Periorbital wrinkles treatment using collagen induction therapy

Submitted on: 04/11/2009
Aproved on: 05/15/2009
We declare no conflict of interest.

Abstract

Introduction: Periorbital wrinkles are very common and permanent cutaneous folds that develop on the periocular area. The treatment for wrinkles varies with the degree of severity. A relatively new treatment, called collagen induction therapy (CIT), seems to be appropriate for the treatment of periorbital wrinkles. Objective: To confi rm the usefulness of CIT in periorbital wrinkles treatment. Patients and methods: In total, 20 patients (12 females, 8 males; between 50-65 years of age) with periorbital wrinkles were included. Each patient was treated with a specific tool in two sessions. Using digital cameras, photos of all patients were taken to evaluate wrinkles’ depth, and silicone rubber was used to make a microrelief impression of the wrinkles. The photographic data were analysed by using the sign test statistic (a < 0.05). Skin layer data were analysed by computerized image analysis. Results: Analysis of the patient photographs, supported by the sign test, and the degree of irregularity of the surface microrelief, supported by Fast Fourier Transform and by wrinkle’s image processing, showed that, after only two sessions, the wrinkles’ severity grade in most patients was greatly reduced. Conclusion: The present study suggests that CIT can be a suitable technique to improve periorbital wrinkles.

Keywords: COLLAGEN, SKIN AGING, AMBULATORY SURGICAL PROCEDURES

INTRODUCTION

Periorbital wrinkles, also known as “crow’s feet”, are very common and permanent cutaneous folds, generally symmetrical, that develop on the periocular area. They are both part of the normal aging process as well as result of sun damage and of the excessive activity of mimic muscles. Wrinkles are caused by a loss of the elastic fibers, collagen and fat within the skin. The normal aging process produces wrinkles that are usually fi ne lines that disappear when the skin is stretched. The sun-caused wrinkles are coarser and deeper and do not disappear when the skin is stretched. Nowadays, wrinkles have a greater social impact and, obviously, science and hedonism overlap in the search for causes, treatments and prevention of wrinkles.

The treatment for wrinkles varies with the degree of severity. The treatments can be based on the prescription of topical medications, chemical peels, dermoabrasion, muscle-relaxing injections, lasers resurfacing, cosmetic fi ller injections, and, most recently, collagen induction therapy (CIT). CIT is an effective method of treating wrinkles and other dematological lesions that involves puncturing the skin multiple times with a small needle to induce collagen growth. It has been used since 1995 to achieve percutaneous collagen induction (PCI). In 1995, Orentreich and Orentreich¹ described “subcision” as a way of building up connective tissue beneath retracted scars and wrinkles. Fernandes,² simultaneously and independently, used a similar technique to treat the upper lip by sticking a 15-gauge needle into the skin and then tunneling under the wrinkles in various directions, parallel to the skin surface. Camirand and Doucet treated scars with a tattoo gun to ‘‘needle abrade’’ them. Although this technique can be used on extensive areas, it was laboriously slow and the holes in the epidermis were too close and too shallow. All these techniques worked because needles break old collagen strands in the most superfi cial layer of the dermis that limit scars or wrinkles. It is presumed that this process promotes removal of damaged collagen and induces more collagen immediately under the epidermis. Fernandes believed that the standard technique of tattooing was too superficial to give good effects for thicker scars or for stimulating neo-collagen synthesis in the reticular dermis. Needles need to penetrate relatively deeply to stimulate the production of elastin fibers oriented from the deep layers of the dermis to the surface. Based on these principles, Fernandes designed a special tool for CIT, consisting of a rolling barrel with microneedles at regular intervals. Skin needling procedure is done under topical anesthesia, by rolling a special tool on the skin area backward and forward, applying some pressure, in various directions to achieve an even distribution of the holes. The microneedles penetrate through the epidermis but do not remove it; the epidermis is only punctured and rapidly heals. The needles seem to divide cells from each other rather than cut through them, therefore, many cells are spared. Because the needles are set in a roller, every needle initially penetrates at an angle and then goes deeper as the roller turns. Finally the needle is extracted at the converse angle therefore curving the tracts, reflecting the path of the needle as it rolls into and then out of the skin for about 1.5 to 2 mm into the dermis. The epidermis, and particularly the stratum corneum, remains "intact" except for the minute holes that were made, each about four cells in diameter. When a needle penetrates into the skin, the injury causes localized damage and minor bleeding by rupturing fine blood vessels. A completely different picture emerges when thousands of fine pricks are placed close to each other. Normal wound healing is promoted, which develops in three phases (inflammation, proliferation and remodeling) and culminates in laying down new collagen in the upper dermis just below the basal layer of the epidermis.

Recently, a new hypothesis has been proposed to explain the CIT mechanism of action: performed, using a high quality device, the fine microneedles - not longer than 1,5 mm - do not set a wound in the classical sense. The wound healing process is somewhat cut short, as the body is only somehow "fooled" into believing that an injury has occurred. According to this new theory, bioelectricity (also called "demarcation current") triggers a cascade of growth factors that stimulate the healing phase.

OBJECTIVE

In order to confirm the usefulness of CIT in periorbital wrinkles treatment, we applied this procedure to treat a group of 20 patients affected with different grades of periorbital wrinkles.

PATIENTS AND METHODS

The present study was conducted from January 2008 to February 2009 at the University of Naples "Federico II", Department of Systematic Pathology, Division of Clinical Dermatology. In total, 20 patients (12 females, 8 males; between 50-65 years of age) with periorbital wrinkles were recruited and signed an informed consent for this study. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki. Exclusion criteria are listed in Table 1.

Before the treatment (baseline, T0), the severity of lesions in each patient was scored by an experienced dermatologist involved in the study. Periorbital fold severity was evaluated using the Wrinkle Severity Rating Scale 4 (WSRS: 1 = absent to 5 = extreme), a 5-point scale with the right end (5) indicating maximum severity and the left end (1) absolutely no lesions. In accordance to severity score, 3 groups of patients were identified: 1 st group (A) comprised 9 patients with a severity score of 3; 2 nd group (B) comprised 7 patients with a severity score of 4; 3 rd group (C) comprised 4 patients with a severity score of 5. Facial fine lines and wrinkles depth were faithfully captured by photographic digital technology: 2 photographs of each periorbital area were taken of every patient by another dermatologist not involved in the study and filed in a database. In addition, to achieve reliable evidence, we made, for each patient, a periorbital cutaneous cast, at identical sites bilaterally, using silicone rubber to make a wrinkles’ impression (silicone replicas). Computerized digital image processing of such specimens provides objective measurement of skin’s topography, which has a significant degree of correlation with clinical grading. Profilometric data were obtained from skin replica analysis at baseline and at the end of the study.

As percutaneous CIT works better when combined with a scientific skin-care programme to restore a youthful appearance, the skin of each patient was treated with a topical product containing alpha–omega hydroxyl-acids, omega hydroxyl-acids, enoxolone and zinc for at least 3 weeks (preparation phase) before the skin needling began.

Three weeks later, before the first session of treatment began (T1), 2 standardized digital photographs were obtained of each patient’s periorbital areas (right and left) and filed in a database. During the first session, each patient was prepared in a manner similar to a surgical procedure: facial skin was disinfected, then a topical anesthetic (EMLA) was applied which was left for 60 minutes. Each patient was treated with a highly specific tool: a rolling barrel 20 mm wide, equipped with 192 needles in 8 rows. The needles used had a length of 1,5 mm and a diameter of 0,25 mm. According to the applied pressure, they penetrate the skin between 0,1 and 1,3 mm. The diameter at maximum penetration level was only 0,07 mm. The special tool was rolled over the areas affected by wrinkles. Rolling consisted in moving four times in four directions (where possible): horizontally, vertically and diagonally right and left (Figure 1). This ensured an even pricking pattern, resulting in about 250 to 300 pricks/cm2. Special attention was given when we rolled around the eyes because this tissue is very thin and sensitive. As expected, after the treatment, the skin bled for a short time. When bleeding stopped, a serous ooze formed and was removed from the surface of the skin with the use of sterile saline solution (Figure 2). Further wound treatment was not necessary. A week later, each patient was seen to estimate the response to CIT and any side effects that may have occurred.

The second session of treatment was conducted 8 weeks after the first one (T2). The purpose was to evaluate the clinical improvement of wrinkles using CIT. Before this second intervention, for each patient, new digital photographs were obtained using identical patient positioning, lighting, and camera settings, filed in a database and compared to the previous one taken before the first treatment. To estimate 2). The purpose was to evaluate the the improvement of wrinkles and the efficacy of CIT, each patient was also examined and, according to severity lesions, a new score was given using the WSRS. Furthermore, all patients were rated as improved or better on the Global Aesthetic Improvement Scale (GAIS) (Table II). The procedure of the second treatment was the same as the first treatment.

The last check-up was conducted 32 weeks after the second treatment (T compared to the photographs taken before the first treatment. Each patient was conferred a new WSRS score and GAIS rating. We assessed the real immediate improvement induced by CIT on periorbital wrinkles after two session of skin needling. Moreover, during the last check-up, we made other cutaneous casts that were compared with the ones made before beginning the first treatment and assessed the degree of irregularity in these casts by a computerized image analysis. photographic digital technology provided an instrument to evaluate the changes in the photodamaged skin during the study. Studies profilometry as an objective technique that could reproducibly measure changes in skin topography with minimal variability or potential for bias.

STATISTICAL ANALYSIS

The digital photographic data were analysed using a test for nonparametric data (sign test for paired data). The null (H0) is that the median of the difference is zero (P+ = P-) and the alternative hypothesis (HA) is that the median of the differences is negative (P+ < P-), = 0.05. The result is given by computing the binomial probability.

COMPUTERIZED IMAGE ANALYSIS OF SKIN CASTS

Acquisition of images:The acquisition of skin casts was carried out using a stereomicroscope connected to an analog video camera.

Evaluation of surface’s microrelief:The morphometric study of skin surface allows to evaluate the surface’s irregularity (skin surface texture) and to determine the possible variation caused

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