Correction of scar changes in rosacea using combined injection methods (clinical case)

Abstract

A description of a clinical case is presented: a patient with subcutaneous scar changes in the area of ​​the cheeks and chin secondary to steroid rosacea. Correction of cosmetic defects was successfully carried out by introducing into the problem area sequentially and alternately an enzyme preparation based on hyaluronidase subcutaneously and a biorevitalizant with hyaluronic acid and a vitamin-mineral complex intradermally.

Key words: rosacea, Metrogyl, Mirvaso, hyaluronidase, Longidase, polyrevitalization, NCTF-135, combination therapy.

Patient Ch., 38 years old, came to the clinic with complaints of redness and flaking of the skin in the area of ​​the nose, cheeks, forehead and chin, accompanied by a feeling of tightness and dryness; pustular rashes on the skin of the cheeks and chin, painful on palpation; “irregularities” in the relief of the skin of the cheeks.

History and diagnosis

The patient considers herself ill for about three years, when she first noted the appearance of persistent redness of the face in the area of ​​the cheeks and chin.

On the recommendation of a dermatologist, I used Metrogyl gel [1] topically and Trichopolum 250 mg orally for a course of 3 weeks. During the therapy, the patient noted a temporary improvement in the form of a decrease in facial hyperemia, but 2 months after stopping treatment, the process resumed. In addition, in addition to redness of the skin, there was a feeling of tightness, itching and multiple large pustular elements, painful on palpation.

When I returned to the doctor, I was tested for demodex - it was not detected. The dermatologist prescribed topical Celestoderm B cream with garamycin for a 4-week course, which resulted in almost complete regression of all existing rashes.

Subsequently, when the disease relapsed, the patient independently haphazardly used topical corticosteroids for almost two years. Gradually, I began to notice the formation of subcutaneous lumps in places where large pustular elements were previously located, facial hyperemia became brighter, and irregularities and retractions appeared on the surface of the skin of the cheeks. According to the patient, without the use of hormonal creams and ointments, the rashes on the facial skin intensified, but even when returning to their use, a complete clinical cure did not occur.

The patient notes that she is forced to use a large amount of foundation every day to camouflage cosmetic imperfections. At the reception, attention is drawn to the fact that the woman is in a depressed psycho-emotional state, formed due to the low effectiveness of previous therapy, disbelief in the success of further treatment and dissatisfaction with her own appearance. During the consultation, we managed to convince the patient that modern injection correction methods will solve not only dermatological, but also aesthetic problems.

Metrogyl for rosacea

Rosacea is a fairly common disease that requires complex treatment and intervention for results.
The disease often goes unnoticed until health consequences appear, which is why it is worth noticing at the first symptoms. If, after visiting a cosmetologist, a diagnosis of Rosacea is made, it is necessary to begin comprehensive treatment. Metrogyl, many cosmetologists recommend using it in addition to the main prescribed treatment to obtain a more pronounced result.

It is worth taking a closer look at the treatment and the necessary comprehensive measures that cannot be excluded from daily care.

Local status

The skin in the central part of the face (forehead, nose, cheeks, chin) is bright pink with a bluish tint and fine-plate peeling on the surface. In the area of ​​the left cheek (near the wing of the nose) and chin on the right there are two large pustular formations measuring 4 mm with a rim of hyperemia along the periphery and a serous-purulent crust on the surface. On palpation - moderate pain in the area of ​​inflammatory elements.

In addition, a pronounced unevenness of the skin relief in the cheek area with multiple places of retraction is visually determined. Upon palpation, multiple spherical compactions are detected subcutaneously in the area of ​​the cheeks and chin, with an average diameter of 3 to 8 mm (Fig. 1A).

Controlling the amount of vitamins

A common cause of rosacea is an insufficient amount of vitamins, which causes problems with the condition of the skin, hair, and nails. As the problem appears, it is recommended to take a blood test for vitamins and their amounts.

Rosacea is a common disease that requires complex treatment and impact on the result. The disease often goes unnoticed until health consequences occur, so it is worth treating it at the first symptoms.

If, after visiting a cosmetologist, a diagnosis of rosacea is made, it is necessary to begin comprehensive treatment. Many cosmetologists recommend using Metrogyl in addition to the main prescribed treatment to achieve a more pronounced result.

If the examination results show an insufficient amount of essential vitamins and microelements, you will need to take them in medicinal form. At the same time, the treatment also remains complex, that is, it will be necessary to influence the inflammatory processes to obtain results.

Recommendations and appointments

Before the start of treatment and at the end of each of its stages, photographic recording of the dynamics of the skin process was carried out. Before the start of injection therapy, informed consent for the procedures was signed, and written permission from the patient was obtained to publish her photographs in print media.

Rice. 1. Patient Ch., 38 years old: A - at the initial consultation; B - after the 1st stage of therapy; B — after the 2nd stage of therapy; D - after the 3rd stage of therapy.

Table. Structure of the combined injection program

Due to the complexity of the clinical case and the development of complications in the form of cicatricial deformation of the subcutaneous tissue, it was decided to create an individual comprehensive program for the correction of cosmetic defects for the patient, including 3 main stages (see table

).

1. Elimination diet with the exclusion of extractives and foods that provoke vasodilation (pickled, spicy, smoked, alcohol, coffee, scalding hot drinks and food).
2. Inside - multivitamin complexes (to compensate for possible deficiencies of vitamins and microelements) for at least 1 month.
3. Topical therapy (at the sites of rashes) - Mirvaso derm gel (in the morning), Solantra cream (in the evening), 4 weeks.
4. For large ulcers - spot liquid Dimexide diluted 1:2 with distilled water, 2 times a day, 2 weeks.
5. Subcutaneous injections of Longidase (lyophilisate 3000 IU), 2 times a week, a course of 10 procedures (at a dose of 3000 IU per procedure).
6. Intradermal injections of the drug NCTF135 3.0 ml, once a week, for a course of 5 procedures.

Normalization of the daily routine

Insufficient sleep or drinking clean water can also negatively affect the skin, causing obvious problems in the form of inflammatory processes. Insufficient sleep affects the body directly, especially if the lack continues for a long time. If you have problems with your skin condition, look at your napkin and the amount of clean water.

As for water, most of a person consists of it, and therefore it is necessary to drink liquid for normal well-being and the functioning of internal organs. It is important to drink clean water, not carbonated water or juices or teas. Water without gases and various chemical additives is best absorbed, which is why it is better to drink pure liquid directly.

The amount of clean water is calculated individually for a person, depending on his body weight, the characteristics of the excretory system, the presence of diseases, etc.

Treatment performed

1st stage

The initial task was to achieve remission of the skin process as quickly as possible, and only then carry out a series of injection interventions to solve cosmetic problems. The situation was complicated by the fact that the patient had developed an addiction to corticosteroids over several years. In such cases, the doctor primarily performs the function of a dermatologist and only then a cosmetologist.

Together with the patient, a decision was made to discontinue local corticosteroids. The patient was explained that discontinuation of hormonal cream could lead to a temporary exacerbation of the skin process—withdrawal syndrome [3]. As a topical therapy, it was decided to choose the combined use of Mirvaso Derm gel and Solantra cream.

The choice of these drugs was dictated by two reasons. Firstly, metronidazole-based products for external use had already been prescribed to the patient and had an insufficient therapeutic effect. Secondly, Mirvaso gel (brimonidine tartrate) and Solantra cream (1% ivermectin) are modern, highly effective treatments for rosacea and perioral dermatitis. Brimonidine is a highly selective α2-adrenergic receptor agonist [4], and ivermectin is an anti-inflammatory drug that suppresses the production of cytokines and causes the death of Demodex mites. Their combined use solves several problems at once: it reduces facial skin hyperemia due to direct vasoconstriction of small blood vessels of the dermis and, in parallel with this, has an anti-inflammatory and antiparasitic effect on the dermal pathogenic flora. Moreover, according to numerous studies, the effectiveness of ivermectin is much higher than that of metronidazole derivatives [5].

Antibacterial, local analgesic and anti-inflammatory effects in the area of ​​pustular elements were achieved through the use of a 30% solution of Dimexide (dimethyl sulfoxide). Quickly penetrating into the deep layers of the skin, it stopped the inflammatory process, reduced the intensity of pain and helped reduce subcutaneous infiltration in the area of ​​pustules [6].

The patient was recommended to use Mirvaso Derm gel in the morning and Solantra cream in the evening for 4 weeks. Interestingly, against the background of such topical therapy, it was possible to avoid exacerbation and in a short time (less than 1 month) to almost completely get rid of facial hyperemia. Presumably, the use of Mirvaso Derm gel played a leading role in the absence of corticosteroid withdrawal syndrome.

The use of Dimexide liquid in a 1:2 dilution locally made it possible to reduce the size of pustular elements and dry them with the formation of a serous crust on the surface (Fig. 1B). As a result, the skin process went into remission (hyperemia decreased, the local inflammatory process stopped), which made it possible to move on to the next phase of therapy. The patient’s subjective state also noticeably improved, as she saw the first positive results and believed in the successful outcome of the therapy begun.

2nd stage

At the next stage, after regression of rosacea symptoms and abandonment of corticosteroid therapy, it was necessary to achieve leveling of the relief of the facial skin and splitting of the formed subcutaneous fibrous tissue.

Currently, a generally accepted means of influencing connective tissue is the enzyme hyaluronidase. But the therapeutic effect of existing enzyme preparations based on hyaluronidase is low due to their rapid destruction in the biological environment of the body and the ability to provoke an antigenic response. To solve this problem, Longidase 3000 IU, which is a conjugate of hyaluronidase with a high-molecular-weight carrier polyoxidonium, became the drug of choice. This is a prolonged, heat-stable form of hyaluronidase that is resistant to inhibitors. In addition, polyoxidonium has immunomodulatory, detoxifying and antioxidant properties. Thanks to this, Longidaza is a multifunctional drug that can not only suppress the acute phase of inflammation, but also prevent the reactive growth of connective tissue and cause the reverse development of fibrosis [7].

Immediately before the procedure, the contents of 1 bottle of Longidase 3000 IU were dissolved in 2.0 ml of 0.9% sodium chloride solution. In the process of diluting Longidase, it is necessary to remember that the solvent must be added to the vial very slowly, without shaking, otherwise the protein will foam and the drug will not be able to be drawn into the syringe. Novocaine solution was not used to dilute the lyophilisate, since the patient was not sure that there was no history of an allergic reaction to novocaine.

The resulting solution was injected subcutaneously into the scar tissue in the cheeks and chin. The procedures were performed 2 times a week, a course of 10 injections. Interestingly, at the beginning of the course of Longidase therapy, the needle had difficulty penetrating the skin, encountering resistance from fibrous tissue. Already by the 5th procedure, the advancement of the needle into the deep layers of the skin was significantly easier, and by the 9th–10th procedures, subcutaneous scar compactions in the area of ​​the cheeks and chin were no longer detectable during palpation, the skin texture was leveled, places of retraction and unevenness disappeared (Fig. 1B ).

3rd stage

The final phase of treatment was a mesotherapy course with NCTF135 (Filorga). Given the widest range of biorevitalizants, this drug was chosen due to its combination of high efficiency, multicomponent composition and good tolerability [8]. NCTF135 has proven itself due to the absence of stabilizers, preservatives, dyes and fragrances. In addition, the author of the article has his own experience of the successful use of this drug in the injection treatment of dermatological pathologies (alopecia, post-acne, vitiligo).

The composition of the drug NCTF135 includes a revitalizing complex of 54 active ingredients: 13 vitamins, 23 amino acids, 6 minerals, 6 coenzymes, 1 antioxidant (glutathione) and hyaluronic acid at a concentration of 0.025 mg/ml. Hyaluronic acid plays an important role in tissue hydrodynamics, processes of cell migration and proliferation. In addition, it activates neoangiogenesis, improving skin microcirculation. Amino acids and peptides serve as building materials for cells, and vitamins A, E, C and group B have antioxidant properties and are involved in basic metabolic processes and skin regeneration.

After preliminary anesthesia with Emla cream (30 min), NCTF135 was administered intradermally in an amount of 3.0 ml using the papular technique. The procedures were performed once a week, in a course of 5 injections. Thanks to the normalization of microcirculation and the moisturizing effect of hyaluronic acid, by the end of the 3rd week of the mesotherapy course, peeling completely disappeared, and the patient noted the disappearance of the feeling of dryness and tightness of the facial skin. By the 5th procedure, the skin acquired a fresher appearance, a natural shade, and became softer and more elastic to the touch (Fig. 1D).

Visiting a doctor and cosmetologist

An option would be to visit a cosmetologist who can make the correct diagnosis and fully study the problem. During treatment, regular visits to the doctor are required to achieve results, since the treatment constantly needs to be adjusted and changed to suit the situation.

At the first visit, the cosmetologist will draw conclusions about the disease, its severity, prescribe treatment, and schedule a visit. If the first prescribed treatment does not bring results, it will require a complete change or adjustment, since the remedies are not suitable for the patient. Treatment of the disease takes time, since it occurs uniquely in a person, that is, it requires a search for individual treatment.

The use of additional preventive drugs, for example Metrogyl, will help speed up the regeneration process and reduce the spread of bacteria. It is bacteria that cause the appearance of pus in places of formation of inflammatory processes, which is why in order to treat purulent formations it is necessary to influence the bacteria and their activity. Antibiotics are required to attack the problem from the inside, but local exposure will help to get a more obvious result in 3-5 days. The product has a safe composition and does not involve the risk of side effects, which is why it can be used when a problem occurs. You should take any medications with caution during pregnancy and breastfeeding, as well as for chronic diseases.