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Mehta N, Sharma A, Sindhuja T, Dudani P, Sahni K, Khanna N, Gupta S. Procedural dermatology and its unmet need. Indian J Dermatol Venereol Leprol 2023; 89:807-818. [PMID: 36688880 DOI: 10.25259/ijdvl_322_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/01/2022] [Indexed: 12/16/2022]
Abstract
Procedural dermatology includes invasive conventional dermatologic surgeries which involve significant use of knife and suture, minimally invasive procedures and device-based procedures. Device-based procedures are the easiest to learn and are less prone to human errors due to automation but can lead to monotony, while conventional surgeries require significant skill, craftsmanship and interest. There has been a recent shift in the approach to procedural dermatology as a therapeutic option with complementary and combination models replacing the conventional hierarchical model in which procedures were last in the step-ladder approach. The demand for both conventional dermatologic surgeries and minimally invasive cosmetic procedures is increasing. Unfortunately, this demand has not been met with adequate supply. Consequently, the number of trained professionals with expertise in these procedures is very limited; they are far outnumbered by unqualified practitioners. A limited number of dermatologic surgeons practicing conventional surgeries has resulted in huge waiting lists for vitiligo surgeries, inappropriate excisions for skin cancers and poor cosmetic outcomes of excisions without proper knowledge of flaps and grafts. Increasingly procedures are being performed by inadequately trained personnel, resulting in complications. There is also an absence of good quality research on the subject of procedural dermatology, which has resulted in a lack of standardisation of various procedures and knowledge about the efficacy of various drug-procedure and procedure-procedure combinations. An increasing variety of gimmicky but costly procedures are being offered to the public without much evidence of efficacy. Individual institutional and broad policy directives are needed to address these issues. Special emphasis is required on formal hands-on procedural dermatology training during residency and beyond it.
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Affiliation(s)
- Nikhil Mehta
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Ananya Sharma
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Tekumalla Sindhuja
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Pankhuri Dudani
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Kanika Sahni
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Neena Khanna
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Somesh Gupta
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Sharad J. Hyaluronic Acid Filler Injection for Localized Scleroderma - Case Report and Review of Literature on Filler Injections for Localized Scleroderma. Clin Cosmet Investig Dermatol 2022; 15:1627-1637. [PMID: 35983128 PMCID: PMC9379108 DOI: 10.2147/ccid.s356641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/04/2022] [Indexed: 11/23/2022]
Abstract
Introduction Localized scleroderma, also known as Morphea, is a chronic inflammatory condition of connective tissue, the etiology of which is unknown. There is skin thickening with increased quantities of collagen in the indurative lesion. Skin hyperemia is seen in the early inflammatory stage. This is followed by fibrosis, sclerosis, and atrophy with hypopigmentation or hyperpigmentation. 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. Case Report A 35-year-old lady with stable localized scleroderma had an atrophic scar on the right side of her face extending from the labio-mental crease to the midline of the chin. The contour of the chin was lost leading to facial disfigurement. The atrophic scar was treated with 2 fillers with the same cross-linking polymer but two different G primes with excellent cosmetic outcome. A brief review of literature involving fillers for localized scleroderma is also discussed. Conclusion Hyaluronic acid filler can be used safely in cases of stable localized scleroderma with facial atrophies. It is an effective, minimally invasive treatment with minimal downtime. It is extremely important to inject fillers only in stable cases of localized morphea. This modality of treatment should be considered for a larger trial in patients with similar disfigurements.
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Affiliation(s)
- Jaishree Sharad
- Skinfiniti Aesthetic Skin and Laser Clinic, Mumbai, Maharashtra, India
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Koren A, Sarbagil-Maman H, Litinsky I, Furer V, Artzi O. Dermal Filler Injections in Patients With Autoimmune and Inflammatory Rheumatic Diseases-The Patients' Perspective. Dermatol Surg 2022; 48:82-86. [PMID: 33337734 DOI: 10.1097/dss.0000000000002888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Injecting dermal fillers in patients with autoimmune inflammatory rheumatic diseases (AIIRDs) is controversial. OBJECTIVE To evaluate the attitudes of patients with AIIRDs regarding the use of dermal fillers and the side effects of those who underwent them. METHODS Patients with AIIRDs who attended a rheumatology outpatient clinic between 2016 and 2018 filled in a questionnaire about their attitudes toward dermal filler injections. The questionnaire evaluated information received from professionals and the factors that influenced their decision of whether or not to undergo the procedures. RESULTS Overall, 194 patients with AIIRDs (mean age 56.5 ± 14.0, 99% women) responded. Forty-two of them had previously undergone the injections and intended to repeat them (Group A), 37 had not received filler injections but intended to do so (Group B), and 114 who had never undergone them did not intend to undergo them. The major motivation for undergoing filler injections was social. Patients treated with dermal fillers refrained from informing their rheumatologist about their injections. They were, however, highly satisfied with the procedure and reported negligible side effects. CONCLUSION The use of dermal fillers was apparently safe and well received by patients with AIIRDs. Physicians' recommendations to refrain from injecting them with dermal fillers should be reconsidered and evaluated in clinical studies.
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Affiliation(s)
- Amir Koren
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Sarbagil-Maman
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Irina Litinsky
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Victoria Furer
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ofir Artzi
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Safety and Efficacy of Dermal Fillers in Patients With Connective Tissue Disease: A Review. Dermatol Surg 2021; 47:360-364. [PMID: 34328288 DOI: 10.1097/dss.0000000000002870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Dermal fillers such as hyaluronic acid, poly-l-lactic acid, and polymethyl-methacrylate are often used to treat cutaneous defects such as lipoatrophy. However, concern exists regarding their use in patients with a connective tissue disease (CTD) because of a theoretical risk of disease reactivation or exacerbation. Evidence regarding their use in patients with CTD also remains limited. OBJECTIVE This review intends to summarize and evaluate the available literature regarding the use of dermal fillers in patients with CTD. MATERIALS AND METHODS A literature search until May 2020 was conducted through PubMed, Ovid MEDLINE, and Ovid Embase to identify articles discussing the treatment of cutaneous defects secondary to CTD. Articles discussing the use of autologous fat transfer alone were excluded. RESULTS Twenty-three articles were reviewed. The amount of available evidence varies between the type of CTD and type of filler with morphea having the most published evidence out of the CTDs discussed and hyaluronic acid having the most published evidence out of the fillers discussed. Most studies demonstrated positive results with no report of disease reactivation or exacerbation. CONCLUSION Despite limited available evidence, dermal fillers seem to be safe as an adjunctive treatment for cutaneous defects in patients with CTD.
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Owczarczyk-Saczonek A, Kasprowicz-Furmańczyk M, Kruszewska A, Krajewska-Włodarczyk M, Bechtold A, Klimek P, Placek W. The Correction of Facial Morphea Lesions by Hyaluronic Acid: A Case Series and Literature Review. Dermatol Ther (Heidelb) 2020; 10:1423-1434. [PMID: 32876907 PMCID: PMC7649201 DOI: 10.1007/s13555-020-00438-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The aim of the study is to assess the long-term safety and efficacy of hyaluronic acid (HA) administration in correction of facial morphea lesions and to review the literature on the subject. Morphea is a chronic inflammatory disease of the connective tissue which may lead to serious deformations. The lesions located on the face particularly affect patients' quality of life and self-esteem; thus, there is a demand for safe and effective methods of treatment. CASE PRESENTATION The paper presents three female patients aged 16, 17 and 70 with facial morphea lesions who had HA preparation Juvéderm® Voluma or Volux, Vycross® technology, Allergan, injected. One of the patients had additionally fractional ablative CO2 laser (FAL) therapy. DISCUSSION The literature provides reports on successful use of HA, polymethylmethacrylate and poly-L-lactic acid for the correction of facial defects in localized scleroderma. HA is a natural component of the extracellular matrix and it therefore minimizes the probability of immunogenicity. The application technique also plays an important role. On the other hand, FAL therapy leads to the degradation of the abnormal collagen and the induction of normal collagen synthesis. CONCLUSIONS HA injection and combination of HA application with FAL are minimally invasive, effective and safe therapeutic options for patients suffering from morphea.
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Affiliation(s)
- Agnieszka Owczarczyk-Saczonek
- The Chair and Clinic of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The Municipal Polyclinical Hospital in Olsztyn, Olsztyn, Poland
| | - Marta Kasprowicz-Furmańczyk
- The Chair and Clinic of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The Municipal Polyclinical Hospital in Olsztyn, Olsztyn, Poland
| | - Anna Kruszewska
- The Chair and Clinic of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The Municipal Polyclinical Hospital in Olsztyn, Olsztyn, Poland
| | - Magdalena Krajewska-Włodarczyk
- Department of Rheumatology, The Municipal Polyclinical Hospital in Olsztyn, Olsztyn, Poland
- Department of Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Agata Bechtold
- The Chair and Clinic of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The Municipal Polyclinical Hospital in Olsztyn, Olsztyn, Poland.
- Psychodermatology Department, Medical University of Lodz, Łódź, Poland.
| | - Paulina Klimek
- The Chair and Clinic of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The Municipal Polyclinical Hospital in Olsztyn, Olsztyn, Poland
| | - Waldemar Placek
- The Chair and Clinic of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, The Municipal Polyclinical Hospital in Olsztyn, Olsztyn, Poland
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Creadore A, Watchmaker J, Maymone MBC, Pappas L, Lam C, Vashi NA. Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with morphea/systemic sclerosis. J Am Acad Dermatol 2020; 83:315-341. [PMID: 32360721 DOI: 10.1016/j.jaad.2019.12.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/24/2019] [Accepted: 12/28/2019] [Indexed: 02/06/2023]
Abstract
Morphea and systemic sclerosis are inflammatory, sclerosing disorders. Morphea primarily affects the dermis and subcutaneous fat, while systemic sclerosis typically involves the skin and internal organs. Functional impairment and cosmetic disfigurement are common in both diseases. Treatment options to mitigate disease progression remain limited. Both functional impairment and cosmetic deficits negatively impact quality of life and psychological well-being in this patient population. While the number of cosmetic procedures performed in the United States continues to rise each year, limited data exist regarding best practices for correcting aesthetic deficits caused by autoimmune conditions. There is scarce information to guide safety decisions regarding laser parameters, soft tissue augmentation, treatment intervals, and the concurrent use of immune-modifying or immune-suppressing medications. Given the fears of disease reactivation and exacerbation from postprocedural inflammation along with limited data, it is difficult for clinicians to provide evidence-based cosmetic treatment with realistic expectations with regard to short- and long-term outcomes. In the first article in this continuing medical education series, we attempt to address this practice gap.
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Affiliation(s)
| | - Jacqueline Watchmaker
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Mayra B C Maymone
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Leontios Pappas
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Christina Lam
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Neelam A Vashi
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts.
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Pirrello R, Verro B, Grasso G, Ruscitti P, Cordova A, Giacomelli R, Ciccia F, Guggino G. Hyaluronic acid and platelet-rich plasma, a new therapeutic alternative for scleroderma patients: a prospective open-label study. Arthritis Res Ther 2019; 21:286. [PMID: 31836018 PMCID: PMC6911298 DOI: 10.1186/s13075-019-2062-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 11/12/2019] [Indexed: 02/06/2023] Open
Abstract
Background Systemic sclerosis is a systemic connective tissue disease characterized by endothelium damage, fibrosis, and subsequent atrophy of the skin. Perioral fibrosis produces a characteristic microstomia together with microcheilia, both of which cause severe difficulties and affects patients’ daily life, such as eating and oral hygiene. Since there are no effective and specific therapies, we have aimed at evaluating the response to filler injections of hyaluronic acid together with platelet-rich plasma. Methods Ten female patients aged between 18 and 70 were included in this study. Each patient was treated with three filler injections of hyaluronic acid and platelet-rich plasma at an interval of 15 to 20 days. Follow-up check-ups were recorded 1, 3, and 24 months after the end of the treatment. During the therapy and the subsequent follow-up, we evaluated the mouth’s opening, freedom of movement of the lips, and skin elasticity. Results After the treatment, patients had achieved good results already after the first injection and the improvement was maintained in the following months, up to 2 years. In particular, 8 (80%) patients showed a greater mouth’s opening and increased upper lip’s thickness during 1-month follow-up and maintained these results after 2 years (maximum mouth’s opening T0 47.61; T3 49.23; T4 48.60 p < 0.0001. Upper lip’s thickness T0 4.20; T3 4.75; T4 4.45 p < 0.0001). Moreover, distance between upper and lower incisors (T0 27.05; T3 29.03; T4 28.14 p < 0.0001), inter-commissural distance (T0 49.12; T3 51.44; T4 50.31: p < 0.0001), and lower lip’s thickness (T0 3.80; T3 4.85, 5.10; T4 4.25; p < 0.0001) were increased in all of patients in 1-month follow-up, keeping these benefits after 24 months and having a significant increase of skin elasticity 1 month after the end of therapy. Conclusions Our study demonstrates that filler injections of hyaluronic acid and platelet-rich plasma represent an efficient local therapeutic alternative for patients affected by scleroderma. The treatment has significantly improved patients’ quality of living.
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Affiliation(s)
- Roberto Pirrello
- Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sezione di Chirurgia Plastica e Ricostruttiva, Università di Palermo, Palermo, Italy
| | - Barbara Verro
- Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sezione di Chirurgia Plastica e Ricostruttiva, Università di Palermo, Palermo, Italy
| | - Giulia Grasso
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", Sezione di Reumatologia, University of Palermo, Palermo, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Palermo, Italy
| | - Adriana Cordova
- Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Sezione di Chirurgia Plastica e Ricostruttiva, Università di Palermo, Palermo, Italy
| | - Roberto Giacomelli
- Department of Biotechnological and Applied Clinical Science, Rheumatology Unit, School of Medicine, University of L'Aquila, Palermo, Italy
| | - Francesco Ciccia
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", Sezione di Reumatologia, University of Palermo, Palermo, Italy
| | - Giuliana Guggino
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", Sezione di Reumatologia, University of Palermo, Palermo, Italy.
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Corrective Hyaluronic Acid Fillers and Combination Cosmetic Treatments for Facial Cutaneous Defects Due to Autoimmune Connective Tissue Diseases: A Retrospective Review. Dermatol Surg 2017; 43:1510-1513. [DOI: 10.1097/dss.0000000000001148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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