Download fil. 08-Review A

REVIEW ARTICLE 129
Mesotherapy
Thada Piamphongsant
■Mesoderm is a middle layer of tissue formed
in the early developing embryo. Therefore the treatment at this skin layer is called mesotherapy. However
the treatments sometimes extended to the superficial
layer or deeper through internal organs. Thus, to
understand the details of such therapy, we need to
have an overview of the treatmentûs principle.
To administer drugs through the skin and lower
tissue layer, several medias are needed.
A) Skin moisturization such as to moisture the
skin with water or emollient, to cover by transparent
plastics, or to use drug delivery patch which has
occlusive effect.
B) Chemical mixture such as DMSO, isopropyl
myristate, propylene glycol. These chemicals will act
as a penetration enhancers.
C) Advance technology adapted to improve the
penetration effect of the media. For example, the drug
capsule is specially designed to have better penetration
property or using some techniques to minimize the
ªï∑’Ë 10 ©∫—∫∑’Ë 2
molecules of drugs such as liposome, nanosome.
D) To change the condition of epidermis by
using electromagnetic wave, microneedles or penetration
of the drug through hair follicles.
E) Application of electrical techniques, i.e. ionto,
phono, sono or electromagnetic method.
In dermatological study, magnesium ascorbyl
phosphate cannot penetrate directly through the skin.
It has to be modified by or combined with other
methods e.g. iontophoresis-it has a synergistic effect
on superficial melasma but not effective in deeper
type. However superficial melasma can be cured by
any bleaching creams and there is no need to use
iontopheresis. In cosmetic dermatology vitamin C is
generally used to treat melasma, however there is
some limitation due to its fast deteriorating property.
Though there are attempts using various technologies
to stabilized vitamin C, the longest duration only lasts
for 3 months. Stabilized vitamin C are used instead
such as ascorbyl tetra-iso palmitate, or enveloped in
º‘ « À π— ß
µÿ≈“§¡ 2548
REVIEW ARTICLE 130
glycosphere. The selection of base substances is also
important as it has an influence in the penetration of
vitamin. It was found that vitamin C in oil-in-water
base has better penetration than in water-in-oil base
and to be in gel form is better than in cream.1
It was found that only a part of vitamin C
structure is important to fibroblast but it was not
possible for fibroblast to incorporate vitamin C. Fullerence-enveloped vitamin C which has similar structure to nanosphere might help in the penetration
process.
Fifty years ago due to poor penetration into the
skin, some French doctors thought of why not inject
vitamin C into the skin?
Nowadays patients quest for the treatment
methods. What they want are safe methods, no
complication, no anesthetic, simple for both physicians
and patients. But most of all it must be effective,
fast and not expensive. Therefore anesthetic mesotherapy seems to answer the question.
Mesotherapy is an advance technique of injection. Multiple injections at a time can be done with
minimum pain. Drugs to be used can be varied depending on the pathology of diseases. Principles of
mesotherapy are2
Right drug
Right dose (not for which can create problems),
and
Right location (suitable depth)
For example :
● Use of multivitamin, and hyaluronic acid for
wrinkles.
● Use of botox for shallow wrinkle, so called
mesobotox. Actually botox injection is a kind of
ªï∑’Ë 10 ©∫—∫∑’Ë 2
mesotherapy.
Technique
Special needles are needed for mesotherapy
injection, which are for the depth of 4, 6 and 13 mm.
At the beginning, botox injection was more popular
than that of mesotherapy, so the latter was used for
other locations that botox could not be used by
dissolving the drug at 5 times dilution. If using the
standard botox injection, it may cause twisted face.
● There are 3 main drug groups used for getting
rid of cellulite as follow :
1) The group that its effect is to increase
penetration and dilate blood vessels such as theophylline.
2) The group that its effect is to dissolve fat
by detergent substance : tween 80, deoxycholate.
3) Calcitonin.
● To eliminate extra fat at specific site by using
phosphatidylcholine
● Inject vitamin C, Asia Cantella for acne scar,
striae.
● Inject glutathione for melasma.
● Inject panthenol, zinc, minoxidil, or biotin for
hair loss.
Furthermore, mesotherapy can be used for other
disorders such as arthritis, prohibit smoking habit,
tension reduction, muscle inflammation and venous
insufficiency.
In fact, mesotherapy has been existing for more
than 45 years and was used at the beginning for
arthritis. It then was observed that cellulites around
the injected sites also disappeared.
The advantages of mesotherapy are as follows :
- No deep cutting, no operation required.
º‘ « À π— ß
µÿ≈“§¡ 2548
REVIEW ARTICLE 131
µ“√“ß∑’Ë 1 Sites of injection.
Level
Epidermis
Papillary dermis
mm
0.1-0.3
0.5-1
Physicians
Scratch test by allergist
Intradermal test by allergist
Intradermal
4
3
Dermatologist : intralesional
Dermis-subcutaneous junction
6
Dermatologist : intralesional
Subcutaneous
Intramuscular
Articular area
12
Dermatologist : intralesional
GP, dermatologist (botox)
Rheumatologist
Mesotherapy
IED (reju)
ID (acne scar),
dermal melasma,
beading technique
IDS (hair loss),
Nappage technique
IDP (cellulite),
allergy injection
DHD (obesity)
Mesobotox
Fibro-osseous junction,
acupuncture pt.
Remarks : IED = intraepidermal, ID = intradermal, beading technique (inject to pop a pimple), Nappage technique (see explanation in this
text), IDS = intradermal superficialis, IDP = intradermal profundus, DHD = deep hypodermic, Acupuncture pt. = needle piercing
- Low dose usage and precise localization
- No complication to any part of the body.
- Time release absorption3. Experimentally
it was found that the penetration of substances that
was injected at the upper dermis level is much better
than at the deeper level as it slowly percolates. Such
substances should be water soluble, neutral status, no
allergic, natural, curable and safe.
injection needle should be 4-6 mm in length.
4. Mesodrip : attach an adapter and slowly inject
at one time with 3.5 gauge needles, and slowly push.
5. By using a mesosystem pistol, the depth of
injection sites and the dosage can be adjusted equally
or every spot of injection by using Nappage or single
injection.
List of drug group
■ Drug injection technique
1. Inject to intraepidermal site.
2. Nappage which is a rapid injection technique,
by using one syringe to inject several times continuously into the dermis.
3. Single spot injection
- Inject for dermatological purpose. This
depends on the depth of clinical sites.
- Inject is similar to immunological test.
This creates a small wheal which is rather painful
and is used to cure the deep scar. For deeper site,
ªï∑’Ë 10 ©∫—∫∑’Ë 2
1. Anesthesia group : lidocain, xylocain
2. Arthritis : NSAIDs, calcitonin, analgesic
group
3. Increase blood circulation group : buflomedil,
pentoxyphyllin
4. Multivitamin
5. Stimulate immune system
6. Drug that effect to reduce tension on
neuron system such as amitriptyline
7. Drug group to cure general disease in our
body such as phloroglucinol
º‘ « À π— ß
µÿ≈“§¡ 2548
REVIEW ARTICLE 132
Pain killer
Use lidocain when having pain anywhere
and as soon as symptoms start. Use procain for chronic pain
● Dosage is 1/60 of edible drug
● May use analgesic, neuron-effect drug
anti-inflammation drug : calcitonin
● When having pain from sprain and strain,
use piroxicam plus lidocain. It was found that
mesotherapy has more advantage than other treatments in many ways. For example : a symptom of
tennis elbow can be improved by taking medicine
within 3 months, by steroid injection within 2 weeks
but by using mesotherapy, the patients can get better
and may have some light exercise within the next day.
If it is muscle pain, then use analgesic drug.
For chronic pain use calcitonin
Neural pain such as herpes zoster : inject spot
by spot along the nerve line along the lower part of
costal cartilage.
●
Cellulite treatment
To get rid of cellulite we need to know the
pathway of lipid dissolution. There are 4 steps of
treatment as follows :
1. To reduce water retention in fat cell by
using dehydrated substance such as mannitol or by
hand massage or using some instruments. Some massagers may claim that it is the way to release fat while
its real effect is only to decrease water.
2. To smoothen blood circulation by applying
drug that enlarge blood vessel such as pentoxyphyllin,
PTMB [4-(1-pyrrolidimyl)-1-(2,4,6-trimethosyphenyl)1-butanone], buflomedil or electricity to warm up.
ªï∑’Ë 10 ©∫—∫∑’Ë 2
Nowadays laser technique is used to hit the cellulite
and using body wrap to warm up (but not to reduce
fat). When the skin is warm water is released (not
fat) temporarily for a few days. Therefore after a few
days cellulite will return, except that the patient will
do some exercise in combination with fasting.
3. Fat dissolution
A) Using detergent. Similar to dish washing solutions that dissolve fat. The detergent emulsifies fat into small particle and turn to be fatty acid
e.g. tween 80, deoxycholate.
B) Using other substances such as phosphatidylcholine, calcitonin.
C) Destroyed fatty acid by using carnitine
and conjugated linoleic acid.
D) Hibiscus extract can reverse chylomicron
to triglyceride.
E) Use additive that can react to c-AMP
to dissolve fat to fatty acid such as coffee, theophylline.
4. To strengthen the destroyed tissue by using
antioxidant mixed with silicium to renew the tissue.
The injected solution might not be composed of
all the essential active ingredients, so slimming cream
is needed to apply on the skin lesion as well because
it has all the ingredients. Some physicians might
think that applying slimming cream is not necessary.
However one should realize that most people do not
like injection. By applying cream the ingredients can
penetrate through the skin better. Most creams consist
of transdermal delivery system which enhances drug
delivery into the skin or the medicine absorption may
be accelerated by covering the treated area with a
transparent plastic during bedtime. We advice patient
º‘ « À π— ß
µÿ≈“§¡ 2548
REVIEW ARTICLE 133
to cover the treated area with thin transparent
aluminum pads (see thru) to produce heat. The most
important suggestion to patients is exercise and control
diet otherwise the fat accumulation will return to the
same level. Drug injection is only 70% effective, so
a cream should also be applied.
Problems in using phosphatidylcholine
(PC)
In USA this substance is classified as a food
ingredient, not as a drug because it is made from egg
yolk sac, not yellow eggs. Americans bought it from
Brazil to extract contaminated substances off.
In Thailand there are many problems about
cellulite injection due to wrong injection technique,
for example :
- The person doing the procedure is not
well trained and do not know the right depth of
injection level. People think that they can just consult
any pharmacist and they are not keen to study the
proper method.
- The drug imported from Brazil is not
pure enough and are oil base. Actually, it should be
water base which is the most suitable preparation.
- Wrong drug mixture. Again, people
just think they can ask the pharmacists or the
personnel responsible for the product.
So there are problems in applying mesotherapy in Thailand. After injection a patient will get
granuloma. In the picture (Fig. 6), a woman used PC
injection and got granuloma, which was probably due
to over application. This substance cannot be injected
at superficial dermis as it may cause skin necrosis
and it can make people blind if the infection site is
ªï∑’Ë 10 ©∫—∫∑’Ë 2
Fig. 6 Granuloma after PC injection. (see colored picture p.
216)
near the eyes. The type of drug to be used also
depends on the grading of cellulite.
The International Physicians Association in
Mesotherapy and most Americans do not recommend
the use of PC due to the following reasons :
1) Create skin granuloma
2) Safety of drug use to cure cellulite cannot
be guaranteed.
3) Other substances can also be used effectively. The fat dissolution effect is also not greater
by using surfactant alone4 and even create more harm.
For fat under eye lids it is suggested to consult the
surgeon as the injection of phosphatidylcholine is too
risky.
Aesthetic mesotherapy
1. Applying hyaluronic acid, vitamins and
other minerals have rejuvenation effect to the face
sooner.
2. Alternative way is to use other substances
to rejuvenate the face within 15 minutes. This is
suitable for the ones with lots of wrinkles, especially
movie stars. Other substances such as DNA, placenta,
º‘ « À π— ß
µÿ≈“§¡ 2548
REVIEW ARTICLE 134
proteo-chrondriotin sulfate is still on experimental ment effect in synthesizing collagen fibers together
process.
with other substances.
Injection to acne scar : by using multi vitamin
Hair loss therapy
silicium and Asia cantella injection give better result.
Several mixtures are used such as panthenol,
biotin, zinc. Other substances such as finasteride, ■ Conclusion
Mesotherapy is the technique originating in
dutasteride and other hormones are still under reFrance and had been used to cure arthritis for more
search.
The danger in taking finasteride orally is than 60 years and to eliminate cellulite for 45 years.
dangerous as there is 30% possibility that it can create The technique nowadays is used in America. In
cancer of prostate gland while there is no evidence 2004, there were 5,000 trainees and the technique is
of PSA (prostatic specific antigen) increment found. certified by American Board of Mesotherapy. In
The size of prostate gland is still normal and can be Thailand, the proper technique usage should be
diagnosed only by tissue biopsy with 30% chance to learned and the drugs should be selected for safe
use. After reading this article and if there is any
be.5
The treatment of Striae Distensae from preg- unclear information the reader may take a jet plane
to America or France to see how advance they are
nancy and over dose of steroid.
Injection of Asia cantella extract has supple- or simply call the author at 0-2424-9619.
■
‡Õ° “√Õâ“ßÕ‘ß ■
1. Huh CH, Seo KI, Park JY, Lim JG, Eun HC, Park KC. A randomized, double-blind, placebo-controlled trial of
vitamin C iontophoresis in melasma. Dermatology 2003;206:316-20.
2. Adelson H. Introduction to mesotherapy. Lecture note. 2004. Salt lake City, USA.
3. Rotunda AM, Suzuki H, Moy RL, Kolodney MS. Detergent effects of sodium deoxycholate are a major feature
of an injectable phosphatidylcholine formulation used for localized fat dissolution. Derm Surg 2004;30:1001-8.
4. Thompson IM, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford LG, et al. The influence of finasteride on
the development of prostate cancer. N Engl J Med 2003;349:215.
5. Kaplan AR. Devernir dûun produit Marque injecte par quatre voies differentes. Bulletin SFM; 1985. p. 62.
ªï∑’Ë 10 ©∫—∫∑’Ë 2
º‘ « À π— ß
µÿ≈“§¡ 2548