Topical Tranexamic Acid Use Amongst Surgical Specialties: A Narrative Review

Abstract

Background: Tranexamic acid is an antifibrinolytic medication often used to prevent hemorrhage. The dosage and route of administration can vary depending on specialty and indication, although one of the most common routes includes intravenous application. Other possible administration modalities include intramuscular and topical applications or irrigation. Although not the most common method, more research is emerging on the topical application of the drug to prevent bleeding. Methods: Specific search terms regarding the topical administration of tranexamic acid were input into PubMed and were reviewed via Covidence. Selected studies were stratified based on specialty (ears, nose, and throat; cardiology; plastic surgery; and orthopedics), and hematologic outcomes regarding tranexamic acid use were reviewed. Results: An evaluation of the studies demonstrated the feasibility of tranexamic acid in the topical form; however, it can depend on the specialty-specific indications. Each field utilizes unique procedures or surgeries, which can play a role in the effectiveness of the medication. Conclusions: While the current literature demonstrates the feasibility of tranexamic acid, further research is needed to understand its viability in other fields, such as obstetrics.

1. Introduction

A hemorrhage describes the loss of blood that occurs from a damaged blood vessel and is a leading cause of mortality in surgical patients [1]. In fact, hemorrhage is the leading cause of death only secondary to trauma in Americans below the age of 46 [1]. Obstetric hemorrhages are responsible for over 70,000 maternal deaths around the world every year [1]. This necessitates effective prevention strategies, as well as innovative approaches for management.

Currently, there are a handful of practices to prevent hemorrhage; however, researchers agree that identifying risk factors first is essential to develop prophylactic methods. Uterine atony is the most common causes of postpartum hemorrhage (PPH), while more general risk factors include advanced maternal age, hypertension, and diabetes [2]. Typical prevention practices for hemorrhage include medications, compression techniques such as aortic compression, and uterotonic medications [2]. However, a promising avenue for prevention lies in vasoconstrictors and antifibrinolytic agents. The latter describes a group of drugs that prevent the breakdown of blood clots, which limits bleeding; a common kind of antifibrinolytic agent is tranexamic acid (TXA) [3].

TXA is an antifibrinolytic drug used to reduce blood loss; it functions by inhibiting the formation of plasmin from plasminogen, which is responsible for breaking down fibrin [4]. By inhibiting this process, TXA stabilizes blood clots. It has significant uses in surgery to minimize blood loss, especially in relation to perioperative blood loss and reducing the need for transfusions. One of these uses has been to manage postpartum hemorrhage, which is a leading cause of maternal mortality [5]. Different combinations of dosage, timing, and route of administration can influence efficacy. One of the largest clinical trials regarding TXA—Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2)—investigated the effect of early TXA administration. Adult trauma patients who sustained a significant bleeding event and received TXA within three hours of trauma showed a significantly decreased risk of death. Furthermore, in the subset of patients who received TXA within 3 h, there were approximately 755 life years saved per 1000 trauma patients. In this trial, patients received a 1g IV loading dose accompanied by a 1g infusion over 8 h [6]. Early studies in 1980 that investigated TXA supported the implementation of 10 milligrams (mg)/kilogram (kg) (IV) three to four times per day for local use and 10mg/kg IV three to four times per hour for systemic bleeding [7]. Overall, these studies and many new advancements suggest that there is a wide range of dosing that depends on the indication.

With the growing evidence of TXA’s life-saving efficacy, it is also important to acknowledge a short list of warnings. Patients who have a history of active thromboembolic disease or a history of allergic reaction to TXA should avoid this form of treatment. Care should also be taken not to administer it inadvertently into the intrathecal space if mistaken for regional anesthesia, as that can be potentially life threatening [8,9]. Side effects such as possible nausea and vomiting may be more common but there is a risk of seizures with higher doses (generally greater than 2 g dose), while possible thromboembolic events are exceedingly rare. To date, there has been no observed increase in thromboembolic disorders according to the 2017 World Maternal Antifibrinolytic (WOMAN) Trial or the recent meta-analyses for obstetric and non-obstetric populations [5,9]. Additional large safety and efficacy studies in the field of obstetrics would help to more definitely answer the question that has already been answered in non-obstetric populations. TXA has been employed in a multitude of different specialties, but is most commonly used in orthopedic, cardiac, and ENT surgeries. Its ease of administration—via saline solutions, retrograde injections, or TXA-soaked Gelfoam—further enhances its applicability in diverse medical settings, including low-resource environments where blood products may be scarce [10]. While IV TXA has been studied extensively, topical TXA is still a newer method of preventing bleeding in surgery. Localized application may be preferred since it minimizes systemic absorption while still effectively targeting the site of surgery. Furthermore, the topical application of TXA is also more cost-effective and easier to access in a wider variety of settings that may lack the personnel and equipment for IV or intramuscular (IM) administration [10]. Our study aimed to examine the uses of topical TXA amongst various medical specialties through narrative review, which can facilitate future feasibility studies within other specialties, especially if current TXA data are limited. This review aims to stratify topical TXA data by surgical specialty, route of administration, and clinical outcomes. This structure may guide specialty-specific protocol development and highlight areas needing randomized study. Therefore, this review succinctly highlights prominent studies in various surgical subspecialties and is intended to catalyze future investigations.

2. Materials and Methods

Specific search terms regarding topical TXA administration were run through PubMed and then imported into Covidence (

Table 1. Literature search strategy used for narrative review.

Item	Specifications
Database	PubMed
Included search terms	Tranexamic acid or TXA Topical or external or ointment or gel Bleed or hemorrhage or anti-fibrinolytic or antifibrinolytic agents Prevent or prophylaxis
Date range of published studies	Primarily 2015–2024, but earlier studies were included if relevant
Inclusion criteria	Peer review studies examining topical tranexamic acid use
Selection method	Two authors approved the inclusion of each study

). To be included, the study must have been published between 2015 and 2024 (with very few exceptions if relevant), as well as having at least one treatment group where TXA was the sole medication (therefore, no additional antifibrinolytic agents). Studies must have explicitly demonstrated or stated that randomization took place to be included in the summary tables. Previous studies have classified the intra-articular and subfascial administration of TXA as being topical, given that it is not being directly administered into systemic circulation [11,12]. To follow precedence, intra-articular and subfascial TXA application is also considered to be topical in the present work. For the results and summarization of findings, statistical significance was reported to be p < 0.05 or below. Given the nature of this narrative review, the search strategy was not intended to be exhaustive but to identify illustrative examples across multiple specialties. Future systematic reviews with broader search terms and databases would be needed to form more generalizable conclusions.

3. Results

Our search results produced 84 studies that investigated the use of topical TXA. Of those studies, the most represented specialties included plastic surgery; cardiology; ear, nose, and throat (ENT); and orthopedics. Based on our search, there were limited studies including the obstetric patient population. The primary and secondary outcomes of each study that met the inclusion criteria were compiled. The most common events reported were hematologic concerns such as quantified blood loss, estimated blood loss, changes in hemoglobin, transfusion rates, etc. Other non-hematologic measurements included duration of operation time, length of hospital stay, cost, surgeon satisfaction, etc. (Figure 1).

3.1. Cardiac Surgery

The impact of topical TXA on reducing perioperative blood loss in cardiac surgery has been the subject of numerous trials (Supplementary Materials—Table S1). Chaudhary et al. conducted a randomized, double-blind, placebo-controlled study in which 100 patients scheduled to undergo open-heart surgery were given a cardiac bath containing 2 g of TXA diluted in 50 milliliters (mL) of saline [13]. The findings indicated a notable decrease in postoperative mediastinal bleeding, the requirement for blood product transfusion, and re-exploration rates within the TXA group, with no variations in surgical characteristics or perioperative complications when compared to the placebo group. In a similar vein, Shah et al. [14] executed a randomized controlled trial involving 100 patients undergoing on-pump cardiac surgeries, including coronary artery bypass graft (CABG) and aortic valve repair. In this study, 2.5 g of TXA in 250 mL saline was administered to the pericardial cavity before the closure of the sternum. The investigation revealed a notable decrease in the average 24 h postoperative blood loss within the TXA cohort (340 ± 112 mL) when juxtaposed with the placebo cohort (665 ± 187 mL; p < 0.001). In a double-blind randomized trial involving 80 patients undergoing on-pump CABG and valve surgeries, Taksaudom et al. observed no notable differences in 24 h blood loss, transfusion needs, or postoperative complications when comparing the group treated with 1 g of TXA in 100 mL saline to the placebo group [15]. The findings suggest that while topical TXA can notably reduce blood loss in cardiac surgeries, its efficacy may vary depending on factors like dosage, administration technique, and the specific surgical context.

The targeted use of TXA at the surgical site reduces systemic exposure and associated risks, including thromboembolic events, while highlighting the importance of local fibrinolysis. A comprehensive analysis of 27 randomized controlled trials involving 10,591 patients demonstrated that topical TXA markedly decreased postoperative bleeding, chest tube drainage, and the necessity for blood transfusions when compared to placebo or no intervention. The analysis underscored its efficacy in preserving blood resources, revealing a 29% relative reduction in the risk of allogeneic blood transfusion [16]. Furthermore, there was no significant increase in adverse events linked to topical TXA, such as myocardial infarction, stroke, or renal failure, indicating a favorable safety profile [17].

3.2. Plastic Surgery

The topical application of TXA has been studied for its role in reducing postoperative bleeding, particularly in mammoplasty procedures (Supplementary Materials—Table S1). Ausen et al. performed a trial with thirty women who were undergoing bilateral reduction mammoplasty. One side of the procedure was administered 25 mg/mL of TXA, whereas the other side received saline [18]. The results demonstrated that the TXA group had a 39% reduction in drain fluid production (p = 0.038), with no significant differences noted in discomfort levels or complications. A subsequent trial by Ausen et al. involving 202 women undergoing mastectomy demonstrated a significant reduction in the 24 h drain output with TXA (110mL vs. 144 mL; p = 0.011), as well as a lower incidence of early hematoma (OR 0.13; p = 0.057) [19]. Nonetheless, there were no notable differences in the postoperative complications observed between the groups. In contrast, Yao et al. examined 98 patients who had bilateral primary reduction mammaplasty with 1000 mg/mL TXA diluted in 10cc of normal saline (0.9% sodium chloride) and found no significant association between the administration of TXA and the incidence of hematomas (p = 0.56) or any other complications [20]. The findings demonstrate that the use of topical TXA effectively reduces postoperative bleeding and drain output without significantly increasing the occurrence of adverse events in mammoplasty procedures.

3.3. Ear, Nose, and Throat Surgery

TXA has been studied in ENT surgeries for its effectiveness in hemorrhage control (Supplementary Materials—Table S1). Achour et al. found that TXA improved the surgical field in patients undergoing functional endoscopic sinus surgery; however, it did not reduce postoperative blood loss [21]. Hussain et al. revealed that TXA decreased 24 h postoperative bleeding in patients undergoing functional endoscopic sinus surgery, but it had no impact on intraoperative bleeding [22]. Whitworth et al. demonstrated that topical TXA was superior to oxymetazoline in achieving hemostasis for anterior epistaxis [23]. Hamed et al. found that TXA enhanced surgical visibility and decreased bleeding in ear surgery relative to epinephrine [24]. Ultimately, TXA demonstrates advantages in enhancing surgical visibility and decreasing postoperative bleeding in ENT procedures; however, its impact on intraoperative bleeding is inconsistent.

3.4. Orthopedic Sugery

Orthopedics comprised the majority of the papers; these procedures included orthognathic surgery [25], total knee arthroplasty [26,27,28], total hip arthroplasty [29,30,31], intertrochanteric fracture surgery [32,33], open elbow joint arthrolysis [34], and thoracolumbar burst fracture surgery [35], among other procedures. The scope of TXA’s applicability is broader than just knee and hip arthroplasty. The recent literature shows that the inclusion of shoulder arthroplasty with TXA can also reduce blood loss during and after operation [36]. Variation in surgery types and indications demonstrate that topical TXA may be more suitable for some cases (Supplementary Materials—Table S2).

TXA can be irrigated preoperatively to prevent hemorrhage in orthognathic surgery, as conducted by Eftekharian et al. [25]. In this double-blinded randomized control trial, 56 participants were either given 1mg/mL of TXA in 0.9% normal saline, or solely 0.9% normal saline. Between the two groups, there was a significant difference in intraoperative blood loss with the TXA group showing a loss of 818 ± 262 mL, versus 575 ± 287 mL in the control group (p < 0.05). Moreover, a noteworthy analysis in this study included surgeon satisfaction. Subjective surgeon satisfaction was classified on a Likert scale ranging from 0 (being poor) to 3 (being excellent). In their study, 92.9% of the surgeons using TXA had grade I satisfaction, compared to 3.6% in the control group using normal saline [25].

Different modalities of TXA administration can also be assessed within orthopedics (Supplementary Materials—Table S2). Aggarwal et al. conducted a double-blinded randomized control study to compare IV vs. topical TXA in total knee arthroplasty [26]. The results showed significant differences between the treatment arms. The mean postoperative total blood loss was 1037 ± 507 mL for IV and 562 ± 249 mL for topical (p < 0.001). Furthermore, postoperative hemoglobin was significantly lower in the IV group (p < 0.001), while the number of allogeneic transfusions was statistically higher intravenously [26]. The combination of TXA with another drug can also elicit decreased blood loss in surgery. A 2015 double-blinded randomized control, also with total knee arthroplasty, combined TXA with diluted epinephrine (DEP). Medication was administered intra-articularly after articular capsule closure. Patients receiving a blend of 3g TXA + 0.25 mg DEP sustained significantly less total blood loss (p = 0.006) compared to the control group, who received just 3 g TXA [27]. The timing of administration has also been questioned to play a role in hemorrhage prevention. TXA administration via IV, topical washing before surgical closure, topical via drain after surgical closure, and control was evaluated in relation to total knee arthroplasty [28]. In the study, regardless of the route, TXA significantly reduced bleeding. There were reported differences in postoperative hemoglobin, day 0–1 blood loss, day 2–5 blood loss, and mean total blood loss; however, there was not a single group that consistently showed better results. The route of topical administration may play a role in bleeding and can be chosen based on the procedure.

In addition to knee arthroplasty, total hip arthroplasty showed substantial feasibility for topical TXA use. Jordan et al. compared TXA to fibrin sealant (FS) with a randomized control study (N = 158) [29]. Participants were either given 10 mL of FS, 1 g of topical TXA, or no treatment at all. The total blood loss was significantly different among the groups (TXA group: 1192 ± 786 mL; FS: 1620 ± 1043 mL; control: 1557 ± 847 mL; p = 0.063). In contrast to previously mentioned findings, there was no statistical difference in blood loss collected in drains among the groups (p = 0.178) [29]. When comparing the intra-articular administration of 2 g TXA in 50 mL normal saline versus IV 20 mg/kg in 100 mL normal saline for total hip arthroplasty, there was a significantly lower mean blood loss in the TXA groups compared to the control group; however, there were no significant differences between the topical and IV methods [30].

Direct comparisons between total knee and hip arthroplasty can also be made. Masaryk et al. evaluated IV (1 g TXA in 100 mL saline at two time points), topical irrigation (2 g TXA in 50 mL saline), and no treatment (N = 452) [31]. Patients undergoing total knee arthroplasty were randomized to one of the three aforementioned groups, and the same was carried out for patients in need of total hip arthroplasty. The concentrations, frequency, and amounts of TXA for a treatment group were consistent between both operations [31]. Overall, TXA significantly reduced postoperative blood loss. Specifically, only in relation to total hip arthroplasty did topical TXA significantly reduce drainage output postoperatively compared to IV (IV: 518 ± 259 mL; topical: 377 ± 213 mL; p < 0.01). Interestingly, the converse was true in relation to total knee arthroplasty. There was a significantly lower drainage output with IV TXA compared to topical (IV: 458 ± 236 mL; topical: 646 ± 281 mL; p < 0.01) [31] (Supplementary Materials—Table S2).

Among the various topical applications of TXA in the orthopedic literature, intra-articular administration is one of the most common routes, in addition to wound irrigation. Subfascial TXA administration also demonstrates a viable opportunity to prevent bleeding. This was notably seen in intertrochanteric fracture surgery. Patients were either given 30 mL (500 mg/5 mL × 6 amps) of TXA or no treatment at all, which resulted in significantly more blood units being transfused in the control group. Furthermore, the postoperative day one hemoglobin and hematocrit platelet drop was significantly higher in the control group. Conversely, the postoperative day one platelet count drop was lower in the control group (p < 0.01). After three days, the statistical differences were no longer applicable [32]. Yee et al. also assessed subfascial application in intertrochanteric hip fracture surgery [33]. There, the administration of 10 mL (1 g) of TXA was compared to that of 10 mL of normal saline. In this randomized control study, there were no significant differences between the two groups [33], indicating that subfascial disbursement may in fact result in varying outcomes.

Instead of the direct irrigation of a wound or surgical site, gauze can also be soaked in the solution and dressed over the region. After open elbow arthrolysis, patients received two gauze pads preabsorbed with TXA (or saline for the control group) that were placed along the anterior and posterior cavity. Following closure, more TXA was injected via the drainage tube. Intraoperative blood loss was substantially lower in the TXA group (p = 0.038), while the day one and two drainage volume was significantly reduced (p = 0.001 and p = 0.016, respectively) [34]. With thoracolumbar burst fracture surgery, the topical soaking of the wound in TXA (1 g in 100 mL saline) resulted in several positive outcomes. Notably, the total and postoperative blood loss were significantly lower in the TXA group (p < 0.001) [35]. TXA in relation to shoulder arthroplasty demonstrates similarly successful results, as is highlighted in a review by Pecold et al. [36], where its use decreased blood loss during and after surgery, in addition to decreases in drain output and drops in hematocrit.

3.5. Obstetric and Gynecologic Surgery

PPH remains a leading cause of maternal morbidity and mortality worldwide, necessitating effective preventive and therapeutic strategies [37]. TXA has been widely studied for its intravenous use in obstetric patients, particularly following the WOMAN trial, which demonstrated a significant reduction in mortality due to PPH when administered intravenously [5].

A few studies have evaluated the efficacy of topical TXA in obstetric surgery, particularly in reducing perioperative blood loss. Rathore and Gupta conducted a comparative study on intravenous and topical TXA in placenta previa cesarean sections, reporting a significant reduction in intraoperative blood loss, additional uterotonic use, and PPH in the topical TXA group, with no significant adverse effects [38]. Similarly, Taha et al. [39] demonstrated that both intravenous and topical TXA effectively decreased intraoperative and postoperative blood loss in placenta previa cases compared to the use of oxytocin alone, with the topical route offering comparable hemostatic benefits. They investigated its use in elective cesarean sections among women at high risk for PPH, comparing topical TXA combined with temporary uterine packing to intravenous TXA alone.

In gynecologic surgery, Sallam et al. [40] examined the efficacy of topical versus intravenous TXA in abdominal hysterectomy, reporting a substantial reduction in blood loss in both groups. These findings align with the study by Mitra et al. [41], which concluded that topical TXA was as effective as intravenous administration in minimizing perioperative blood loss in hysterectomy patients. Two case series had limited data showing the role of topical TXA in the field of obstetrics and gynecology [42,43].

The field of obstetrics and gynecology has significantly fewer studies evaluating the role of TXA for preoperative bleeding prevention compared to other surgical specialties, highlighting a critical gap in research. Future studies should address this disparity and also explore the feasibility, optimal dosing, and clinical outcomes of topical TXA in obstetric patients.

4. Discussion

By stabilizing blood clots, TXA effectively limits blood loss, reducing the need for transfusions and improving surgical outcomes [41]. In particular, topical TXA has gained attention as a method to localize the drug’s effects to the surgical site, minimizing the systemic side effects associated with IV administration [43]. This unique mechanism makes it especially valuable for various patient populations, surgical settings, and specific clinical scenarios. However, while its efficacy has been extensively demonstrated in surgeries at risk for bleeding, as well as specialties like orthopedics, cardiology, and trauma, some areas, such as obstetrics, have not yet routinely adopted or extensively studied the topical application of TXA.

The localized application of TXA reduces systemic exposure, addressing the theoretical risk of thromboembolic events that is likely higher with IV administration due to greater systemic absorption [42]. As noted in the Cochrane review by Ker et al., while IV TXA effectively reduces bleeding in surgical patients, systemic effects, including thrombotic complications, remain a concern [9]. Topical TXA mitigates these risks by acting primarily at the bleeding surface, as evidenced by a significant 29% reduction in blood loss and a 45% reduction in blood transfusion requirements, without significant increases in thromboembolic events [9]. These findings suggest that topical TXA could be a viable alternative for patients at higher thromboembolic risk, which may be worth further discussion in fields like ENT or cardiac surgery.

The versatility of topical TXA extends beyond surgical applications. Both the prior review and our review highlight its utility in procedures ranging from orthopedic surgeries to epistaxis management, demonstrating its effectiveness in various bleeding scenarios. A consistent finding across studies is the lower need for allogeneic blood transfusions among patients receiving topical TXA. On average, patients treated with topical TXA required 45% fewer transfusions compared to those in control groups, as demonstrated in the Cochrane review by Ker et al. [44].

This is especially important for patients who have inherited bleeding disorders, since, otherwise, treatment can be costly and may require thrombogenic pharmacologic therapies, including desmopressin, plasma-derived clotting factor concentrations, recombinant coagulation factors, and prothrombin complex concentrates. As with any medication, these therapies come with risks such as thromboembolism and can contribute to the development of inhibitors. Research on TXA in these populations is optimistic as pre-clinical studies demonstrate an improved hemostatic effect with a combination of TXA and Factor VIII in the setting of severe hemophilia A [45]. Therefore, topical TXA is potentially a more practical and cost-effective alternative to systemic therapy for patients who have existing bleeding disorders, since bleeding risk is not always strictly correlated with the plasma level of the factors themselves. For these patients, TXA may reduce intraoperative and postoperative hemorrhagic risk.

Additionally, this aspect of TXA use is critical in resource-limited settings or for populations such as Jehovah’s Witnesses, who decline blood products. Topical TXA offers a method to manage hemorrhage that aligns with these patients’ beliefs and is particularly beneficial for those with active clot burden, such as pulmonary embolism or deep vein thrombosis in pregnancy close to delivery, as well as for individuals on anticoagulation therapy due to thrombophilia or a history of venous thromboembolism [46]. Expanding its use to such high-risk groups underscores its potential to address complex bleeding scenarios while mitigating thrombotic risks.

Beyond TXA, alternative topical hemostatic agents such as Fibrillar (oxidized regenerated cellulose) and Tisseel (fibrin sealant) have demonstrated efficacy in controlling bleeding in high-risk surgical settings, including cesarean hysterectomies and gynecologic surgeries [47]. Fibrillar acts as a physical matrix to promote clot formation, while Tisseel mimics natural clotting mechanisms by providing fibrinogen and thrombin to the surgical site [48]. These agents have been particularly effective in cases of high estimated blood loss, such as fibroid or cancer surgeries, where achieving reliable hemostasis is critical. For instance, cesarean hysterectomy and myomectomy are procedures where achieving effective hemostasis is critical to prevent complications. However, their use may be limited by cost considerations, preparation time, or potential for adverse reactions, such as tissue adhesion or localized inflammation [48]. The potential role of topical TXA alongside or in comparison to agents like Fibrillar and Tisseel merits further exploration in these contexts, given its ease of application.

TXA reduces the risk of life-threatening bleeding and mortality in various fields. Some large studies may not show an impact on morbidity reduction, but the timing of administration is an important factor that has not fully been evaluated to assess efficacy [9]. Specifically, if TXA is given after the procedure or delivery starts, this may not fully evaluate its impact on morbidity reduction.

Emerging research has also investigated topical TXA in peripheral arterial procedures. A recent meta-analysis by Steunenberg et al. demonstrated both the efficacy and safety of TXA in non-cardiac arterial procedures, supporting its broader utility in vascular settings [49]. The safety of TXA in more delicate vascular procedures, such as carotid endarterectomy, was reinforced by Hines et al., who found that topical TXA did not increase thrombotic complications [50]. Despite TXA having a good general safety profile, there are concerns with isolated reports. For example, Nardi et al. described ischemic stroke events in two young patients with bleeding gynecologic disorders carrying heterozygosity of MTHFR C677T after TXA exposure, which emphasizes the importance of risk assessment prior to TXA use, even with topical administration [51]. As surgeons continue to broaden TXA use into unique specialties, it requires diligent and ongoing research into its safety and efficacy in novel procedures. Qualitative views on TXA are imperative, in a similar manner to how Painter et al. presented in relation to Fellows of the Australian and New Zealand College of Anaesthetists (ANZCA) survey data. In total, 87% of the participants (N = 289) agreed that perioperative IV TXA requires more RCTs to assess its safety and efficacy [52].

While evidence strongly supports the efficacy of topical TXA in surgical bleeding control, this review underscores the need for further research in non-surgical bleeding scenarios. Addressing these gaps could expand the scope of topical TXA, enabling broader adoption in emergency medicine, obstetrics, and trauma care. Moreover, its favorable safety profile and minimal systemic effects suggest that it could become a cornerstone of bleeding management across disciplines.

Arising studies are demonstrating the multimodal use of TXA, specifically in relation to wound healing. A recent 2025 animal model study assessed scar prevention in rats undergoing craniectomy. Cotton pads soaked with either normal saline or 30 mg/kg TXA were applied to the incision site and scar formation was analyzed via electron microscopy. The results showed a significantly different grading in scar formation between the experimental and control group [53]. Advancements are not limited to wound healing, as topical TXA has shown to be a potential asset in reducing postoperative hematoma formation. Sipos et al. revealed that topical TXA in chest masculinization plastic surgery allows for reduced hematoma formation requiring evacuation. Although not statistically significant, this preliminarily suggests that there is limited concern for hematoma formation and that larger studies are warranted to investigate whether there is a significant reduction in such postoperative complications [54].

5. Conclusions

Evaluating various routes of TXA administration is a large aspect of prophylactic surgical management. This review of the most frequently represented studies with topical TXA highlights which specialties may need further research to determine if its use is appropriate. Nevertheless, it is evident that topical administration may be more suitable for specific fields or methods of surgeries given the differences in access or exposure of the organ at hand. More research on the impact of other patient characteristics on the effectiveness of topical TXA can also be beneficial, such as in relation to pre-existing comorbidities or coagulopathies. This then poses the question of how TXA can be optimal for specific patient populations. The expansion of topical TXA applications into other specialties needs to be further studied as the majority of cases are seen within orthopedics. This leaves room for research in fields where hemorrhage is frequent, such as in obstetrics when preventing and treating PPH. Currently, numerous studies demonstrate that shifting from an IV route to a topical one may be an acceptable and less-invasive method to address hemorrhage.