Dr Kathryn Taylor-Barnes examines how and why inflammation occurs, while offering advice on how to manage it best for your patients
The skin’s primary role is to protect our body. This protection is a barrier to temperature changes and external trauma, as well as being essential in maintaining homeostatic hydration.1 Our skin is on the ‘front line’ and is a vital component in maintaining body harmony with the outside world. Inflammation is a physical condition that can occur on the skin as a result of both lifestyle choices and aesthetic procedures, which can be irritating and painful to a patient. As such, this article will aim to share advice on how inflammation can be managed successfully with various treatments.
When we neglect our health and lead a poor lifestyle, our skin can deteriorate significantly. For instance, acne is made worse by eating junk food and poor or inappropriate skincare efforts.2 Eczema and psoriasis need external emollients and good levels of fluid consumption to avoid the skin drying out, which can lead to flare- ups. In each of these conditions, flare-ups can appear as ‘islands’ of inflammation on the skin. As we already know, sun exposure causes ageing and damage to the skin; solar damage generates dangerous free radicals, which can also cause skin irritation and ignite inflammation. As such, advising patients on the importance of a healthy, balanced diet, staying hydrated and protecting their skin from the sun can certainly play a role in reducing inflammation. In addition, antioxidants, both ingested (polyphenols in green tea)3 and topical (vitaminC),4 as well as physical and chemicals unprotection barriers, are key to opposing solar damage.
Aesthetic practices routinely advise patients that to achieve younger looking skin, treatments should aim to smooth, refine, brighten and build collagen. Various clinical skin treatments such as lasers, skin peels, topical retinoid and alpha hydroxy acids (AHAs) do this by increasing cellular turnover, excitation of fibroblasts, removal of desiccated skin layers and deliberate stripping of the skin’s surface, in addition to suppressing melanocytes by using topical hydroquinone and tretinoin or retinol creams.5 These types of treatments cause a more uniform and controlled degree of inflammation in the skin. This is opposed to a more confined focus of inflammation caused by injectable treatments, such as botulinum toxin and dermal fillers, mesotherapy, cryotherapy and surgical skin excision. The treated areas can leave inflammation that disrupts the harmony of surrounding skin. This approach may be more damaging and ignite skin ageing and ‘inflamm-ageing’, which is why controlling excessive inflammation in these particular treatments may be of greater importance than we might realise.
After injection, dermal fillers routinely require the practitioner to lightly massage the area to conform to the contour of the surrounding tissues.6 In doing so, the digital pressure can attract fluid causing further inflammation to the hydrophilic HA filler ‘bed site’ and encourage swelling and free radical escape. Having a good serum concentration of anti-inflammatory in the blood at the time of treatment may help slow down the filler-degradation rate and help improve filler stability and longevity. We should be mindful that certain techniques for injecting dermal fillers agitate the skin and increase inflammation. These techniques are fanning injection, rapid bolus deposition and injecting large volumes of product in one area in a single treatment session.7 The larger needle/cannula gauge size may provoke more inflammation. In regards to the common needle vs cannula debate, while many chose to use a cannula to avoid traumatic bruising, I would suggest that we might actually be causing more swelling within the dermis due to more aggressive tissue dissection with our implement. When looking at the array of dermal fillers on offer today, polycaprolactone is different and this difference has an impact on post-injection inflammation. It does not degrade, but instead gradually resorbs without changing shape, and this preferred biologic activity will help prevent the risk of secondary reactions. Dr Pierre Nicolau has had extensive experience with polycaprolactone. He notes that, “The advantage of bio stimulators such as Ellansé is that one has a controlled reaction versus an uncontrolled and unwanted one such as with hyaluronic acid and other dermal fillers. Ellansé disappears without the risk of causing an inflammatory reaction, as proven in histological studies. At the end of the bio resorption process, the shorter polycaprolactone chains simply dissolve and are completely removed from the body through normal metabolic processes.” Dr Nicolau recommends only using dermal fillers that are resorbable so that unwanted side effects can be avoided. BDDE is the cross- linked substance used in the majority of recognised HA fillers.
After reaction with HA, the epoxide groups of BDDE are PH neutralised and there is a very small amount of unreacted BDDE that remains in the product.8 This has historically been considered too insignificant to create an inflammatory effect. In my opinion, however, this unreacted portion could have more impact on inflammation than we may have considered in the past. “It’s very difficult to know the exact amount of BDDE that has been used in a given HA dermal filler, the total amount of free-endings of the BDDE, or what is left once the HA has disappeared from the tissues. These factors represent an unknown measure of risk regarding potential adverse events that may occur from using these products,” says Dr Nicolau.9 Some new HA fillers, including Dermafill, have reduced levels of BDDE compared to other HAs on the market. Dermafill exceeds the stricter standards of the FDA very low levels of BDDE controls, as stated in the product guidance note. BDDE is found in all HA fillers but, as I have already mentioned, I believe that the BDDE unreacted portion may be a factor in inflammation caused by cosmetic injection with HA, although research is needed to verify this.
I have been interested in oral supplements in the hope they may be complementary to my aesthetic injection treatments and have the added bonus of helping to reduce inflammation and ‘inflamm-ageing’. Methyl sulphonyl methane (MSM) and omega 3 and 6 from flaxseed work well in combination and may reduce the risk of an inflammatory response. MSM inhibits the release of pro-inflammatory mediators, such as nitric oxide and prostaglandin E2.10 These are released in the skin after cosmetic injection treatments or facial and body surgery, causing the area to become red, swollen and sore. Omega 3 from flaxseed inhibits the formulation of platelet-activating factors, which increase the risk of inflammation when produced in excessive amounts.11 It is also important to maximise dietary antioxidant intake in the form of easily absorbed vitamin C (calcium ascorbate) and L lysine. Nutraceuticals such as Skinade, which is a daily drink, contain multiple naturally occurring ingredients together with the supplements listed above to provide a significant anti-inflammatory effect. I have observed that my patients’ skin tolerates procedures better and heals quicker especially when they are already on a course of Skinade at the time of treatment. In fact some plastic surgeons are now routinely recommending their patients take nutraceuticals pre and post surgery as they have observed improved healing rates. Oxidative stress and excessive inflammation are common risk factors for a whole variety of health problems. These inflamm-ageing associated problems include development of insulin resistance, type 2 diabetes, asthma, obesity and metabolic syndrome. Also chronic inflammation and chronic oxidative stress are risk factors for cancer development (e.g. breast, prostate, colon cancer and skin cancer).12 TA-65 is another product that claims to repair damaged telomere ends and halt and reverse biological ageing. A new study has just been released by T.A. Sciences, USA. The TA-65 research group found that after taking two capsules daily (250 units) over sixteen weeks, there was a decline in the expression of inflammatory cytokines. In addition, interleukin 6 and interleukin 8 were found to decline by two-fold and seven-fold. Also with up to seven-fold reduction in inflammation, this could have a significant beneficial effect in treating dermatitis, eczema, psoriasis, rosacea, acne and all the other inflammatory skin conditions.13 When we consult with patients about having a dermal filler treatment, the topic of downtime is always raised. Searching for the ‘holy grail’ I have had extensive experience in my clinics with Stylage (Vivacy), which contains mannitol and has anti-inflammatory benefits, claiming to improve product longevity. A new filler from Italy, Algeness, is composed of polysaccharide sugar gel derived from red algae.14 Algeness HD does not have the hydrophilic properties of its rival HA and, as water is not encouraged into the injection bed, I have found that there is less swelling and release of pro-inflammatory mediators. In my early experience with this new product, I have observed its claims to be true when injected slowly and without pre-mixed anaesthetic, reducing the occurrence of patients looking red and swollen. Regarding HA filler, the rare but dangerous inflammation-driven side effect, Angioedema can occur within the first two weeks of injection and the incidence is about one to five per 10000.6 Angioedema, caused by IGE mediated immune response together with dermal filler associated nephritis,15 further highlights the dangerous nature of the extreme end of the inflammatory ladder.
Stem cells may play a significant role in reducing inflammation, allergic reactions and promoting healing associated with aesthetic procedures. Autologous fat transfer may help reduce the potential for allergic reaction.16 Stem cells in fat are very powerful releasers of growth factors that enhance tissue healing.17 There is, however, a lack of real clinical data on aesthetic use and this needs to be carefully monitored as more practitioners gather clinical observations and research data.
An opportunity is present to encourage a good anti-inflammatory, skin-friendly diet, possibly including a nutraceutical, as well as appropriate pre- and post-skincare regimes that will enhance what our treatments are trying to achieve, and aim to stop inflammation getting out of control. I would hope that the future will bring new topical, injectable and ingested products and supplements that can help to safely control the inflammatory process, while slowing the ageing process and possibly assisting with skin cancer prevention in our growing ageing population.