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Hyaluronic acid filler injection in patients with localized scleroderma

Hyaluronic acid filler injection in patients with localized scleroderma

Hyaluronic acid filler injection in patients with localized scleroderma

Source: Dovepress

What is localized scleroderma?

Localized scleroderma, also known as Morphea, is a chronic inflammatory condition of connective tissue, the etiology of which is unknown.

It is a rare disease, most commonly seen in young adults. According to studies, the incidence of localized scleroderma is around 0.3 to 3 cases/100,000 inhabitants/year. 90% of children with localized scleroderma are diagnosed in childhood or adolescence between the ages of 2 and 14. In adults, the peak incidence is usually around the age of 50 and occurs much more often in women than in men.

Therapeutic options include corticosteroids, oral or subcutaneous methotrexate, calcipotriol, imiquimod, tacrolimus, mycophenolate mofetil, medium-dose UVA1 phototherapy, and CO2 fractional laser treatment. There is disfigurement in approximately 50% of patients. Surgical excision, autologous bone grafting, and autologous fat grafting have been performed with varying degrees of success in linear morphea. Hyaluronic acid, Calcium hydroxylapatite, Poly L lactic acid, and permanent fillers such as Silicone have been used to correct deformities that occur as a result of morphea. The aim of this case report was to establish hyaluronic acid fillers as an efficacious modality of treating stable localized morphea with facial disfigurement.

Although these modalities help stop the progression of the disease and the disorder itself is not life-threatening, the atrophic scars and hyperpigmentation or hypopigmentation that are seen are permanent. About 50% of patients may experience strong signs, which create a “disfiguring” effect, which can have a negative impact on image and even self-esteem.

A recent study by specialists has shown that hyaluronic acid, calcium hydroxyapatite, Poly L lactic acid and permanent fillers such as silicone, used to correct the deformities that occur as a result of the disease, can have very good results, and patients they can enjoy a harmonization of traits that will help them regain their confidence and self-esteem.

Case study – the effect of fillers in patients with scleroderma

A 35-year-old lady was referred by a dermatologist for treatment of an atrophic scar on her chin. She had been diagnosed with localized scleroderma and was treated for two years. Her active disease resolved, and she was left with an atrophic scar.

We are talking about a non-smoking, healthy patient with no other medical disorders. There was no history of herpes infection in the past and she was not taking any oral or topical morphine medication throughout this treatment. The patient had no significant medical problems related to the condition she was suffering from in the last three years. The area of atrophy was asymptomatic, and on examination, she presented with an atrophic scar on the right side of the face, extending from the labiomental fold to the midline of the chin. The outline of the chin was lost, resulting in disfigurement of the face. The scar was uneven and hyperpigmented, however, the patient had no difficulty opening her mouth, eating, chewing, swallowing, or speaking.

The dermatologist who treated the patient revealed that the lesion was stable and had not spread for three years. The recommended treatment was one based on systemic corticosteroids for 3 months, followed by oral methotrexate 15 mg/m2/week for one year. Subsequently, the disease remained stable for 3 years.

A thorough check-up, which included an MRI and laboratory investigations, was done at the doctor’s recommendation, approximately 3 years after the scleroderma was found to be stable. The results of the investigations were good, and the subsequent biopsy confirmed that the lesion had not progressed. Histopathology showed sclerotic bundles of collagen infiltrating the entire skin surface and extending into the subcutaneous adipose tissue. The appendages were replaced by fibrosis, the vessels of the hypodermis had a thickened wall, and the lumen size was significantly decreased.

At the same time, an orthodontic and maxillofacial evaluation and an ophthalmic evaluation were performed, both of which were normal. It is very important to mention that the patient did not want any surgical intervention, therefore the doctor looked for the best therapeutic option in her case.

The patient was counselled, and the treatment protocol was discussed. The patient was asked to avoid non-steroidal anti-inflammatory drugs, vitamin E, gingko biloba, essential fatty acids, herbal supplements, green tea for five days before the injection to reduce the chances of bruising.

On the first day of treatment, the patient was photographed with a high-performance camera both in front and in profile, in good lighting conditions. The face was thoroughly cleaned and topical 2.5% lidocaine/prilocaine was applied to the affected side. After 30 minutes, the local anesthesia was removed, the area was thoroughly cleaned with chlorhexidine, alcohol and saline, and after all this process, 1 ml of Restylane Lyft® was taken, which was injected with the help of the atraumatic cannula, at the level of the affected area . A 22-gauge cannula, 50 mm long, with a blunt tip was used, through which it was then inserted, obliquely, towards the angle of the mandible, to inject the substance at the level of the entire affected surface. The injection technique was a mobile one (back and forth) to be able to provide a natural, uniform filling effect. The entire deformity was then filled with 0.6ml of Restylane Lyft® using a similar technique, which helped place the acid over the entire area to fade the entire scleroderma area as harmoniously as possible. A second layer was applied subcutaneously, and the remaining 0.4 ml of the product was injected into the areas where the deformation was still visible. Slow injections were given retrograde to prevent any compression of the vascular structures and to prevent bruising. The entry point was cleaned with betadine and the injected area was gently massaged to model the hyaluronic acid. The patient was advised not to self-massage to prevent dislodgement of the product, and was even instructed to avoid vigorous physical activity for 24 hours after the injection. Furthermore, she was advised to avoid the use of cosmetics or skin care products for approximately 12 hours after the hyaluronic acid filler procedure, but also to postpone facial treatments on the injected area for up to four weeks. Throughout this period, the patient discussed with the doctor how the obtained result is evolving. When it came back to control after about four weeks, the acid had already settled very well, leaving a small, easily noticeable scar.

This treatment, volumization by hyaluronic acid injection, has no adverse reaction, being a safe procedure for patients, even if they suffer from conditions such as scleroderma.

Because the hyaluronic acid injected in the area managed to provide such a beautiful and natural effect, blurring the deformation in the area, the doctor decided that, in order to completely blur even the small asymmetries visible now, during the one-month check-up, may inject a very small amount of Restylane®.

The product was placed on the skin to correct the asymmetries still visible from the first procedure. The same protocol was followed as in the first stage of treatment, which included photographing the patient from the front and profile, cleaning the area, applying topical anesthesia, and finally injecting the filler with a 50 mm long atraumatic cannula.

Hyaluronic acid filler injection in patients with localized scleroderma

After the second injection, the scar was almost completely faded, and at this stage approximately 0.5 ml of low-G hyaluronic acid was used, layered over the previously injected high-G substance. As with the first procedure, there were no adverse effects and the patient tolerated the procedure well. Later, it was monitored at a longer time interval, after 6 months, and then after 1 year.

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It was seen that after 1 year the patient still looked very well, the skin was smooth and the deformity barely visible except for mild post-inflammatory hyperpigmentation (PIH). It was interesting to note that this PIH was much lower compared to the PIH that was seen prior to the injection of the filler in the first injection. There were no signs of disease recurrence 1 year after the first intervention.

Study conclusions

Hyaluronic acid filler- is a simple, quick, and minimally invasive option for stable atrophic lesions of localized morphea. Its ease of administration, low immunogenicity, and reversibility with hyaluronidase coupled with excellent patient satisfaction make it one of the best options to provide contour restoration in cases of deformities such as localized morphea. Hyaluronic acid volumizes, softens, and hydrates the skin by potently binding to water. It is said to play a role in cell growth, membrane receptor function, and adhesion It has also been shown to stimulate collagen production which explains the longer-lasting results of HA filler when injected two or three times for the same indication. Wang et al were able to show that upon injecting HA fillers, fibroblasts take on a more morphologically stretched shape and a more active phenotype, resulting in neocollagenesis.

In cases of stable localized morphea, including en coup the sabre, the skin may be somewhat tethered to underlying structures. Nilforoushzadeh et al described subcision of acne scars with a 22 G microcannula. The author decided to try this in the case of localized morphea too and managed to subcise the fibrous bands in the bound areas using a 22G microcannula with a back and forth movement. The cannula is less traumatic, there is less pain, there are fewer chances of bruises, oedema, and there is an ease of administration of the product with a microcannula.

Slow injections should be given adding less pressure while injecting. Large volumes should be avoided as a bolus to prevent vascular compromise by direct external pressure on the on the area.

Despite the theoretical risk of reactivation of Scleroderma because of trauma from the injection, there are no such evidence-based reports. Most of the patients who underwent filler treatment were not on any immune modifying medication and their disease was stable. It is known that the disease activity lasts around 3 to 5 years and can extend up to 25 years. The progression time is uncertain and filler injections do not prevent a possible relapse to the proliferative phase.

Study conclusions

Hyaluronic acid filler can be used safely in cases of stable localized scleroderma with facial atrophies. It is an effective, minimally invasive treatment modality with, minimal downtime. Apart from filling the defect, hyaluronic acid is also known to have bio-stimulatory effects leading to neocollagenesis. According to the study, there has been no reactivation or exacerbation of the disease for up to 2 years. The outcome of treatment depends on the selection of patients. It is extremely important to inject fillers only in stable cases of localized morphea where there is no growth or alteration in the consistency of the lesion.

This modality of treatment should be considered for a larger trial in patients with similar disfigurements.

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