Complications and side effects after mesotherapy procedures

Side effects

The main pharmacotherapeutic effect of drugs may be accompanied by additional effects that do not represent pharmacological value and are therefore considered undesirable. Such effects are referred to as side effects. They are predictable, do not lead to a deterioration in the patient’s condition and go away on their own, without any therapy. In particular, side effects are symptoms of inflammation that develops in the skin in response to mechanical trauma from a needle - activation of cellular structures that provide the barrier function of the skin occurs. Inflammation always has a clear and consistent stage pattern:

1. alteration (skin damage);

2. exudation (activation and release of biologically active substances);

3. proliferation (final stage).

During the exudation stage, lymphocytes and macrophages migrate to the site of skin damage. These cells have high resorption activity and the ability to phagocytose. They contain a wide range of hydrolytic enzymes and carry out intracellular digestion of foreign antigens. Plasmocytes—immune cells that produce immunoglobulin antibodies—are activated and increase in number.

The following side effects can be observed with mesotherapy :

Pain

The cause of pain is both an injection - mechanical trauma to the skin, and the administration of a drug with a non-physiological pH level (the patient’s subjective sensations will be the most comfortable when injecting solutions with a pH range of 7.0-7.5). Pain threshold - the threshold of pain - is not a constant, it depends on the individual characteristics of the individual, psychological state, location of injections, phase of the menstrual cycle and a number of other factors. It is my deep conviction that if we are talking about allopathic dermal mesotherapy, then the patient should not experience excruciating pain when performing anti-age manipulations. It should be noted that there are groups of drugs, the administration of which is accompanied by severe pain, despite high-quality anesthesia.

Skin nerves are divided into two groups:

• vegetative (are dendrites of the spinal ganglia) - regulate the functioning of glands, blood vessels and muscles;
• cerebrospinal (originating from the spinal cord, are axons of neurons in the anterior and lateral horns of the spinal cord) - are responsible for various types of sensitivity. Neuroreceptors responsible for pain sensitivity (nocioreceptors) are free nerve endings in the dermis.

Pain is a mechanism for controlling tissue integrity. The biological purpose of skin pain is to provide the protective function of the skin, that is, to warn the brain about the presence of a threatening influence and prevent damage to the body by a traumatic agent. Painful stimulation causes a chain reaction consisting of autonomic, respiratory and behavioral (including mental) components.

Pain may occur as a result of:

• irritation of mechanoreceptors of the superficial layers of the skin and spread along myelinated A-delta fibers (epicritic pain with clear differentiation of its localization);
• exposure to metabolic and toxic factors that disrupt cell activity and are transmitted along unmyelinated C-fibers (protopathic pain of a rough, dull nature, not differentiated by localization).

Electrical impulses from pain receptors go along afferent fibers to zone I of the dorsal horns of the spinal cord, and from there along the axons of the neurons contained there through the spinothalamic tract to the thalamus.

Pain is a subjective sensation, its intensity varies from person to person.

Depending on the location of the source, pain is usually divided into:

• somatic (superficial - skin and deep - coming from muscles, ligaments and bones);
• visceral, the source of which is spasm or ischemia of hollow organs.

In response to a pain impulse, activation of cellular structures in the dermis occurs, providing the barrier function of the skin - lymphocytes and macrophages migrate to the “dangerous” zone. These cells have high resorption activity and the ability to phagocytose. They contain a wide range of enzymes and carry out intracellular digestion of foreign agents. Plasmocytes - immune cells that produce immunoglobulin antibodies - are activated and increased quantitatively. Also, when the skin is damaged, chemical compounds are released that are considered pain mediators. These substances include histamine, kinins (bradykinin, kallidin, etc.), prostaglandins (for example, PGE2), possibly acetylcholine and some metabolites, in particular H+ and K+ ions. Depending on the concentration, these substances can cause painful sensations of varying nature and degree: tingling, burning, squeezing or cutting pain. There are specialized pain receptors, or nociceptors, which are free nerve endings located in the skin. Pain mediators act on these receptors, resulting in the formation of a pain (nociceptive) signal. Unlike all other receptors, nociceptors are incapable of adaptation.

In addition to the nociceptive system, there is an antinociceptive system, which has its own functional and neurochemical mechanisms and provides pain suppression. The antinociceptive system inhibits the conduction of nociceptive signals at all levels of the nervous system and weakens the formation of pain. The antinociceptive system includes formations located in different parts of the central nervous system: the somatosensory area of the cerebral cortex, the nuclei of the thalamus, hypothalamus, periaqueductal gray matter, caudate nucleus, raphe nuclei, gelatinous substance in the spinal cord.

The occurrence of pain may be associated with the pharmacological characteristics of the administered substance - for example, vegetative pain during the administration of vascular drugs is associated with spasmodic vasoconstriction or vasodilation (sharp contraction or stretching of the vascular wall). By nature, visceral pain as a result of the introduction of angioprotectors is late (occurs in the dermis after 1-2 seconds, in the hypodermis - after 20-30 seconds), clearly localized, quickly passing, the patient defines it as a burning sensation. The occurrence of pain during the administration of DMAE-containing solutions is associated with the unfriendly pH and osmolarity of the DMAE solution. Unfortunately, it is not possible to influence the mechanism of occurrence of such pain or change its nature at the present stage of development of medicine.

The mechanisms of pain are varied, we can only summarize it as follows: relieve pain as much as possible!

Erythema

In response to multiple injections during a mesotherapy session, primary erythema develops. Its intensity depends on the anatomical and physiological characteristics of the skin (level of vascular reactivity, vasomotor instability, etc.) and is a symptom of inflammation resulting from injury (injections). In some cases, the cause of erythema may also be the pharmacological effect of the administered drug - if it contains substances that cause vasodilation. That is, there are two reasons for the development of erythema: mechanical and pharmacological. This erythema is short-lived and goes away on its own some time after the procedure. But erythema can also be a symptom of an allergic reaction or infection: if it persists for more than a day and is accompanied by additional symptoms, then the mesotherapist should treat it as a complication, conduct a differential diagnosis, identify the cause and prescribe appropriate treatment.

Hematomas

Mesotherapy is a blind method; multiple injections, of course, can be accompanied by accidental injury to the vessel and the formation of microhematomas. The procedure is complicated by microcirculation disorders (swelling, pasty skin, dryness, so-called “parchment” skin, etc.), increased fragility of blood vessels, disorders of the blood coagulation system, constant use of anticoagulants and antiplatelet agents, and much more. In order to prevent hematomas, 2-3 weeks before the proposed procedures, the patient can be prescribed in home care the use of products that strengthen the walls of blood vessels: rutin, troxerutin, extracts of ginkgo biloba, mountain arnica, sweet clover, etc.

Complications

Recurrence of herpes

ICD-10 B00 Infections caused by HSV (Herpes simplex) are one of the most common complications, especially when working in the nasolabial area. Ideally, of course, during the initial consultation it is necessary to refer the patient for laboratory diagnostics, but in practice, as a rule, we limit ourselves to a survey.

In the diagnosis of herpes, methods for isolating and identifying the virus and identifying virus-specific antibodies in the blood serum are used:

• virological methods for detecting herpes simplex viruses;
• PCR diagnostics;
• methods for detecting herpes antigens;
• cytomorphological methods;
• registration of the immune response to the herpes simplex virus;
• assessment of immune status.

To determine the herpes virus, enzyme-linked immunosorbent assay (ELISA) methods are becoming increasingly common. Polymerase chain reaction (PCR) confidently determines which herpes virus - type I or II - the infection occurred.

It is important to find out whether, and how often, the patient has manifestations of herpetic infection. It is most often caused by herpes simplex viruses (HSV) - HSV-1 and HSV-2, antibodies to which are detected in 90-92% of the adult population of the planet. Infection with HSV-1 usually occurs in the first three years of a child's life, and with HSV-2 during puberty. According to WHO, diseases caused by HSV rank second in the world - 15.8%. A correct understanding of the mechanisms of the occurrence and development of herpesvirus infection, the complexities of the interaction of various parts of the immune system and the characteristics of their response allows us to plan a differentiated approach to the comprehensive prevention of the disease.

Assessment of the severity of HSV infection.

• Mild course: no more than 3 relapses per year, relapse duration is less than 7 days, small affected area, general condition does not suffer.
• Course of moderate severity: from 4 to 6 relapses per year, duration of relapse - 7-14 days, several rashes/"confluent" lesions, disturbance of general health at the time of relapse.
• Severe course: more than 6 relapses per year, episodes of relapse - up to 2 times a month, duration of relapse - more than 14 days, impairment of physical and mental well-being, quality of life during relapse and without exacerbation.

The cosmetologist must assess the severity of the HSV infection and, if necessary, preventively (suppressive therapy) prescribe the patient an etiotropic drug: Acyclovir (Zovirax), Valacyclovir, Famvir, or others. In most patients who received suppressive therapy, relapses are either absent or mild - they last a few days shorter, proceeds more easily. Unfortunately, recently the number of people infected with viruses and drug resistance to etiotropic antiviral drugs has sharply increased, so it is impossible to completely eliminate the risk of developing such a complication.

Allergic reactions

These are hypersensitivity reactions mediated by immunological mechanisms. Drug allergies are prone to progression and complications, therefore, due to the nature of the manifestations and possible consequences, it potentially poses a threat to the patient’s life. Intradermal administration of drugs increases the risk of patient sensitization. A thorough collection of allergy history is the first stage in the prevention of drug allergies! Anamnesis is considered not burdened by allergies if the patient has not had any allergic diseases in the past and tolerated all medications, foods and contacts with chemicals, including cosmetics.

The second stage is an allergy test or, if necessary, a laboratory examination. If there is a clear history of an allergy to a drug, then it and drugs that have cross-reacting common determinants cannot be administered to the patient and skin tests with this drug are not recommended. When evaluating test results, you should always remember that in case of a negative result, the possibility of an allergic reaction cannot be excluded. An alternative to testing is laboratory testing.

Patients with a history of allergies require mandatory laboratory examination under the supervision of an immunologist!

Classification of allergic reactions:

Allergic reactions are divided into three groups.

The first group includes immediate-type reactions that occur instantly or within the first hour after administration of the drug:

• anaphylactic shock ;
• acute urticaria;
• Quincke's edema ;
• bronchospasm;
• acute hemolytic anemia.

The second group includes subacute reactions that occur during the first day after administration of the drug:

• agranulocytosis;
• thrombocytopenia;
• maculopapular exanthema;
• fever.

The third group includes delayed-type reactions that occur within several days or weeks after administration of the drug:

• serum sickness;
• allergic vasculitis and purpura;
• lymphadenopathy;
• damage to internal organs (allergic nephritis, hepatitis, etc.).

Most clinical manifestations of drug allergies are accompanied by the presence of mixed reactions of various types. Allergic reactions most often encountered in cosmetology include skin itching, urticaria and angioedema.

Allergic urticaria

ICD-10 L50 Urticaria - begins with intense itching of the skin with a rash of exudative, cavityless blisters, swollen, dense, bright pink in color, rising above the skin level, of various sizes and shapes, often with a pale area in the center. The blisters disappear without a trace after 12-24 hours (one of the criteria for differential diagnosis). With generalized allergic urticaria, the patient’s general condition suffers - weakness, malaise, headache, dizziness, and intense itching appear.

Quincke's edema

Quinke; (ICD-10 T78.3; D84.1 Angioedema) is a clearly localized painless area of edema of the dermis and subcutaneous tissue. It is more often observed in places with loose tissue (lips, eyelids) and on mucous membranes (soft palate, tongue, tonsils). Angioedema is especially dangerous in the larynx (approximately 25% of cases) due to the risk of airway obstruction. Unlike urticaria, itching is not typical.

Treatment: modern antihistamines with a prolonged effect are considered as basic therapy. If necessary, detoxification therapy is carried out. At all stages, it is recommended to locally use drugs containing corticosteroid hormones (Prednisolone ointment, Fluorocort, Flucinar, Lorinden, etc.).

Urticaria and angioedema can be precursors to a severe allergic complication - anaphylactic shock (ICD-10 T78.2 Anaphylactic shock, unspecified). The clinical picture is caused by a complex set of symptoms and syndromes from a number of organs and systems of the body.

There are 5 clinical types of drug-induced anaphylactic shock:

• typical shape;
• hemodynamic option;
• asphyxial;
• cerebral;
• abdominal.

Most often there is a typical form. The patient's condition deteriorates sharply, fear of death, nausea, vomiting, and cough appear. Severe general weakness, itching of the skin, a feeling of a rush to the head, pressure behind the sternum, difficulty in breathing, disturbances of consciousness, up to loss of consciousness appear and progress. The pulse is frequent, thread-like, sometimes arrhythmic. Blood pressure progressively decreases, diastolic pressure is not determined. The tones are dull. Moist rales are heard in the lungs, and a picture of pulmonary edema subsequently develops. With extremely severe, “lightning-fast” shock, a picture of sudden cardiac arrest occurs.

The hemodynamic variant is characterized by the appearance of pain in the heart area, a sharp decrease in blood pressure, dullness of tones, threadlike pulse, and arrhythmias. The skin is pale, in some cases acquiring a marbled tint. With proper timely diagnosis and treatment, the outcome is favorable in most cases.

In the clinical picture of the asphyxial variant, acute respiratory failure, caused by swelling of the laryngeal mucosa, bronchospasm, and pulmonary edema, comes to the fore. The severity of the disease and prognosis are determined by the degree of respiratory failure.

The cerebral variant, which occurs much less frequently, is characterized by central nervous system disorders with signs of psychomotor agitation, fear, impaired consciousness, convulsions, and respiratory arrhythmia; Sometimes phenomena of cerebral edema with a picture of status epilepticus are observed. The prognosis in many cases, with the right medical tactics, is favorable.

Significant diagnostic difficulties can be presented by the abdominal variant of anaphylactic shock, which is characterized by the appearance of symptoms of an acute abdomen. In this case, a mild disorder of consciousness, a slight decrease in blood pressure, and the absence of bronchospasm are observed.

Depending on the clinical manifestations, there are three degrees of severity of anaphylactic shock: mild, moderate and severe.

1. In mild cases, weakness, dizziness, headache, a feeling of “compression” of the chest, heaviness in the head, tinnitus, numbness of the tongue, lips, and fear of death are felt. Skin itching, skin hyperemia, and Quincke's edema may develop. Blood pressure drops sharply, the pulse is thready, tachycardia up to 120-150 beats per minute.
2. In moderate cases, suffocation, often clonic-tonic convulsions, cold sticky sweat, pale skin, cyanosis of the lips, and dilated pupils are noted. Blood pressure is not determined. Nasal, gastrointestinal and uterine bleeding may develop.
3. In severe cases, the patient quickly loses consciousness. There is marked pallor of the skin, cyanosis of the face, lips, acrocyanosis, and wetness of the skin. The pupils are dilated, convulsions and wheezing with prolonged exhalation develop. Heart sounds are not heard, blood pressure is not determined, and the pulse is not palpable. Despite timely provision of medical care, patients often die.

Treatment for anaphylactic shock should be started immediately. A set of emergency measures is carried out, which is determined by the severity of the process and the presence of specific and nonspecific complications and syndromes. It is important to follow a certain sequence of measures taken.

Medical care for drug allergies at the prehospital stage

Stopping the intake of the allergen - immediately stop the procedure, open the ampoule with isotonic sodium chloride solution, shake it onto the injected area and wash off the remaining drug with a gloved hand. If the procedure is performed on the extremities, apply a tourniquet proximal to the injection site for 25 minutes (loosen it every 10 minutes). Inject papular injection site with a 0.1% solution of adrenaline (epinephrine) 0.2-0.3 ml in 4 ml of isotonic sodium chloride solution (can be undiluted). Adrenaline is the drug of choice. Cover the area where the manipulation was carried out with cold packs.

Anti-shock measures: place the patient on his back; in case of collapse, the legs should be raised above the head, but in cases of severe ventilation disorders, in the absence of severe hypotension, a position with the head end elevated may be preferable. Turn the head laterally (to avoid aspiration of vomit), extend the lower jaw, and if there are removable dentures, remove them. Unbutton and loosen tight parts of clothing, cover the patient, and do not give him any additional fluids. Early intramuscular administration of 0.5 ml of 0.1% epinephrine solution is recommended to all patients with clinical symptoms of shock, airway swelling or difficulty breathing. It is better to administer adrenaline in fractional doses of 0.1-0.2 ml to different areas, rather than in one portion, since, having a pronounced vasoconstrictor effect, it will also interfere with its own absorption. Additionally, as a means of combating vascular collapse, it is recommended to administer 2 ml of cordiamine or 2 ml of a 10% caffeine solution. If the patient’s condition does not improve, then it is necessary to administer intravenously, very slowly, 0.5-1 ml of a 0.1% solution of adrenaline in 10-20 ml of a 40% glucose solution or isotonic sodium chloride solution (or 1 ml of a 0.2% norepinephrine solution) . The total dose of 0.1% adrenaline solution should not exceed 2 ml.

Antiallergic therapy: for angioedema and urticaria, injection use of antihistamines is recommended. First-generation antihistamines have a wide range of side effects, which forces them to refuse their long-term use for allergic diseases. In many developed countries (including some countries that produce these drugs), their sale is prohibited. But in the acute period, when parenteral administration of antihistamines is required, and taking into account the fact that there are still no second-generation ampoule drugs, the most effective is Tavegil - 2.0 ml intramuscularly or slowly intravenously. It acts for a long time, 8-12 hours, does not cause a drop in blood pressure and has a slight sedative effect. Less effective in such cases is Suprastin 1.0-2.0 ml intramuscularly or slowly intravenously.

Glucocorticoid therapy is carried out for generalized urticaria, Quincke's edema, and anaphylactic shock. I would not recommend using drugs intended for intravenous administration. At the moment when the patient is diagnosed with hypotension, the blood vessels have collapsed, and the cosmetologist’s hands are trembling from excitement, performing an intravenous injection seems problematic. Preferably intramuscular administration. The most effective are Dexamethasone or Diprospan in an initial dose of 2.0 ml intramuscularly deep. Into any available large muscle, the main thing is deep.

Any cosmetology treatment room should have an emergency first aid kit and instructions on emergency measures.

The main stages in the prevention of drug allergies are the fight against polypharmacy (unreasonable prescription of a large number of drugs), a thorough history taking and early identification of persons predisposed to allergies. As a rule, the development of severe forms of drug allergies in the anamnesis is preceded by milder manifestations of an allergic reaction to any medications, food products, insect bites, or food products.

Delayed reactions

In the late post-injection period, dermatitis may develop (ICD - 10 L25.0 Unspecified contact dermatitis caused by cosmetics) - a disease that occurs as a result of repeated exposure to allergens contained in cosmetics. These substances can be albumin, bentonite, kaolin, biotin, collagen, elastin, glycerin, lanolin, liposomes, placenta extracts, propylene glycol, royal jelly, tyrosine, salt, agar-agar, and other chemicals.

Infectious lesions of soft tissues. Theoretically, a wide range of complications are possible:

• L01 Impetigo;
• L02 Skin abscess, boil and carbuncle;
• L03 Phlegmon;
• L05 Pilonidal cyst;
• L08 Other local infections of the skin and subcutaneous tissue;
• L08.0 Pyoderma;
• L08.1 Erythrasma;
• L08.8 Other specified local infections of the skin and subcutaneous tissue;
• L08.9 Local infection of the skin and subcutaneous tissue, unspecified.

The causative agent of the purulent process is most often staphylococcus (as the only source or in association with streptococcus, Escherichia coli, Proteus and other types of microflora). The cause of the development of purulent complications is a violation of the rules of asepsis either by the cosmetologist during the procedure or by the patient in the early post-invasive period. General clinical manifestations are typical for purulent-inflammatory processes of any localization: increased body temperature from subfebrile to 41° (in severe cases), general malaise, weakness, loss of appetite, headache. The extent of these changes depends on the severity of the pathological process. The basis for the treatment of such complications is timely and adequate surgical intervention. The key word is timely: at the slightest suspicion of an infectious complication, we immediately call a surgeon for help!

Most often in their practice, cosmetologists encounter pyoderma.

Pyoderma (ICD-10 L08.0 Pyoderma) - purulent-inflammatory skin diseases, usually caused by pyococci: staphylococci, streptococci, much less often pneumococci, Pseudomonas aeruginosa, etc. Pyoderma accounts for 30-40% of all skin diseases. They are clinically characterized by suppuration of the skin, usually occur acutely, less often have a chronic course and, depending on the depth of the lesion, can result in complete restoration of the skin or leave behind scars.

Skin abscess (ICD-10 L02 Skin abscess, boil and carbuncle) is an accumulation of pus limited by a capsule that occurs during acute or chronic focal infection and leads to tissue destruction in the lesion (often with perifocal edema). A feature of an abscess is the presence of a pyogenic membrane - the inner wall of a purulent cavity created by the tissues surrounding the source of inflammation (a manifestation of the body’s normal protective reaction). The pyogenic membrane is lined with granulation tissue; it delimits the purulent-necrotic process and produces exudate.

Phlegmon (ICD-10 L03 Phlegmon) is a diffuse purulent inflammation of soft tissues, characterized by their impregnation with pus with a tendency to quickly spread and involve nearby muscles, tendons, and fatty tissue in the process. In this way, phlegmon differs from an abscess, in which there is a focus of purulent inflammation, delimited from the surrounding tissues by the so-called pyogenic membrane. Phlegmon can develop in any part of the body, and if it progresses rapidly, it can affect a number of anatomical areas, for example, the femoral, gluteal, lumbar, etc.

Necrosis is necrosis, tissue death as a result of the toxic effects of a drug. In cosmetology practice, toxic (according to the etiological factor) direct (according to the mechanism of action) necrosis may occur as a result of the administration of a mesotherapy drug in violation of the rules of the procedure and in case of inadequate selection of the drug. The clinical manifestation of necrosis may be flaccid cellulitis or a small ulcer. An important symptom is skin anesthesia, probably caused by the death of nerves located in necrotic tissues. There is local pain at the site of the lesion, hyperemia, fever and swelling. The general condition suffers, the pulse increases, and the temperature rises significantly. The most important approach to any skin infection is to be alert for the possibility of necrotizing infection. This approach allows for timely diagnosis of the lesion and the necessary therapy.

Long-term complications that can occur two to four months after the procedures are viral hepatitis and HIV infection. In the first place among the methods of transmission of viral hepatitis and HIV in medical institutions, injections with an injection needle are noted. Moreover, in most cases, this is due to the careless attitude of medical staff towards used needles and other instruments. The high probability of infection is due to the fact that viruses are stable in the external environment; the incubation period can last six months. In addition, there are a fairly large number of asymptomatic carriers among patients. In order to protect yourself from infection, each patient should be considered as potentially infected, since even a negative result of testing the patient's blood serum for the presence of antibodies to HIV may be a false negative. This is explained by the fact that there is an asymptomatic period of 3 weeks to 6 months, during which antibodies in the blood serum of an HIV-infected person are not detected.

So…

Like any medical procedure, mesotherapy can cause complications and side effects. The key to the safety of the procedure is careful selection of patients, taking into account indications/contraindications, adequate selection of drugs, as well as careful adherence to the procedure protocol and sanitary and hygienic norms and rules.