From the Archives: Fall 2004 Issue of Lupus Now
Ask the experts
Q: Is treatment with lasers, collagen, Restalyne, Botox or thermage okay for people with either cutaneous or systemic lupus? What about microdermabrasion, chemical peels, and sclerotherapy for spider veins?
A: With the recent attention on plastic surgery and other cosmetic procedures, more people—including those with lupus—are questioning the safety of various skin treatments. Some may be considering dermatologic interventions for disease-related reasons, including side effects from lupus treatment (such as stretch marks) or from lupus itself (such as scars from discoid lupus).
However, a distinction should be made between reconstructive or reparative treatments for damaged skin and purely cosmetic procedures. Lupus patients in remission who are left with permanent scarring may be treated the same way as a person who has been in a car accident or in a fire. Certainly we are cautious with these treatments, because any technique that manipulates the skin could reactivate the lupus. There are a number of criteria we establish before considering a person with lupus for these types of skin treatments. First, the person’s lupus must be in full remission. Also, his or her rheumatologist and dermatologist must agree with the planned treatment.
In the last three to four years, pulsed-dye and other laser treatments have been particularly helpful in reducing the blood vessels caused by the lupus malar, or “butterfly,” rash. This is the same technology that has been used on children with port-wine birthmarks on the face. Carbon dioxide (CO2) laser resurfacing of scars has also shown promise in selected patients. Again, all patients considered for laser treatment are pre-screened as outlined above. We also make sure any drugs they are taking will not significantly delay healing. Striae (stretch marks) are a very troublesome problem subsequent to steroid treatment. No one technology works as well as we would like.
Collagen has been used for years to fill in scars in the skin, often caused by acne or burns. But the use of collagen in lupus—or any autoimmune disease—has been quite controversial. Dermatologists who treat lupus patients with collagen have not seen an increase in significant or unusual reactions, but caution is advised. And, although we pre-test everyone for any allergic reaction, there can be problems if a person is on high doses of immunosuppressives or corticosteroids, since a false-negative test result may occur. Recently, a new form of collagen derived from a human cell line has been introduced, and no allergy pre-testing is required for its use.
The latest filler is Restalyne (pronounced REST-uh-lyn), a synthetic hyaluronic acid gel which is injected into the skin in tiny amounts with a very fine needle. A similar product has been injected into the joints of osteoarthritis patients. Restalyne is a natural substance, so theoretically there should be minimal or no allergic reaction. However, since patients with lupus have increased levels of hyaluronic acid, or mucin (a characteristic of inflamed skin), we are proceeding carefully in treating such patients with Restalyne. So far in our practice we have treated six people with extremely low amounts of Restalyne to monitor their responses. Over time, we feel this bioengineered filler will prove very useful—especially for people who have scars that lasers cannot totally fill in.
As for Botox, we really don’t have any issue with this as a skin treatment. In 2002 the FDA granted approval to use Botox Cosmetic (Botulinum Toxin Type A) as a treatment to reduce the severity of frown lines for up to 120 days. Small doses of the injectable form of sterile, purified botulinum toxin block the release of a chemical called acetylcholine by nerve cells that signal muscle contraction. The product is a protein complex produced by the bacterium Clostridium botulinum, which contains the same toxin that causes food poisoning, (although there is no chance of contracting botulism from Botox injection). Since this treatment basically just paralyzes the muscles, no allergy testing is required, and it does not appear to have any side effects when used prudently.
Thermage (pronounced thur-MAJ), approved by the FDA in 2002, uses heat from a radio frequency device to tighten or lift the skin. It’s currently being used in the eye and forehead areas. Heating up the skin causes new collagen to form—a process similar to laser treatments. But thermage uses deeper, radio-frequency-produced heat rather than light-induced heat. So, theoretically, there is a greater possibility of reactivating skin involvement of lupus. Clinical trials are needed to determine if this treatment is safe for people with lupus.
Microdermabrasion is a relatively harmless procedure which addresses superficial skin problems, such as blemishes and pore size. It should be used with caution to avoid potential reactivation of cutaneous lupus.
Finally, doctors are using injections of detergent-based sclerosing agents, or sclerotherapy, to reduce spider veins in the legs. Patients with lupus will be more susceptible to side effects, such as local reactions and infection. This procedure is not recommended for larger blood vessels. Combination treatment with laser technology is sometimes helpful, but caution is advised until more studies are done.
NOTE: Any person with clotting disorders, including the anti-cardiolipin antibody/antiphospholipid antibody and lupus anticoagulant, is generally not a good candidate for cosmetic procedures, whether they have lupus or not.
Andrew Franks Jr., M.D., FACP, is a practicing dermatologist at Gramercy Park Dermatology Associates in New York City. He is also a Clinical Professor of Dermatology and Attending Physician in Rheumatology at New York University Medical Center. Dr. Franks is one of the guest lecturers for the LFA-sponsored continuing medical education and patient education program on lupus, “Lupus Now! State of the Art Approaches from the Experts.”
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