Oral Tranexamic Acid for Melasma: What Studies Show and the Clot Checks First

Melasma causes brown or gray-brown patches on the cheeks, forehead or upper lip. It’s more common in people with darker skin tones,¹ and it can linger for years. When creams and sunscreen haven’t been enough, some dermatologists prescribe tranexamic acid pills, a use that’s off-label.

What it’s approved for

Tranexamic acid tablets are FDA-approved for heavy menstrual bleeding, at a much higher dose (1,300 mg three times a day for up to 5 days a month).² For melasma, studies have used far lower daily doses over several months.³¹

What studies show

• A U.S. randomized trial gave 250 mg twice a day or placebo for 3 months, along with sunscreen. Melasma scores dropped 49% with tranexamic acid versus 18% with placebo. Three months after stopping, part of the gain was lost: 26% below baseline versus 19%.³ No serious side effects were seen, but the trial was small (39 completed) and mostly included Hispanic women.³
• A 2017 meta-analysis of 11 studies and 667 people found tranexamic acid reduced melasma, alone or added to other treatments. Side effects were minor, such as lighter periods, mild stomach upset and skin irritation.⁴
• A 2018 review suggested considering it when about 12 weeks of creams such as hydroquinone haven’t worked.¹

The clot checks

Tranexamic acid helps blood clots hold together. The approved label says not to use it with:²

• a current or past blood clot, including in the eye’s blood vessels
• an inherited or other built-in tendency to clot
• combined hormonal birth control

The melasma review said studies haven’t shown a higher clot risk at low doses, but people should be carefully screened for risk factors first.¹ After 50, that includes talking about hormone therapy, past clots, heart rhythm problems and recent surgery. Kidney problems may require a lower dose.² Our article on estrogen pills, patches and clot risk explains why the form of hormone therapy matters.

Sun protection still matters

Daily sunscreen was part of the trial treatment.³ Our guides to choosing sunscreen, age spots and mercury in dark-spot creams cover other steps.

Questions to ask

1. Is this melasma, or another kind of dark spot?
2. Do I have any clot risk factors that rule this out?
3. What dose and how long, and what happens when I stop?
4. Should I keep my creams going at the same time?

Try: “My melasma hasn’t improved with creams. Would low-dose tranexamic acid be safe for me, given that I’m on hormone therapy?”

Skin, Head to Toe includes a short-shelf planner and a 12-week SkinLog. Use them to take monthly photos in the same light and track every product you use. See the book.