Dr Brianna Castillo
The use of adjunctive topical tranexamic acid (TXA) showed benefits in significantly reducing postoperative bleeding with second intention healing, or allowing wounds to heal naturally without sutures, following Mohs micrographic surgery, in a double-blind, randomized, controlled trial.
The findings suggest that “topical TXA application is an inexpensive and easy topical preventative measure to consider adding to the wound care of granulating defects in the setting of Mohs micrographic surgery,” first author Brianna Castillo, MD, chief dermatology resident at the University of Missouri, Columbia, told Medscape Medical News.
The study results were presented May 12 at the American College of Mohs Surgery (ACMS) 2022 Annual Meeting.
In wound healing by second intent after Mohs micrographic surgery, postoperative bleeding is common and can lead to patient distress, as well as return visits or emergency care, resulting in additional healthcare costs, Castillo said.
Topical TXA, an antifibrinolytic, synthetic lysine analogue that prevents blood clots from breaking down, is commonly used in surgical settings including cardiothoracic, orthopedic, gynecologic, oral, and trauma surgery, showing no increased risk of thrombotic events. However, its use is relatively new in dermatology.
TXA is only approved by the US Food and Drug Administration as an oral formulation for menorrhagia in women and as a short-term preventative measure for hemophilia; however, other formulations are available for topical and subcutaneous uses, Castillo noted.
To evaluate the potential benefits of the treatment in postsurgical Mohs microsurgery bleeding, Castillo and colleagues enrolled 124 patients undergoing the surgery between October 2020 and December 2021 who had surgical defects deemed appropriate for second intention healing.
The patients were randomized to groups of 62 patients each to receive normal saline-soaked Telfa pads applied to the wound bed upon completion of surgery or TXA 25 mg/mL at a volume of 1 mL/cm2-soaked Telfa pads to the wound bed upon completion of the surgery.
In both groups, a standard pressure dressing was placed on top of the Telfa pads.
Most participants were men (90 vs 34 patients), 45 were taking antiplatelet therapy, and 20 were taking anticoagulants, and in all cases, patients were similarly randomized in the two groups. Most of the surgical defects were on the head and neck or an extremity, and most (74) were under 2 cm.
All patients were provided with instructions to apply pressure to their wounds and to report bleeding complications. They were interviewed by phone 3 days following their surgeries regarding postoperative bleeding and any potential issues relating to the TXA treatment.
In follow-up interviews, six patients in the placebo group (9.7%) reported active bleeding from their wound within 48 hours of surgery, with one patient requiring an intervention, while there were no reports of bleeding in the TXA group (P = .028). No side effects were reported in either group.
In the setting of Mohs micrographic surgery, subcutaneous TXA has previously been studied as an intraoperative hemostatic agent, with bleeding measured prior to the second layer or closure, Castillo explained. However, “no studies have evaluated topical TXA with the aim to reduce postoperative bleeding in the setting of Mohs micrographic surgery,” she said.
Castillo noted that topical TXA is relatively inexpensive and typically available in hospital pharmacies. “It’s only about $7 per vial of 10 ccs and we do dilute it,” she noted during the session. “It has a pretty good shelf-life and does not have to be refrigerated.”
“We have implemented this into our practice at the University of Missouri,” she added.
Commenting on the study, M. Laurin Council, MD, associate professor of dermatology, in the division of dermatology, department of internal medicine at Washington University, St. Louis, Missouri, noted that second intention healing is “an excellent option for certain patients after skin cancer removal.”
“One problem with this method, however, is that postsurgical wounds may bleed in the hours after a procedure, [and] this can be incredibly distressing to patients and their families,” she told Medscape Medical News.
“The study presented here shows great promise for the drug TXA for preventing postsurgical bleeding in this subset of patients,” said Council, who is also director of dermatologic surgery and director of micrographic surgery and the dermatologic oncology fellowship at Washington University.
Commenting that “the results are impressive,” she noted the study had some limitations. “This is a small pilot study, and we don’t know about confounding factors in each group, such as the proportion of patients who are on blood thinners or who have low platelets, and therefore trouble clotting, for example.”
The authors have reported no relevant financial relationships. Council has consulted for AbbVie, Castle Biosciences, and Sanofi-Genzyme/Regeneron, however, the consulting was not relevant to the current study.
ACMS Annual Meeting. Presented May 12, 2022.
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