) 1.25 (1.08, 1.42) 1.15 (0.9, 1.4) <0.001*
PIH 0.04 (0, 0.08) 0.12 (0.01, 0.24) -0.08 (-0.16, 0) 0.055
Values presented as mean (95%CI.). P-value corresponds to Paired t test.
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Table4.7 Systemic side effect
In this study, we evaluated the side effects in every session of the
treatment including local side effect and systemic side effect as demonstrated in the
figure 4.7 and table 4.6 as local side effect and systemic side effect showed in Table
4.7. We asked the patients immediately after each treatment about the localized side
effects such as pain, itching, erythema and edema. For the bruise and post
inflammatory hyperpigmentation, the patients were asked whether they observed the
side effects after the previous treatment.
The systemic side effects such as abnormal menstruation (spotting,
delayed menstrual cycle, etc.), nausea and vomiting, headache and back pain after the
treatment were evaluated.
Concerning the local side effects, the results showed that the average pain
score is 1.99 (95%CI; 1.67-2.3) for the side treated with TA 50 mg/ml and 2.3
(95%CI; 2.03-2.57) for the side treated with TA 4 mg/ml. The pain score was higher
in the side treated with TA 4 mg/ml. however, there was no significant difference in
both side. (p> 0.05). As for the results of side effects such as erythema and swelling,
higher average scores were observed in the side treated with 50mg/ml as compared to
another side with the scores of 1.77 (95%CI; 1.49-2.06) and 2.4 (95%CI; 2.15-2.65),
respectively. For the side treated with TA 4 mg/ml, the scores were 1.1 (95%CI; 0.88-
0.68) and 1.25 (95%CI; 1.08- 1.42) for the erythema and swelling side effect
respectively. Moreover, the significant difference between these concentrations in
terms of unwanted effects such as erythema and swelling was observed stating that
50mg/ml of TA can cause more erythema and edema. In addition, other localized side
Systemic side effect
Before Incidence (%)
Number (No.)
Abnormal menstruation 2 0.009 (2/218) 2
Nausea&Vomiting 0 0.004 (1/218) 1
Headache 0 0.014 (3/218) 3
Backpain 2 0.009 (2/218) 2
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13.97
4.59
Before week 16
DLQI
effects such as itching, bruise and PIH, no significant difference between 2 regimens
of TA was noted.
Regarding systemic side effects, two patients had experienced a delayed
menstruation period for 1-2 weeks but only for 1 cycle after the first session of
treatment. The patients were asked more information about gynecologic problems.
They had irregular menstruation before the treatment which may be due to pre-
menopause. One of them did the annual gynecologic checkup which found
endometrium thickening but no further treatment was required. Another patient has
not done the check up yet. For other systemic side effects as shown in the table 4.7,
one patient had nausea and vomiting after the treatment only at week 4. Three
patients had headache and two patients had back pain after the treatment but no any
treatments were needed. All of the patients could tolerate the side effects and
completed the study. Although the systemic side effects such as abnormal
menstruation are unlikely, we still recommended that menstruation history be
obtained carefully in all female patients before treatment and that patients should be
advised accordingly about the adverse effects which might happen during the
treatment.
4.3.4 Dermatologic Quality of Life Index (DLQI)
Figure 4.8 Dermatologic quality of life Index
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Table 4.8 Dermatologic quality of life index (DLQI)
Before After Difference at week 16 p-value2
DLQI 13.97 (12.66, 15.28) 4.59 (3.7, 5.48) -9.38 (-10.72, -8.05) <0.001*
Values presented as mean (95%CI.). P-value corresponds to Paired t test.
The Dermatologic quality of life index for this study was described in
figure 4.8 and table 4.8. According to the table 7, it showed that mean score of DLQI
was 13.97 (95%CI; 12.66-15.28) and reduced to 4.59 (95%CI; 3.7-5.48) at week 16.
The statistics showed significant decrease in DLQI score between before and after the
treatment (p<0.001).
4.4 Discussion
This was the study of comparative effect of localized intradermal
microinjection in different concentration of tranexamic acid 50 mg/ml versus 4 mg/ml
for melasma treatment in Thai patients. It is a prospective randomized triple blinded
split face trial. The outcomes were measured by both objective and subjective
assessments. Objective assessment included the melanin level (the primary outcome)
and Hemoglobin level from the skin analysis camera (Antera3D®). The subjective
assessment included mMASI score which was evaluated by 2 dermatologists, both
local and systemic side effects which were evaluated at every visit, patients’ self-
assessment which was analyzed at the end of the study and the DLQI before and after
the study.
Since malasma is an acquired hyperpigmented skin disorder and
commonly found in different places around the world with prevalence varying from
5.9% to 35 %, Thailand is not an exception(56). Melasma has serious impact on
personal self-esteem not only physical appearance but also emotional aspect.
Although there are many treatments modalities for melasma, but the results of the
treatment are inconsistent with variable side effect and high recurrent rate. Nowadays
no treatment modality can achieve the patient’s satisfaction. Therefore, melasma is a
challenging disorder for the dermatologists.
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Tranexamic acid (TA), trans-4-aminomethycyclohexanecarboxylic acid, is
a hydrophilic agent. It is a plasmin inhibitor. It has been widely used clinically in
abnormal bleeding such as menorrhagia, excessive bleeding in trauma cases or in
operation room by inhibiting fibrinolysis. TA was commonly administrated via oral
or intravenous route with the dose of 1 to 1.5 g three to four times a day and 4 g/day
for 5 days, respectively, for a high dosage for menorrhagia(53). Recently, there was a
study showed the involvement of mechanism of action of TA involve in interaction of
melanocyte and keratinocyte by inhibiting plasminogen/plasmin system. And
decrease in melanin production. (57). Both fibroblast growth factor and
prostaglandins are potent stimulate of melanocyte activity(40).TA can prevent the
conversion of plasminogen to plasmin lead to decrease in number of fibroblast
growth factor and prostaglandins. Thereby diminish melanocyte activity and decrease
melanin production consequence(26)(47). Therefore, TA has been used as an
alternative treatment for melasma. In addition, TA was claimed to decrease allergy
and inflammation especially due to its ability to inhibit plasmin.
Nowadays, TA has been used widely for melasma treatment for its
promising result. TA was available in topical form, oral form and intradermal
injection form.
Kim et al(58), did the meta-analysis and systemic review about efficacy
and safety of tranexamic acid in melasma in different forms such as topical, oral, and
localized microinjection. The study revealed that the most effective option in
decreasing MASI score was the oral TA, followed by that with localized intradermal
micro injection of TA and topical TA, correspondingly. But no statistical difference
between 3 subgroups (oral, microinjection and topical) was observed. Oral
tranexamic acid was reported in many studies to be effective for melasma.
Unfortunately, the side effects remained as concern such as gastrointestinal
discomfort, headache, hypomenorrhea and spotting menstruation. The most potential
risk is systemic thromboembolism(59). On the other hand, the result outcome of
topical TA was still debatable. According to the study by Ebrahimi, et al(52), this
double- blinded split-face trial evaluated the efficacy and safety of 3% topical TA
twice a day compared with combined solution of 3% HQ plus 0.01% dexamethasone
for 12 weeks. Even through both interventions are effective in melasma treatment in
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term of lowering MASI score. But no significant difference was observed between
them. On the other hand, Kanechorn Na Ayuthaya P, et al(46) in 2012, demonstrated
the similar efficacy between 5% TA and vehicle in treatment of melasma.
In order to avoid the side effects caused by systemic administration of TA,
In this study, we comparatively by evaluated the efficacy of localized intradermal
microinjection in different concentrations of tranexamic acid 50 mg/ml versus 4
mg/ml by objective and subjective assessments such as melanin level and hemoglobin
level by Antera 3D®, mMASI by two dermatologists, local and systemic side effects
and patients’s self-assessment.
In this study, most of the patients have mixed-type melasma especially
distributed in malar area. The epidemiological study showed that the most common
factor for melasma in this study is sunlight (UV radiation, 64%) followed by
pregnancy (19%) and oral contraceptive pill (12%). As for the role of UV irradiation
in melasma , It stimulates melanogenesis both directly to melanocyte and indirectly to
keratinocyte by paracrine interaction between keratinocyte and melanocytes(13).
Recently there were many studies have been reported the efficacy and side
effects of localized TA intradermal microinjection. There was a pilot study in 2006,
lee, et al. (7), in which they evaluated the effectiveness of 4 mg/ml of TA in
localized intradermal microinjection weekly in melasma treatment for 12 weeks. It
was a prospective opened label study. The significant decreased in MASI score was
noted in week 8 and week 12 from the baseline. In 2009, Steiner, et al.(53) Performed
a comparative study which evaluated the efficacy and safety between topical 3% TA
(twice a day) and 4 mg/ml TA intradermal microinjection administrated weekly for
12 weeks. Seventeen patients completed the study. The significant improvement in
both groups was shown at the end of the study but there was no significant different
between these two modalities. In 2013, a study by Budamakuntla et al.(1),
demonstrated the comparative study evaluated efficacy and safety of microinjection
of TA versus microneedling of TA in melasma treatment. The study was done in
Kamatake India. Thirty patients in group A administrated with 4 mg/ml localized
intradermal microinjection of TA and another 30 patients in group B were treated
with microneeding in the same concentration of TA. The treatments were performed
monthly interval at baseline, week 4, week 8, and 3 months follow up after the end of
Ref. code: 25605929040458YKT
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the treatment. The significant decrease in MASI score was noted in both groups.
Although the MASI score in microneedling TA group showed superior to other
group, but there was no significant difference between both groups. Lately, there was
a split-face controlled trial study in 2017, by Saki, et al.(54), which compared the
efficacy of topical 2% HQ versus 20 mg/ml TA intradermal microinjection.
According to the methodology of the study, one of the face was treated with TA
intradermal injection one session per month for altogether 3 sessions and topical 2%
HQ on the other side of face once a night for three months. The results showed
monthly TA injection was superior to topical 2 % HQ in decreasing melanin value in
the first 4 weeks, however, there was no significant difference between both groups
after the end of the study. As for the result, the study assumed that prolonged
treatment duration could lead to better improvement in fading melasma. Moreover,
the study showed TA microinjection can achieve the good result within a short period
of time comparing to the topical HQ.
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Table 4.9 Studies of the injection of tranexamic acid for the treatment of melasma
This clinical trial found out that although, there was significant decrease
in mMASI score by both of regimens since week 4 but superior efficacy of TA 50
mg/ml in reduction of MASI score was observed comparing to 4 mg/ml (34% versus
25 %). Furthermore, there was a significant difference decreasing in mMASI score
since week 4. According to the melanin level detected by Antera3D®, the results
showed the same outcome as mMASI score. It showed that the result of the side
treated with 50 mg/ml TA was significant since week 4 (p<0.05) and the melanin
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reduced almost 13 % from the baseline. On the other hand, for the 4 mg/ml TA side,
the significant decrease in melanin level started at week 8 and there is a reduction in
melanin level approximately 5 % from the baseline. Baseline melanin level and
mMASI score for both sides of the face showed no any significant. Hence, in this
study we suggested that the higher concentration of TA may have more effectiveness
and shorter onset of action in diminished the melanocyte activation and melanin
production. As state by Seong, et al.(12), in 2007, they evaluated the influence of TA
in different dosages on the melanocytes activity, viability, and melanogenesis from
cultured normal human melanocytes. The consequence showed that there was a
statistically significant decrease in melanocyte viability and melanin production by
TA in a dose dependent manner. According to table 10, Saki, et al(54) stated that the
melanin level after 20 mg/ml TA intradermal microinjection was 5.6 % and 6.44%
improvement at week 8 and at 3 month follow up, respectively. In our study, the
melanin level after 50 mg/ml TA injection was 8.35% and 13% improvement and for
4 mg/ml TA intradermal microinjection was 2.26 % and 5.11 % improvement at week
8 and 1 month follow up, respectively. It appears that TA for intradermal
microinjection was dose dependent. In addition to the dose dependent nature of TA,
longer durations of the treatment can achieve a better result in melanin reduction and
fading of the hyperpigmented lesion.
Recently there were studies demonstrated about vascularity increasing in
melasma pathogenesis. Kim, et al.,(43) reported about the vascular characteristics of
melasma in 2006. The result showed that the erythema intensity was higher in
melasma lesion when compared with peri-normal skin. Moreover, the result from the
computer-assisted image analyzed of factor VIIIa-related antigen-stained sections
also noted the significant increase in number and size of dermal blood vessel. The
study suggested that there could be angiogenesis in melasma lesion. Concerning the
vascular endothelial growth factor (VEGF), the area with melasma showed higher
expression from keratinocytes in comparison with peri-normal skin(60). There were
reports suggested that the effectiveness of TA can diminish the erythema in melasma
skin by diminishing number of vessels and number and activity of mast
cell(47)(61)(62). TA as a plasmin inhibitor, can not only inhibit the angiogenesis but
also arrest basic fibroblast growth factor (bFGF) inducing neovascularization
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(63)(64). In melasma lesion, the mast cells were proliferated in the dermis more than
normal skin. Chronic UV irradiation induced mast cell up-regulation. Mast cells can
induce vascular proliferation through secreting angiogenic factors for example VEGF,
FGF-2 and transforming growth factor-β(65). In our study, we measured the vascular
intensity in term the hemoglobin level by using Antera3D®, there was significant
decrease in Hb level at week 8 in both side of the face however but no significant
difference between 2 regimens were observed.
The mean dose of TA injection in our study was 150- 200 mg which is
lower than the usual dose for antifibrinolytic effect(53). Therefore, in this study, no
significant systemic side effect was observed. Three patients reported delayed
menstruation but after asking for more information, two of them have this experience
before the study due to pre-menopause. One of them had just stopped OCP for 2
months before the study.
Concerning for the local side effect between 2 concentrations, erythema
and swelling were significance observed on TA 50 mg/ml side. However, theses side
effects disappeared in 2 hours after the injection. For other local side effects, for
example pain, irritation, bruise and PIH, the result showed no significant difference
between 2 regimens. All side effects were minimal. All patients could tolerate and
completed the study.
Regarding the patients’ self-assessment and dermatological quality of life
index, it was found out that the majority of patients preferred the side treated with TA
50 mg/ml more than the other side (85% versus 35%) stating that they could observe
the fading of melasma faster and more noticeably on the 50 mg/ml of TA side when
compared to the side treated with 4 mg/ml. As for the dermatological quality of life
index, it was evaluated at the end of the study (week 16). There was a significant
difference between before and after the study. It showed that most of the patients
were satisfied with the result of intradermal microinjection of TA in melasma.
The fact that Thailand is located near the equator means that the sunlight
is very strong even though the study period was not conducted during the summer
season. Sunlight is the greatest triggering factor and can interfere with the treatment.
Another drawback of this present study was the improper usage of sunscreen. Most
patients applied the sunscreen in inadequate portions and only occasionally. Also, the
Ref. code: 25605929040458YKT
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short follow up period after the treatment might not detect the noticeable recurrence
of the hyperpigmented lesion. Future studies should keep an eye on the earlier
mentioned points to achieve a more accurate result.
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CHAPTER 5
CONCLUSIONS AND RECOMMENDATIONS
5.1 Conclusion
According to this study, it was a prospective, randomized, triple blinded,
split-face trial study. We evaluated the efficacy and side effect of intradermal
microinjection of 50 mg/ml TA versus 4 mg/ml TA in melasma treatment. As for the
methodology, two concentrations of TA intradermal microinjection were randomized
in to different sides of the face. The injection administrated every 2 weeks for 12
weeks. The patients came to follow up at week 4, 8, 12, and 1-month after the end of
the treatment in order to evaluate the outcome of the treatment. According to the
results of this study, it was found out that the efficacy of localized TA intradermal
microinjection could improve the melasma without significant side effects. The side
treated with 50 mg/ml could decrease mMASI score and melanin level significantly.
Moreover, the side treated with 50 ml/ml could achieve better result in term of fading
of pigmentation within shorter period of time comparing to 4 mg/ml TA. Regarding
the recurrence of the pigmentation of melasma at the end of the follow up showed that
the mMASI score and melanin level had continuously decreased as shown in the table
4.4 and 4.2, respectively, on both side of the faces.
With regard to local side effects, although there was more redness and
swelling had been observe on the side treated with 50 mg/ml TA comparing to the
side treated with 4 mg/ml but the pain score, irritation, erythema, bruise, and PIH
were no significant difference between 2 concentrations. These kind of local side
effect were tolerable by all patients. About for the systemic side effects, we cannot
evaluate separately for 50 mg/ml TA and 4 mg/ml TA because of this was an intra-
individual study.
Last least, the patients’self-assessment score which evaluated by the
patients themselves at the end of the study showed that the majority of the patients
were satisfied with the outcome of 50 mg/ml TA intradermal microinjection for
melasma treatment. Even though there were some patients preferred 4 mg/ml TA.
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TA 50 mg/ml intradermal microinjection not only showed significant
decrease in mMASI score and melanin level but also showed the fading of
pigmentation was seen earlier when compared with the other side. Therefore, we can
assume that TA was a dose dependent for intradermal microinjection modality. Fifty
mg/ml TA appeared to be promising therapeutic option for melasma.
5.2 Recommendations
- A further study using TA with drug delivery system could be used in
order to achieve better results and with less pain.
- A further study with a longer follow up period after the treatment could
be done in order to observe any rebounding of hyperpigmentation clearly.
- A further study prospective double-blind split-face study for topical HQ
with 50 mg/ml TA intradermal microinjection versus 50 mg/ml TA intradermal
injection only should be performed in order to evaluate the efficacy and safety of TA
intradermal microinjection with HQ and whether it may achieve the better result.
5.3 Limitation
- The limitations of this study are the sunlight and patients’ activities,
patients’ compliance and sunscreen applying habit.
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APPENDICES
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APPENDIX A
MELANIN LEVEL ASSESSMENT
TA 50 mg/ml TA 4 mg/ml
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16 1
1 0.72 0.725 0.689 0.623 0.622 1 0.666 0.7 0.658 0.664 0.645
1
2 0.773 0.698 0.624 0.594 0.59
2
2 0.69 0.676 0.69 0.662 0.601
1
3 0.715 0.678 0.634 0.615 0.585
3
3 0.67 0.655 0.654 0.625 0.638
1
4 0.824 0.714 0.684 0.628 0.637
4
4 0.652 0.686 0.652 0.624 0.609
1
5 0.728 0.704 0.694 0.629 0.626
5
5 0.75 0.749 0.703 0.686 0.696
1
6 0.527 0.513 0.512 0.501 0.55
6
6 0.55 0.541 0.538 0.535 0.535
1
7 0.692 0.639 0.609 0.601 0.617
7
7 0.732 0.696 0.677 0.682 0.674
1
8 0.756 0.68 0.669 0.647 0.619
8
8 0.702 0.7 0.658 0.643 0.65
1
9 0.623 0.58 0.505 0.487 0.498
9
9 0.573 0.568 0.553 0.545
0
.537
1
10 0.831 0.802 0.75 0.694 0.684
1
10 0.768 0.739 0.737 0.726 0.734
2
11 0.699 0.717 0.677 0.678 0.688
1
11 0.758 0.699 0.669 0.657 0.662
2
12 0.704 0.688 0.626 0.624 0.647
1
12 0.7 0.69 0.684 0.731 0.729
2
13 0.71 0.626 0.572 0.568 0.581
1
13 0.65 0.63 0.623 0.624 0.579
2
14 0.69 0.666 0.603 0.576 0.564
1
14 0.67
0
.667 0.665 0.63 0.642
2
15 0.707 0.68 0.654 0.63 0.628
1
15 0.689 0.673 0.668 0.647 0.639
2
16 0.583 0.535 0.53 0.487 0.501
1
16 0.486 0.466 0.435 0.449 0.447
1
17 0.769 0.665 0.682 0.663 0.67
1
17 0.724 0.709 0.716 0.707 0.69
18 0.65 0.609 0.615 0.59 0.564
1
18 0.706 0.662 0.662 0.66 0.655
Ref. code: 25605929040458YKT
70
TA 50 mg/ml TA 4 mg/ml
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
1
19 0.718 0.677 0.661 0.634 0.615
1
19 0.697 0.702 0.683 0.655 0.627
2
20 0.693 0.681 0.645 0.615 0.593
2
20 0.514 0.596 0.588 0.578 0.587
2
21 0.699 0.66 0.652 0.608 0.606
2
21 0.625 0.61 0.613 0.604 0.612
2
22 0.687 0.689 0.658 0.616 0.638
2
22 0.622 0.627 0.638 0.604 0.607
2
23 0.716 0.712 0.706 0.664 0.678
2
23 0.693 0.682 0.688 0.682 0.683
2
24 0.672 0.654 0.621 0.616 0.618
2
24 0.614 0.613 0.622 0.619 0.592
2
25 0.661 0.678 0.659 0.618 0.603
2
25 0.754 0.732 0.734 0.753 0.763
2
26 0.544 0.527 0.501 0.476 0.463
2
26 0.547 0.553 0.578 0.544 0.535
2
27 0.69 0.651 0.659 0.637 0.647
2
27 0.667 0.7 0.646 0.641 0.661
2
28
-
-
-
--
-
-
-
-
-
-
2
28 - - - - -
2
29 0.623 0.623 0.6 0.565 0.521
2
29 0.654 0.628 0.659 0.612 0.592
3
30 0.718 0.693 0.659 0.655 0.649
3
30 0.646 0.634 0.659 0.653 0.638
3
31 0.733 0.652 0.625 0.616 0.61
3
31 0.684 0.68 0.677 0.642 0.594
3
32 0.685 0.731 0.685 0.638 0.627
3
32 0.694 0.673 0.648 0.638 0.641
3
33 0.607 0.614 0.62 0.59 0.545
3
33 0.656 0.657 0.68 0.668 0.643
3
34 0.694 0.688 0.683 0.637 0.634
3
34 0.649 0.598 0.613 0.604 0.592
35 0.771 0.713 0.678 0.66
0
.64
3
35 0.761 0.753 0.736 0.725 0.72
Ref. code: 25605929040458YKT
71
APPENDIX B
Hemoglobin level
TA 50 mg/ml TA 4 mg/ml
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
1
1
1
1.961
1
1.807
1
1.557
1
1.546
1
1.1593
1
1
1
1.919
1
1.828
1
1.758
1
1.693
1
1.919
2
2
1
1.829
1
1.693
1
1.762
1
1.727
1
1.689
2
2
1
1.555
1
1.683
1
1.575
1
1.638
1
1.555
3
3
1
1.664
1
1.703
1
1.641
1
1.728
1
1.542
2
3
1
1.723
1
1.64
1
1.599
1
1.658
1
1.723
4
4
1
1.632
1
1.779
1
1.685
1
1.51
1
1.628
2
4
1
1.595
1
1.648
1
1.655
1
1.493
1
1.595
5
5
1
1.436
1
1.431
1
1.438
1
1.412
1
1.458
2
5
1
1.442
1
1.483
1
1.446
1
1.412
1
1.442
6
6
1
1.742
1
1.439
1
1.472
1
1.337
1
1.511
2
6
1
1.655
1
1.335
1
1.377
1
1.384
1
1.655
7
7
1
1.742
1
1.731
1
1.708
1
1.673
1
1.751
2
7
1
1.76
1
1.783
1
1.736
1
1.738
1
1.76
8
8
1
1.722
1
1.557
1
1.419
1
1.609
1
1.566
2
8
1
1.695
1
1.613
1
1.649
1
1.625
1
1.695
0
9
1
1.703
1
1.614
1
1.672
1
1.585
1
1.777
2
9
1
1.846
1
1.792
1
1.591
1
1.654
1
1.846
1
10
2
2
1
1.966
1
1.654
1
1.677
1
1.82
1
10
1
2.143
1
2.065
1
1.819
1
1.937
1
2.143
1
11
1
1.651
2
2.373
1
2.005
1
2.084
1
1.775
2
11
2
2.308
1
1.993
1
1.92
1
1.813
1
2.308
1
12
1
1.33
2
1.245
2
1.335
2
1.337
2
1.264
3
12
1
1.629
1
1.667
1
1.85
1
1.849
1
1.629
1
13
1
1.869
1
1.574
1
1.651
1
1.585
1
1.707
3
13
1
1.678
1
1.623
1
1.659
1
1.492
1
1.678
1
14
1
1.99
2
2.031
1
1.862
1
1.782
1
1.681
3
14
1
1.722
1
1.738
1
1.658
1
1.578
1
1.722
1
15
1
1.79
1
1.743
1
1.789
1
1.587
1
1.779
3
15
1
1.734
1
1.692
1
1.792
1
1.704
1
1.734
1
16
1
1.547
1
1.546
1
1.628
1
1.417
1
1.395
3
16
1
1.569
1
1.642
1
1.563
1
1.534
1
1.569
1
17
1
1.607
1
1.506
1
1.475
1
1.429
1
1.45
3
17
1
1.541
1
1.472
1
1.421
1
1.424
1
1.541
Ref. code: 25605929040458YKT
72
TA 50 mg/ml TA 4 mg/ml
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
1
18
1
1.631
1
1.479
1
1.595
1
1.519
1
1.684
1
18
1
1.776
1
1.749
1
1.69
1
1.596
1
1.776
2
19
2
2.188
2
2.148
2
2.025
1
1.981
1
1.936
2
19
2
2.252
2
2
2.144
2
2.282
2
2.252
3
20
1
1.469
1
1.449
1
1.496
1
1.483
1
1.452
2
20
1
1.435
2
1
1.335
1
1.294
1
1.435
4
21
1
1.875
1
1.583
1
1.747
1
1.609
1
1.628
2
21
1
1.806
1
1.584
1
1.579
1
1.619
1
1.806
5
22
1
1.447
1
1.227
1
1.303
1
1.366
1
1.4
2
22
1
1.618
1
1.589
1
1.57
1
1.552
1
1.618
6
23
1
1.919
1
1.837
2
2.002
2
2.089
1
1.869
2
23
1
1.871
1
1.906
1
1.885
1
1.804
1
1.871
7
24
1
1.674
1
1.735
1
1.792
1
1.786
1
1.675
2
24
1
1.52
1
1.542
1
1.633
1
1.621
1
1.52
8
25
2
2.146
2
2.127
1
1.93
1
1.861
1
1.023
2
25
1
1.909
1
1.866
1
1.72
1
1.631
1
1.909
0
26
1
1.651
1
1.511
1
1.51
1
1.62
1
1.561
2
26
1
1.625
1
1.559
1
1.6
1
1.665
1
1.625
1
27
1
1.7
1
1.633
1
1.623
1
1.625
1
1.62
2
27
1
1.592
1
1.5
1.502
1.479
1.592
1
28
1
- - - - -
2
28
0
- - 0
1
29
1
1.749
1
1.645
1
1.613
1
1.672
1
1.726
3
29
1
1.439
1
1.32
1
1.218
1
1.363
1
1.376
1
30
1
1.8
1
1.813
1
1.762
1
1.699
1
1.748
3
30
1
1.745
1
1.917
1
1.844
1
1.629
1
1.793
1
31
1
1.59
1
1.795
1
1.833
1
1.79
1
1.824
3
31
1
1.459
1
1.488
1
1.577
1
1.483
1
1.551
1
32
1
1.777
1
1.645
1
1.71
1
1.631
1
1.591
3
32
1
1.53
1
1.55
1
1.551
1
1.485
1
1.461
1
33
1
1.918
1
1.932
1
1.752
1
1.768
1
1.855
3
33
1
1.834
1
1.707
1
1.626
1
1.673
1
1.747
1
34
1
1.693
1
1.729
1
1.671
1
1.634
1
1.981
3
34
1
1.775
1
1.632
1
1.504
1
1.589
1
1.876
3
35
1
1.497
1
1.365
1.387
1.365
1.414
3
35
1
1.871
1
1.826
1
1.905
1
1.731
1
1.908
Ref. code: 25605929040458YKT
73
APPENDIX C
modified MASI score
TA 50 mg/ml TA 4 mg/ml
Subj wk0 Wk4 Wk8 Wk12 Wk16 Subj Wk0 Wk4 Wk8 Wk12 Wk16
1 1.8 1.2 1.2 0.9 1.2 1 1.8 1.8 1.8 1.2 0.6
2 2.4 2.1 2.1 1.8 1.2 2 2.4 2.1 2.4 1.8 0.6
3 3.6 2.7 1.2 1.2 0.6 3 3.6 3 3 2.1 2.7
4 2.7 2.7 2.7 2.1 2.4 4 1.8 2.4 1.8 1.2 0.6
5 2.7 2.4 2.1 1.2 0.9 5 1.8 1.8 1.2 0.9 1.2
6 1.2 1.2 1.8 0.9 1.2 6 3 2.7 2.4 2.4 2.4
7 2.7 2.7 2.4 2.1 2.7 7 2.7 2.4 2.1 2.4 1.8
8 0.9 0.6 0.3 0.3 0.3 8 1.8 1.8 0.9 0.6 0.9
9 3.6 3 3.6 2.7 2.4 9 4.5 4.5 4.2 3.6 3
10 3 2.4 1.8 1.2 1.2 10 4.5 3 2.7 2.7 3
11 2.7 1.8 2.7 1.8 1.8 11 2.7 2.4 2.1 1.8 2.1
12 1.2 1.8 2.4 2.4 1.8 12 1.8 1.8 1.8 2.1 2.1
13 2.7 2.7 2.4 1.8 2.4 13 2.7 2.4 2.4 2.4 1.8
14 4.5 3.6 2.7 2.4 2.4 14 4.5 4.5 3.6 3.6 3.6
15 3.6 3 2.7 2.4 2.4 15 4.5 4.5 3.9 3.9 3
16 1.8 0.9 1.2 1.8 1.8 16 2.1 1.8 1.2 1.8 1.8
17 3 2.7 2.1 2.1 2.4 17 3.6 3 3.6 3 2.7
Ref. code: 25605929040458YKT
74
TA 50 mg/ml TA 4 mg/ml
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
S
Subj.
W
wk0
W
wk4
Wk8
Wk12
Wk16
18 2.1 1.8 2.4 2.1 1.8 18 2.7 2.4 2.4 2.4 1.8
19 4.5 3.6 3 2.7 2.7 19 4.8 4.8 4.5 4.2 3
20 3.6 3 2.7 2.4 2.1 20 3.6 3.6 3.6 3 3.6
21 2.4 3 2.4 2.4 2.1 21 2.4 2.1 2.1 1.8 2.1
22 3.6 3.6 2.7 2.4 2.1 22 3.6 3.9 4.5 3 3
23 3.6 2.7 3 2.7 2.4 23 4.5 3.6 3.6 3.6 3.6
24 1.8 2.7 2.4 2.4 2.1 24 3.6 3.6 4.2 4.2 3.6
25 4.5 4.5 3.6 3.6 3.6 25 4.5 3.6 3.6 4.5 4.8
26 1.8 1.8 2.4 2.1 1.8 26 1.8 2.1 2.7 1.8 1.2
27 3.6 3 2.7 2.4 3 27 4.5 4.8 4.2 4.2 4.5
28 - - - - 28 - 0
29 1.8 1.2 0.6 0.6 0.6 29 1.8 1.2 1.8 0.9 0.6
30 3.6 2.4 2.1 1.2 1.8 30 4.5 3.6 4.8 4.8 3.6
31 2.7 1.2 1.2 1.2 1.2 31 3.6 3.6 3.6 2.7 2.4
32 4.5 3.6 2.7 2.7 2.4 32 4.5 3.6 3 2.7 2.7
33 3 2.7 2.4 2.1 2.1 33 3.6 3.6 3.6 3 2.7
34 3.6 3.6 2.7 2.7 3 34 3.6 2.7 3 3 2.7
35 3 1.8 1.8 1.2 0.6 35 3.6 3.6 3 2.7 2.7
Ref. code: 25605929040458YKT
75
APPENDIX D
DIGITAL IMAGE OF SUBJECTS
Figure5.1 Photograph and melanin level of subject 1 showing intradermal
microinjection of 4 mg/ml TA
micron injection of 4 mg/ml TA
Figure 5.2 Photograph and melanin level of subject 1 showing intradermal
micron injection of 50 mg/ml TA
Ref. code: 25605929040458YKT
76
Figure 5.3 Photograph and melanin level of subject 2 showing intradermal micro
injection of 4 mg/ml TA
Figure 5.4 Photograph and melanin level of subject 2 showing intradermal micro
injectioninjection of 50 mg/ml
Ref. code: 25605929040458YKT
77
Figure 5.5 Photograph and melanin level of subject 3 showing intradermal micron
injection of 4 mg/ml TA
Figure 5.6 Photograph and melanin level of subject 3 showing intradermal micron
injection of 50 mg/ml TA
Ref. code: 25605929040458YKT
78
Figure 5.7 Photograph and melanin level of subject 4 showing intradermal micron
injection of 50 mg/ml TA
Figure 5.8 Photograph and melanin level of subject 4 showing intradermal micron
injection of 4 mg/ml TA
Ref. code: 25605929040458YKT
79
APPENDICES E
PATIENT RECORD FORM
แบบบนทกขอมลท ำกำรวจย
เรอง การศกษาเปรยบเทยบประสทธภาพของการรกษาฝาโดยการใชยา tranexamic acid
ฉดเขาใตผวหนง
เลขทแบบบนทกขอมล………………………
ขอมลทวไปของผปวย ( patient demographic information)
เฉพาะเจาหนาท
1. วน/เดอน/ป
2. ชอ/นามสกล
3. ทอย /เบอรโทรศพท
4. เพศ………….
5. อาย………….
6. อาชพ ……… 1. ขาราชการและวสาหกจ ……..2. พนกงาน
……… 3. แมบาน ………4. นกเรยน/นกศกษา
……… 5. กจการสวนตว ………6. คาขาย
……… 7. อน ๆ
7. สบบหร สบ................. ............ ไมสบ
8. ดมแอลกอฮอล ดม................. ไมดม............
9. โรคประจ าตว............................................
10. ยาททานประจ า รวมถงวตามน...............................................
11. ประจ าเดอน .................มาตามปกต หมดประจ าเดอน...............
Ref. code: 25605929040458YKT
80
12. แพยา/แพอาหาร.....................................................................
13. ระยะเวลาทเปนฝา ……………………………….
14. ประวตคนในครอบครวทเปนฝา ………1. ม ………2. ไมม
15. ปจจยกระตนทท าเกดฝา
……… 1. ตงครรภ ……..2. การไดรบฮอรโมน
……… 3. การไดรบแสงแดด ………4. การใชเครองส าอางค
………5. ยากนชก ………6. ยาทมปฎกรยากบแสง
16. ผลของฝาทกระทบความกงวลในจตใจ 1. ไมรสก 2. รสกเสยความมนใจเลกนอย
3. รสกเสยความมนใจปานกลาง 4.รสกเสยความมนใจมาก 5. รสกเสยความ
มนใจมากทสด
17. ประวตการรกษาทเคยไดรบมากอน ………..1. เคย ………..2. ไมเคย
18. จ าแนกชนดของสผวตาม skin type 1.………2. ………3.………4. ………5…….
Ref. code: 25605929040458YKT
81
แบบสอบถำม
Pain score
ขวำ
ขวำ
ซำย
0 = ไมปวด/เจบ
1-3 = เจบเลกนอย
4-6 = เจบปานกลาง (ยงสามารถท ากจวตรประจ าวนไดตามปกต)
7-10 = เจบมาก (ไมสามารถท ากจวตรประจ าวนได)
Ref. code: 25605929040458YKT
82
ผลขำงเคยง
ขวำ
ประเมนผลขางเคยง: โดยผปวย ……..1. ม ……..2. ไมม
ผลขางเคยง
ไมมเลย
นอยมาก
(2)
คอนขางนอย
(3)
ปานกลาง
(4)
คอนขางมาก
(5)
มากทสด
(6)
แสบรอน,คน
(irritation)
แดง
อาการช า
บรเวณทฉด เขม
ขน
Ref. code: 25605929040458YKT
83
ซำย
ประเมนผลขางเคยง: โดยผปวย ……..1. ม ……..2. ไมม
ผลขางเคยง
ไมมเลย
นอยมาก
(2)
คอนขางนอย
(3)
ปานกลาง
(4)
คอนขางมาก
(5)
มากทสด
(6)
แสบรอน,คน
(irritation)
แดง
อาการช า
บรเวณทฉด
เขมขน
Ref. code: 25605929040458YKT
84
ผลขางเคยงภายใน ม ไมม
ประจ าเดอนมาผดปกต
คลนไสอาเจยน
ปวดศรษะ
ปวดหลง
Ref. code: 25605929040458YKT
85
ความพง
พอใจจากก
ารรกษาโดยรวม
ไม
เปลยนแปลง
(0)
ดขนเลกนอย
(1)
Slightly
improvement
(0-25%)
พอใจ
(2)
Fair
improvement
(26-50%)
พอใจมาก
(3)
Good
improvement
(51-75%)
พอใจมากทสด
(4)
Excellent
improvement
(>75%)
Ref. code: 25605929040458YKT
86
BIOGRAPHY
Name
Miss Prapalpitch Wongwicharn
Date of Birth August 31, 1988
Educational Attainment 2016-present: Master of Science (dermatology)
Chulabhorn International College of Medicine,
Thammasat University
2008-2013: Doctor of medicine, Mahidol
University
Work Experience
Publication
Award
2014-2016: Medical Doctor, Practitioner Level
U-thong Hospital
2013-2014: Chao Phraya Yom Marat Hospital
None
None
Ref. code: 25605929040458YKT