Tranexamic acid

Tranexamic acid works by blocking plasmin, an enzyme that ultraviolet light switches on in the skin. Plasmin carries the message that tells pigment cells to produce more melanin, so blocking it stops the instruction before it is sent. This is why Tranexamic acid is useful for tackling melasma and sun spots. In the UK, topical Tranexamic acid is sold over the counter and no licensed topical product exists. It is also available in prescription-strength and combined formulas. At City Skin Clinic, your doctor may prescribe Tranexamic acid alongside other actives, in a cream or gel compounded for you, at a strength and protocol to suit your skin.

What Is Tranexamic Acid and How Does It Work?

Tranexamic acid is a synthetic derivative of the amino acid lysine, developed in the 1960s to control heavy bleeding and still licensed in the UK for that purpose. Its use on the skin came later, and it is now used mainly for melasma and other pigmentation that keeps returning.

Ultraviolet light releases plasmin in the surface layers of the skin, and plasmin carries the message telling pigment cells to make more melanin. Tranexamic acid blocks plasmin, so the message is never sent. This is a different step from Hydroquinone and Azelaic acid, which slow the enzyme that builds melanin further down the line. Plasmin also feeds the small blood vessels supplying a melasma patch, so blocking it reduces the vessel changes as well as the pigment. The pathway is switched on by ultraviolet light, which is why Tranexamic acid is used for sun-driven and hormonal pigmentation rather than as a general lightener. Tranexamic acid is used for:

• Melasma: the hormonally driven brown patches on the cheeks, forehead and upper lip. This is where Tranexamic acid is most used, because it acts on both the pigment and the vessel changes that make melasma relapse.
• Hyperpigmentation and dark spots: general hyperpigmentation, including sun spots and age spots built up over years of UV exposure.
  Post-inflammatory hyperpigmentation: the marks left behind after acne or inflammation, where it performs comparably to Azelaic acid in clinical studies.
• Redness alongside pigment: an anti-inflammatory action that helps where flushing and discolouration sit together, as they often do in melasma.

How City Skin Clinic Uses Tranexamic Acid

We use Tranexamic acid in our pigment treatments, as a cream or a gel, almost always alongside other actives. Your doctor sets the strength and the pairings around your skin, your history and what you want to change. The treatments we may use it in are:

• Melasma
• Hyperpigmentation
• Skin Ageing

Tranexamic acid is rarely the only active in a formula. Because it works at a different step from the actives that block the melanin-making enzyme, it combines with them rather than competing. Your doctor may pair it with one or more of the following:

• Hydroquinone: the strongest pigment suppressor we use. It blocks the enzyme whilst Tranexamic acid quietens the signal, and it is prescribed in limited courses with breaks.
• Tretinoin: speeds up cell turnover, so pigment already in the surface cells clears faster.
• Azelaic acid: competes with the enzyme that makes melanin and calms the inflammation that drives pigment production.
• Niacinamide: slows the handover of pigment into surface skin cells and supports the barrier alongside stronger actives.
• Hydrocortisone: a mild steroid added to some melasma and hyperpigmentation formulas to reduce inflammation.

How Do You Get Tranexamic Acid Treatment in the UK?

No topical Tranexamic acid product holds a UK licence, and the ingredient itself is not prescription only, so there are two routes for your skin. Over the counter it is a cosmetic ingredient, sold in serums, gels and creams, and for mild unevenness that is often enough. The second is a compounded formula, which is an unlicensed prescription treatment made individually for each patient by a specialist pharmacy. Your doctor sets the strength, adds the other actives your skin needs and chooses a cream or a gel. Tranexamic acid also exists as a tablet, which is licensed for heavy bleeding rather than for pigmentation. However, it is sometimes used off-label for melasma. We treat skin with topical formulas only and do not prescribe oral Tranexamic acid, so you would need to see a GP or a dermatologist if you wish to explore this option.

To access our custom skin treatments, you will need to complete the online consultation form or book a virtual video consultation with one of our doctors first. Your doctor will assess your skin, design a formula around what it needs and look after you afterwards. The same doctor stays with you, adjusts the treatment course by course and answers your questions by email.

There is no subscription and no auto-renewal. Each course is a single order you place yourself.

Over the Counter or Compounded Tranexamic Acid

There is no licensed topical product to sit between the two routes, so the choice is a cosmetic product or a compounded formula. A compounded formula is worth considering when one active has not settled the problem or when what you are treating needs actives that are not sold over the counter.

How Effective Is Tranexamic Acid?

Topical Tranexamic acid matches Hydroquinone and Azelaic acid in some head-to-head trials over 12 weeks. However, it has not been shown to beat either. Matching them still matters, because Hydroquinone is the benchmark for pigment and is prescribed in limited courses with breaks. An active that holds similar ground and can be used continuously has a real role between those courses.

In the Hydroquinone trial, no side effects were recorded in the Tranexamic acid group against 10% reporting redness and irritation on Hydroquinone. That difference did not reach statistical significance but patient satisfaction did, at 33% against 7%. Three limits are worth stating plainly though. The trials are small, at around 60 patients each. The Hydroquinone comparison used 2%, which sits below the strength usually prescribed for stubborn melasma, so it does not show how Tranexamic acid performs against Hydroquinone at full strength. And some trials of topical Tranexamic acid used on its own have found no clear benefit over 12 weeks.

Where it performs consistently is alongside another active. A serum combining 3% Tranexamic acid with kojic acid and 5% Niacinamide reduced pigment measurements at 12 weeks. A formula combining 2% Tranexamic acid with 2% Niacinamide did the same at four and eight weeks against a plain base. That is also how it is prescribed here.

People may see a first visible change as early as four to eight weeks, with the fuller effect over months, but results vary. Melasma also relapses without daily sun protection, whichever active is used. It can also come back even when sun protection is strict.

What Strengths Does Tranexamic Acid Come In?

Over the counter, most Tranexamic acid products sit between 2% and 5%, usually in a serum. The published trials sit in a similar range. The head-to-head against Hydroquinone used 5%. The combination studies used 2% and 3% alongside other actives. Higher strengths have been trialled, but no published comparison shows that going higher works better.

In a compounded formula the strength depends on what else is going into the cream or gel, what is being treated and how your skin behaves. Your doctor will aim for the strength you can use consistently without irritation, which matters more than the number.

What Are the Side Effects of Tranexamic Acid?

The most common side effects of Tranexamic acid are dryness, redness, flaking and mild stinging where you apply it. They are local rather than systemic, and serious reactions are rare.

• Dryness, redness or flaking: where you apply it, most likely in the first few weeks.
• Mild stinging or itching: on application, and usually brief.

In the trial against Hydroquinone no side effects were recorded in the Tranexamic acid group at all. If your skin does get dry or irritated, dropping to once a day is usually enough. Tell your doctor either way, because it may mean the formula wants adjusting. Follow-up is free.

Two things are worth separating by route. Lightening of the surrounding skin is not among the reported side effects of topical Tranexamic acid, though it is reported when Tranexamic acid is injected. Your doctor may still direct you to apply it to the affected areas rather than across the whole face. The clotting effects associated with Tranexamic acid come from tablets and injections, where the whole body is exposed to it. In trials of topical Tranexamic acid the side effects reported have been local rather than systemic. Those trials were small but tell your doctor your full medical history and they will advise you. Whilst allergic reactions are rare, they can still happen. Stop and seek advice if you get swelling of the face or eyes, a rash beyond the application site or any difficulty breathing.

Who Should Not Use Tranexamic Acid?

Tranexamic acid suits most people, including those with sensitive skin. There are, however, a few situations that need extra care and some that rule it out:

• Allergy to Tranexamic acid or any ingredient in the formula: an outright reason not to use it.
• A history of blood clots or a clotting disorder: the concern comes from oral and injected Tranexamic acid rather than from a cream, and absorption through the skin is low. Tell your doctor anyway, so they can help you risk assess and make the safest decision.
• Broken or inflamed skin: wait until it has settled, and keep it away from the eyes, lips and nostrils.
• Pregnancy and breastfeeding: Tranexamic acid is generally best avoided during pregnancy and breastfeeding. This is a precaution rather than a known risk, because there is little research either way. The melasma trials excluded pregnant women. We also know that Tranexamic acid crosses the placenta once it reaches the bloodstream. Melasma often starts or worsens in pregnancy. Azelaic acid is considered safe at that time, so it is usually the active a pregnancy formula is built around instead.
• A history of blood clots or a clotting disorder: the concern comes from oral and injected Tranexamic acid rather than from a cream. Tell your doctor anyway, so they can help you risk assess and make the safest decision.