CARLSBAD, Calif. — In 2003, researchers asked 303 patients with systemic sclerosis (scleroderma) what bothered them most about their disease from a cosmetic point of view: Orofacial features, such as thin lips and oral furrows, or non-facial features, such as finger ulceration and waxy skin changes.
Respondents expressed significant concern about specific orofacial features, including thin lips (73%), oral furrows (80%), loss of facial lines (68%) and a smaller, tighter mouth (77%).
“Patients with systemic sclerosis may have a loss of red lip, microstomaand perioral wrinkles, Kathleen Cook Suozzi, MDwho directs the Aesthetic Dermatology Program at Yale University School of Medicine in New Haven, Connecticut, told the Controversies and debates in Laser and Cosmetic Surgery annual banquet. “How can we address these changes for our patients?”
Recent research has shown this hyaluronidase Injections can help improve the orofacial changes commonly experienced by patients with scleroderma. In 2019, researchers in Alabama reported the case of a 53-year-old woman treated with hyaluronidase for microstomia caused by scleroderma. After four visits over a 7-month period and a total hyaluronidase dose of 470 IU, the patient reported an improved Oral Damage in Systemic Sclerosis Score (MHISS) (38 of 48). subjective improvement in symptoms, including greater ease in eating and dental treatment; and improved mouth closure.
In 2023, researchers published a cohort study of four women between 43 and 61 years of age with autoimmune sclerosing conditions that resulted in oral microstomia. After hyaluronidase injections, all improved in mouth opening ability and MHISS, with the change stabilizing between three and five treatments. More recently, in a study pending publication in JAAD Case ReportsSuozzi and colleagues retrospectively evaluated 12 women with scleroderma who received between 150 and 300 units of hyaluronic acid (HA) filler for microstomy between 2020 and 2023. Of the 12 women, 58% had diffuse disease and 42% had limited disease . Overall, mouth opening width increased by 0.65 cm (P = 0.0027) and the height of the mouth opening increased by 0.88 cm (P < .0001). "In general, patients needed three to four treatments to reach the maximum effect, and then they reached a plateau," Suozzi said. "It wasn't that the treatment wasn't working anymore, but it was because their mouth opening had reached a size of about 5cm, which is clinically normal. Interestingly, we found that if the patient's disease got worse and their microstomia started to come back, when you challenged them again, they continued to respond, so patients can continue to use this treatment over time.
In separate case series of seven patients, Suozzi et al prospectively evaluated the effect of HA soft tissue filler with Restylane Silk for lip augmentation. Study participants experienced statistically significant increases in the difference between pre- and post-injection fullness in both the upper and lower lips. Also, the mean post-treatment score fell between “much improved” (2) and “improved” (3) on both the Investigator’s Global Aesthetic Improvement Scale and the Subject’s Global Aesthetic Improvement Scale.
Suozzi recommends using nerve blocks to inject HA or hyaluronidase filler in patients with scleroderma and minimizing injection sites. “Initially we used 30% lidocaine preparations around the mouth for an hour before the procedure, and the patients were still in pain, so now we use nerve blocks,” he said. “For hyaluronidase, we do a trial dose of 75-100 units, usually in the socket. It’s amazing how well it works. People will usually relapse after their trial dose and have improvements in their readings. This is a really easy treatment and I think it can be done in a general dermatologist’s office. There is concern about cross-reactivity with bee venom, so you want to ask patients about that.”
Suozzi reported that he had no relevant financial relationships.
