Evaluation of effectiveness of tranexamic acid as mesotherapy in improvement of periorbital wrinkling in a trial study

Tranexamic acid is used to treat pigmented disorder in dermatology for a long time however there are limited data for effectiveness of tranexamic acid for rejuvenation and improvement of wrinkle. Here we want to find the effectiveness of tranexamic acid as mesotherapy in improvement of periorbital wrinkle in a clinical trial study.

color changes such as yellowish appearance, loose skin, rough skin, telangiectasia, and malignancies. 3 Also, the histopathological features of the skin exposed to sunlight are flattening of the dermis and epidermis, reduction of collagen, cellular atypia, and elastosis. 4 Other causes of skin aging include wrinkles caused by dryness, which ultimately lead to a reduction in skin cells and skin sclerosis.
Epidermal and dermis wrinkles, which are respectively caused by a decrease in the moisture of the stratum corneum and a decrease in collagen and natural factors that moisturize the dermis. 5 From a molecular point of view, ultraviolet rays induce the synthesis of plasminogen activator in the aging process, which increases the activity of plasmin in keratinocytes. This leads to the stimulation of arachidonic acid by phospholipase A2, which is involved in skin aging. Another role of plasmin is to stimulate the secretion of fibroblast stimulating factor, which is involved in the process of sclerosis of the skin. 6 Another molecular process is an increase in the number of mast cells in the skin exposed to UV radiation, which is followed by a significant increase in its tryptase content. 7 Tryptase reduces type 4 collagen and also increases the number of Mast cells, and weakens the basement membrane. In addition, mast cells play an important role in the development of solar elastosis, so that the elastin content of skin exposed to the sun is related to the number of mast cells. 6,8 Recent studies have showed the role of tryptase in the extracellular matrix, degradation of basement membrane components and consequently the role of this enzyme in aging processes. 1 Tranexamic acid is an amino acid with anti-plasmin activity with homeostatic function, anti-inflammatory, anti-allergic effects, and in addition, it inhibits pigmentation caused by ultraviolet rays. 9 Recent studies have reported the use of tranexamic acid as an antiinflammatory agent to improve dryness-induced wrinkles and pigmentation caused by ultraviolet radiation. 10 In some study use of oral tranexamic acid for 2 months showed response rate of 89.7% for visible lightening of skin. 11,12 In this study, due to the different effects of tranexamic acid, which has an inhibitory effect on plasmin and tryptase, it can prevent the factors causing the aging processes of skin. Also, random observations in patients who have used mesotherapy for other purposes and anti-wrinkle effects have been reported, and due to very few number of studies conducted in this field, we decided to search and examine the effect of mesotherapy traperexamic acid on skin wrinkles.

| ME THOD
This clinical trial was carried out at the dermatology clinic in the academic year of 2019-2020.

| Subject selection
We considered 20 patients who suffered from cheeks or forehead melasma with wrinkle to participate in this study. These participants undergo tranexamic acid mesotherapy to treat melasma in the target areas. Inclusion criteria were people who had skin wrinkles and there was no age limit.
Exclusion criteria include: 1. any complication that is related to the treatment process or is not tolerated by the patient. 2. The patient does not want to continue treatment for any reason. 3.
History of cancers, pregnancy, lactation, DVT, pulmonary embolism, stroke. 4. Severe smoking patients 5. People who are exposed to the sun for a long time and intensely. The selection of the patient was done by the main researcher of the project and then the complete information related to the study was explained to the patient and the consent form was completed by the patient before entering the study.

| Calculating the sample size
The method of determining the sample size after statistical consultation due to the lack of relevant human studies and the existence of only a few studies in this field that have been at the animal level and had positive results, so this research project was selected as a pilot.
We considered the sample size of 20 patients. One patient did not refer for follow-up photo 1 month after the end of the project.

| Treatment
Tranexamic acid is injected as mesotherapy (traenxamic acid ampoules by 1 cc syringes used for injection) in the area of wrinkles intradermally at intervals of 1 cm in the amount of 0.1 cc which is done at intervals of 1 week for four sessions and then a month later by the doctor and is photographed by Visioface device and using the Delta scale in quantitative registration method.

| Statistical analyses
Statistical analysis was performed by using SAS® software. Onesample Kolmogorov-Smirnov (KS) test was utilized to examine the normality distribution of the study variables. At the next step we used Wilcoxon signed ranks test for the numerical data analysis since the KS test values showed that the included variables have not follow normal distribution. P value was considered statistically significant <5% and SPSS (v. 22) was utilized as our analytical software.

| RE SULTS
Finally 19 participants were included in our study and effects of therapeutic procedure on their periorbital wrinkles were evaluated.
All of participants was female except one of them. They were at the age range of 31 to 62 years old with mean (±SD) of 43 (±7.2) years old. Most of them were at 40 to 49y age group.
Results of our study as quantitative scales including volume, area, area percent and depth of periorbital wrinkles before and after tranexamic acid mesotherapy are showed at  Mean of periorbital wrinkles depth at before and after treatment were 9.8 and 9.6, respectively, without remarkable difference (pvalue was 0.257).

| DISCUSS ION
As it has been shown in previous studies, the process of skin aging and the formation of wrinkles is influenced by internal and external factors. Internal factors such as aging cause epidermal atrophy and flattening of the epidermal-dermal junction. On the other hand, one of the most important external factors affecting skin aging is sunlight exposure, especially UV rays. Also, dry skin causes skin wrinkles, which reduces skin cells and sclerosis. As a result, to reduce wrinkles, we should prevent the damaging effects of UV rays. 13,14 From a molecular point of view, ultraviolet rays induce the synthesis of plasminogen activator in the aging process, which increases the activity of plasmin in keratinocytes. Plasmin increases the secretion of fibroblast-stimulating factor and arachidonic acid, which are involved in the processes of skin sclerosis and skin aging, respectively. 5 Plasmin also leads to increased angiogenesis. Another molecular effect of UV radiation is an increase in the number of mast cells in the skin exposed to UV, which is followed by a significant increase  In Karin Endo's study, tranexamic acid was investigated as an anti-aging agent for the skin using UVA-irradiated fibroblasts as a model for dermal fibroblasts that were chronically exposed to the sun. As in our experiment, these results showed that tranexamicacid has the potential as an anti-photopigment agent. 16 Ivan D. da Silva Souza investigated the effect of a new topical tranexamic acid derivative that named, cetyl tranexamate mesylate in females. The results showed that topical application of this compound was associated with an acceptable response to reduce dark spot and redness of the skin. 17 In a trial study of mice by Kichi Hiramoto et al., similar to the results of our study in humans, tranexamic acid inhibited the formation of wrinkles in these mice, although wrinkles following dry skin were also observed. 5 Another study done by Kichi Hiramoto et al., stated that on the effect of tranexamic acid on plasma markers of damaged skin due to prolonged exposure to ultraviolet light on female mice also concluded that skin aging caused by ultraviolet radiation is improved with tranexamic acid by regulating hormones in the hypothalamicpituitary pathway. 18 Due to the novelty of research in this field and the lack of sufficient data, more trials and case-control studies are recommended to compare the effect of tranexamic acid with placebo in the treatment of face wrinkles. We emphasize that we do not claim that tranexamic acid has a definitive anti-aging effect; rather, our findings suggest that it may have such an effect.

| CON CLUS ION
In conclusion, the use of tranexamic acid with anti-plasmin and anti-inflammatory effect has been effective in preventing the dam-

ACK N OWLED G M ENTS
Declared none.

FU N D I N G I N FO R M ATI O N
None.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declare that they have no conflicts of interest.

DATA AVA I L A B I LIT Y S TATE M E NT
The data are available with the correspondence author and can be reached on request.

E TH I C A L A PPROVA L A N D C O N S E NT TO PA RTI CI PATE
This research was reviewed and approved by the research ethics committee of Iran University of Medical Sciences (IR.IUMS.FMD. REC.1400.011). Written informed consent was taken from the patients to include the clinical details.

CO N S E NT FO R PU B LI C ATI O N
Not Applicable.