Features of injection procedures in patients with thyroid dysfunction

Vladlena Averina , dermatologist of the highest category, scientific coordinator of the Academy of Scientific Beauty corporation (Ukraine)

Lyudmila Osipova , Ph.D., chief freelance immunologist at DUS Ukraine, associate professor of the Department of Immunology, NMAPO named after P.L. Shupika (Ukraine)

The thyroid gland is one of the key organs of the endocrine system. It takes part in controlling body weight, the functioning of the cardiovascular, nervous and reproductive systems, and is responsible for regulating water-salt balance. In most cases, thyroid disease is accompanied by a violation of its hormone-producing function in the direction of its decrease or increase

Among all diseases, at present, the most frequently detected pathology is autoimmune thyroiditis.

Autoimmune thyroiditis (AIT) occurs in 3⎼4% of the world's population. The frequency of clinically expressed forms of the disease is 1%. The number of women with autoimmune thyroiditis exceeds the number of men by 4⎼8 times, the frequency in the population is ⎼ 6⎼11%.

Hypothyroidism is a clinical syndrome caused by a persistent decrease in the effect of thyroid hormones (TH) on target tissues.

The most common cause of hypothyroidism is autoimmune thyroiditis, a disease in which the thyroid gland experiences aggression from the body’s own immune system, resulting in the destruction of a significant portion of the gland’s cells. Thus, the thyroid gland gradually loses its main function ⎼ stops producing thyroid hormones, and their deficiency develops.

When autoimmune thyroiditis develops, a large number of antibodies to the thyroid gland (most often antibodies to thyroid peroxidase) are often detected in the blood of patients - protein structures that cause autoimmune inflammation in the gland. However, for the patient and the doctor, from a clinical point of view, thyroid hormones are more important than antibodies, since it is hormones that determine the patient’s quality of life.

The etiology of autoimmune thyropathies has not been sufficiently studied. Provoking factors in the development of AIT may be radiation damage, excessive consumption of iodine, iodine-containing drugs, the use of X-ray contrast agents, lithium preparations, smoking, pregnancy and aging, each of which affects the immune system. In recent years, the hypothesis of a genetic defect of the immune system, as a result of which the cells of the endocrine glands undergo morphological changes of varying severity, has been increasingly confirmed.

Autoimmune thyroiditis mainly affects women of childbearing age. It is found in every tenth woman aged 17 to 50 years.

Hypothyroidism can be either manifest or subclinical. With manifest hypothyroidism, the level of thyroid-stimulating hormone (TSH) increases in the blood. Thyroid-stimulating hormone, or TSH, thyrotropin, thyrotropin (from the English thyrotropine, TSH, thyroid stimulating hormone), ⎼ tropic hormone of the anterior pituitary gland. TSH stimulates the production of thyroid hormones T3 and T4, and when their levels rise, they suppress the release of TSH ⎼ this is how the “feedback” regulation principle works. Thus, the norm of TSH and T4, as well as T3, is dependent. There is an inverse relationship between the concentrations of free T4 and TSH in the blood: exceeding the concentration of thyroxine (T4) to a certain level leads to a decrease in the production of TSH, while a decrease in the concentration of T4 relative to this level increases the production of the hormone.

In case of manifest hypothyroidism, against the background of increased TSH levels, the free T4 level is reduced below normal. Free thyroxine T4 ⎼ fraction of thyroxine circulating in the blood that is not bound to blood proteins. Produced by follicular cells of the thyroid gland under the control of TSH via a negative feedback mechanism. T4 is the precursor of T3. Increases heat production and oxygen consumption by all body tissues, with the exception of brain tissue, spleen and testicles. Stimulates the synthesis of vitamin A in the liver. Reduces the concentration of cholesterol and triglycerides in the blood, accelerates protein metabolism. Free T4 most adequately and directly reflects the hormonal function of the thyroid gland. Free T3 (free triiodothyronine) is a thyroid hormone that stimulates the metabolism and absorption of oxygen by tissues. T3 is more active than T4, but is found in the blood in lower concentrations.

Most often, if the TSH level in the blood is elevated, but the T4 content is st. still remains within normal limits, there are no clinical symptoms of thyroid dysfunction. The frequency of clinically manifest hypothyroidism is 1⎼2%, and in women it occurs 10 times more often than in men, especially in old age. Subclinical hypothyroidism is detected in 6⎼8% of women (10% over the age of 55 years) and 3% of men. Every year, 5⎼15% of all cases of subclinical hypothyroidism become manifest.

As we have already said, the most informative is the determination of the level of TSH in the blood, and to a lesser extent - the thyroid hormones themselves, thyroxine (T4 free) and free triiodothyronine (T3 free). The pituitary gland reacts very sensitively to a decrease in the amount of thyroid hormones and immediately sends its signal to activate its work - TSH. While the thyroid gland can activate its work under the influence of increased doses of TSH, the levels of its hormones (T3 free and T4 free) will remain normal with an increased concentration of TSH (this is the state of subclinical hypothyroidism), and only if the thyroid gland is unable to perform its functions , in the analyzes low levels of T3 St. will be observed. and T4 St. with high TSH.

Some manifestations of changes in the skin, nails or hair are observed in almost all patients with hypothyroidism, but they are too non-specific, so patients may not pay attention to them for a long time or explain them for other reasons. The skin becomes puffy, pasty, pale, swollen. The changes are especially pronounced on the face and eyelids. Hair becomes sparse, dry, dull, and breaks off easily. Hair loss is typical not only in the scalp area, but also in eyelashes, eyebrows, and in areas of genital hair growth.

The most characteristic manifestation of dermopathy in hypothyroidism is pronounced swelling due to decreased clearance and increased synthesis of hyaluronic acid. In addition to mucinous edema, clinical manifestations of hypothyroid dermopathy include dry, pale skin, thinning of the epidermis with areas of hyperkeratosis, decreased skin temperature, decreased sebum and sweating.

Hypothyroidism manifests itself in the form of symptoms such as weight gain, goiter, dry skin, hair loss, constipation, and increased sensitivity to cold.

In patients with hypothyroidism in the stage of subcompensation or decompensation, due to impaired metabolism of hyaluronic acid, the hydrophilicity of skin tissue is increased. Therefore, they have an extremely high risk of developing long-term swelling after the administration of HA-based drugs and the likelihood of contouring the gel above the surface of the skin. Standard decongestant measures are usually ineffective. Against the background of a deficiency of thyroid hormones and concomitant immunity disorders, poor healing and prolonged, but not too violent inflammation at the sites of gel injection are possible.

On the other hand, due to the slow degradation of HA, the duration of preservation of the aesthetic result may increase.

The most common cause of hypothyroidism is autoimmune thyroiditis, and autoimmune diseases are on the list of contraindications for contouring.

Autoimmune chronic thyroiditis is a disease based on autoimmune damage to the thyroid gland; antibodies are formed to various components of the thyroid gland (normally, antibodies in the human body are produced only to a foreign substance). This is the most common inflammatory disease of the thyroid gland. Autoimmune thyroiditis can lead to both hypothyroidism and hyperthyroidism.

Skin is a classic target for the action of TH (thyroid hormones). It is known that T3 St. participates in the differentiation of the epidermis, increasing its sensitivity to growth factors, in the regulation of the activity of the sebaceous glands, apocrine sweat glands, hair growth and the production of proteo- and glycosaminoglycans by dermal fibroblasts. The entire spectrum of action of THs is mediated by interaction with their receptors, which serve as transcription regulators. By binding to its receptors on melanocytes, TZ St. has an inhibitory effect on melanogenesis, which was shown in studies on melanoma cell culture.

Thyrotoxicosis is a condition opposite to hypothyroidism, which is a clinical syndrome associated with excess production of thyroid hormones by the thyroid gland.

In autoimmune thyroiditis, antibodies are produced exclusively to the thyroid gland and to no other organs.

The main goal of treatment is to maintain stable euthyroidism, that is, a normal amount of thyroid hormones in the blood. In the presence of euthyroidism, treatment is not carried out. That is, only the consequence of the disease is eliminated - hormone compensation is carried out by taking L-thyroxine. The dosage of L-thyroxine is selected individually by an endocrinologist. Treatment is prescribed with a small dose, gradually increasing it under the constant control of thyroid hormones. A maintenance dose of the drug is selected, against which normalization of hormone levels is achieved. Such therapy with levothyroxine at a maintenance dose is usually taken for life. Regular hormonal examination of T3 St., T4 St. is indicated. and TSH once every 6 months.

In case of autoimmune lesions of the thyroid gland, it is also recommended to check the level of antibodies to thyroid peroxidase. Antibodies to thyroid peroxidase are autoantibodies directed against an enzyme in thyroid cells (this enzyme is involved in the formation of thyroid hormones). Thyroid peroxidase is an enzyme that is involved in the formation of active iodine, which is involved in the iodification reaction of thyroglobulin. Autoantibodies directed against the enzyme lead to suppression of its function, which ultimately leads to a decrease in the release of thyroid hormones (thyroxine ⎼ T4, and triiodothyronine ⎼ T3). In this case, anti-TPO can only be a kind of “witness” of an autoimmune process. Detection of antibodies to thyroid peroxidase is the most informative test for identifying autoimmune damage to the thyroid gland.

Accordingly, patients with well-compensated hypothyroidism (persistently normal TSH and thyroid hormone levels for at least 6 months) and the absence of clinical symptoms can undergo contouring. If the diagnosis of “hypothyroidism” was established less than a year ago, the course of the disease is unstable (the dose of L-thyroxine taken constantly has to be adjusted) or we are talking about an incompletely examined process in the thyroid gland, you should refrain from contouring.

Thyrotoxicosis (or hyperthyroidism), like hypothyroidism, is not a disease, but a complex of symptoms that can occur with various diseases. This is a condition when too many hormones are released into the blood. Laboratory signs of thyrotoxicosis will be the opposite of hypothyroidism: TSH decreases sharply or disappears completely, and thyroid hormones (T3 and T4 free) become higher than normal.

Sweating and wetness of the skin in patients with thyrotoxicosis are almost always observed. Many of them have delicate, thin skin, sometimes darkening occurs on the eyelids (Jellinek's symptom), face, neck, white line of the abdomen, on the lower back, extensor surfaces of the limbs and in other places. With prolonged course of thyrotoxicosis, swelling of the eyelids develops (Zenger's symptom). Sometimes, in people who have been suffering from thyrotoxicosis for a long time, widespread or focal compactions of the subcutaneous tissue are observed on the legs, on which, when pressed, no pit remains. The reason for their appearance is unclear. In some cases, histological examination of such focal swellings reveals the proliferation of adipose tissue, in others changes that resemble scleroderma are revealed. Sometimes these seals have the structure of myxedema skin and subcutaneous tissue, as a result of which they received the name myxedema cutis tuberosum circumscriptum. Myxedema cutis tuberosum circumscriptum is not related to ordinary myxedema. Urticaria and persistent itching, sometimes observed in patients with thyrotoxicosis, are associated with the toxic effect of thyroxine. Similar phenomena also occur when taking thyroid drugs. In these patients, dilator (red) dermographism can also be noted as an expression of lability and mild excitability of vasomotors. The electrical resistance of the skin (the so-called Vigouroux symptom) in patients with thyrotoxicosis is slightly reduced.

Hair growth at the beginning of the disease seems to be even enhanced, but later, especially in severe forms of thyrotoxicosis, hair falls out everywhere and turns gray early. After surgical treatment, even in severe cases of thyrotoxicosis, not only the restoration of normal hair growth and the cessation of hair loss are noted, but also the disappearance of graying.

Treatment methods for thyrotoxicosis and various clinical variants of functional autonomy of the thyroid gland differ. The main difference is that in the case of functional autonomy of the thyroid gland against the background of thyreostatic therapy, it is impossible to achieve a stable remission of thyrotoxicosis: after the cessation of thyreostatics, it naturally develops again. Thus, the treatment for functional autonomy consists of surgical removal of the thyroid gland or its destruction using radioactive iodine-131. This is due to the fact that thyreostatic therapy cannot achieve complete remission of thyrotoxicosis; after discontinuation of the drug, all symptoms return.

Therefore, without stable compensation of thyroid hormone levels, it is impossible to carry out any plastic surgery or invasive cosmetic procedures.

Materials and methods

We observed 14 patients (women) with autoimmune thyroiditis (group I), five of them underwent contouring with hyaluronic acid preparations, four received biorevitalization, six received botulinum toxin injections in the area of the upper third of the face. All patients took L-thyroxine at a dose of 25⎼75 mcg per day for at least 1 year. The control group (group II) consisted of 18 patients with autoimmune thyroiditis who took L-thyroxine in the same doses. Patients from the control group did not undergo cosmetic procedures.

All patients were examined for TSH, T3 free, T4 free. and anti-TPO (antibodies to thyroid peroxidase) on the CobasE 411 device before cosmetic procedures, as well as 3 and 6 months after these procedures.

The results obtained were processed using variation statistics methods. For each indicator, the arithmetic mean M and the average error of the arithmetic mean m were calculated. The reliability of the indicators was calculated using the t-test using the Student's table.

Results and discussion

The data obtained as a result of the study are presented in Table 1. Indicators of thyroid function in patients with hytothyroidism before and after cosmetic procedures:

As can be seen from the table, in groups I and II patients during the first study, TSH levels were as follows: in group I – 4.18 ± 0.12 µIU/ml, in group II ⎼ 4.01 ± 0.09 µIU/ml, that is did not differ from the norm. Levels T3 St., T4 St. also did not differ from the norm. The levels of anti-TPO were slightly increased in both groups: in group I – 137.4 ± 9.6 IU/ml, in group II – 146.4 ± 10.8 IU/ml (with the norm being 0⎼34 IU/ml). After cosmetic procedures, during repeated examinations after 3 and 6 months in groups III, the levels of TSH, T3 free, T4 free. also did not differ significantly from the norm; the levels of anti-TPO remained slightly elevated, but did not differ significantly from the values in the first study. In group I, after 3 months, anti-TPO was 142.6 ± 11.5 IU/ml, in group II ⎼ 128.9 ± 8.3 IU/ml (p > 0.05); when examined after 6 months in group I ⎼ 112.8 ± 9.7 IU/ml, in group II ⎼ 134.1 ± 10.4 IU/ml (p > 0.05). That is, the levels of anti-TPO during the study period did not differ significantly from those before the procedures, and also did not differ significantly from those in the control group.

conclusions

As can be seen from the studies conducted, in a compensated state, the use of hyaluronic acid for the purpose of contour correction and biorevitalization does not affect the function of the thyroid gland and does not lead to significant changes in indicators. The use of botulinum therapy also does not affect changes in thyroid hormones.

The parameters studied do not differ from those in patients who did not undergo any cosmetic procedures. Therefore, in patients with compensated hypothyroidism, the use of hyaluronic acid and botulinum toxin does not worsen the disease.

It should be noted that the number of observations was small; with a larger number of patients, different data may be obtained.

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First published : Les Nouvelles Esthetiques Ukraine, No. 3(97)/2016