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Gerber PA, Buhren BA, Bölke E, Philipp-Dormston WG, Homey B, Schrumpf H. Time- and Dose-Dependent Effects of Hyaluronidase on the Degradation of Different Hyaluronan-Based Fillers In Vitro. Plast Reconstr Surg 2023; 151:560-567. [PMID: 36730370 DOI: 10.1097/prs.0000000000009916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hyaluronidase (HYAL) is regarded as the standard for the management of complications associated with hyaluronan (HA)-based fillers. Therefore, the understanding of interactions of HA fillers and HYAL is essential. METHODS Nine different commercially available HA fillers (Belotero, Juvéderm, and Restylane) with varying degrees of cross-linking were used for the analysis. Fluorescently dyed HA fillers were individually incubated with varying doses of HYAL [bovine HYAL (Hylase "Dessau"; Riemser Pharma, Germany); 5, 10, and 20 U/mL] or sodium chloride and monitored by time-lapse microscopy. HA filler degradation was assessed as a decrease in fluorescence intensity of HA filler plus HYAL compared to HA filler plus control, quantified by computerized image analysis. RESULTS HA fillers show significant differences in their reaction to HYAL. Levels of degradation of HA fillers are positively correlated with increasing concentrations of HYAL. At the highest concentration of HYAL (20 U/mL), all fillers except one (Belotero Volume) reached a significant level of degradation at 5 to 9 hours. CONCLUSIONS In this study, the authors show that most HA fillers can be dissolved by HYAL in a dose- and time-dependent manner. Of note, the fillers' technology and degree of cross-linking seem to exert stronger effects on the degradability by HYAL as compared to the concentration of HA. CLINICAL RELEVANCE STATEMENT The authors' in vitro analyses support clinical recommendations stating that in the case of a vascular filler incident, HYAL should be applied early and at significant doses ("Time is skin!"). CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Affiliation(s)
- Peter Arne Gerber
- From the Department of Dermatology, Medical Faculty, University Hospital Duesseldorf.,Dermatologie am Luegplatz
| | - Bettina A Buhren
- From the Department of Dermatology, Medical Faculty, University Hospital Duesseldorf
| | - Edwin Bölke
- From the Department of Dermatology, Medical Faculty, University Hospital Duesseldorf
| | | | - Bernhard Homey
- From the Department of Dermatology, Medical Faculty, University Hospital Duesseldorf
| | - Holger Schrumpf
- From the Department of Dermatology, Medical Faculty, University Hospital Duesseldorf
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Buhren BA, Schrumpf H, Gorges K, Reiners O, Bölke E, Fischer JW, Homey B, Gerber PA. Dose- and time-dependent effects of hyaluronidase on structural cells and the extracellular matrix of the skin. Eur J Med Res 2020; 25:60. [PMID: 33228813 PMCID: PMC7686775 DOI: 10.1186/s40001-020-00460-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction Hyaluronic acid (hyaluronan; HA) is an essential component of the extracellular matrix (ECM) of the skin. The HA-degrading enzyme hyaluronidase (HYAL) is critically involved in the HA-metabolism. Yet, only little information is available regarding the skin’s HA–HYAL interactions on the molecular and cellular levels. Objective To analyze the dose- and time-dependent molecular and cellular effects of HYAL on structural cells and the HA-metabolism in the skin. Materials and methods Chip-based, genome-wide expression analyses (Affymetrix® GeneChip PrimeView™ Human Gene Expression Array), quantitative real-time PCR analyses, enzyme-linked immunosorbent assay (ELISA), immunohistochemistry (DAB), and in vitro wound healing assays were performed to assess dose-dependent and time-kinetic effects of HA and HYAL (bovine hyaluronidase, Hylase “Dessau”) on normal human dermal fibroblasts (NHDF), primary human keratinocytes in vitro and human skin samples ex vivo. Results Genome-wide expression analyses revealed an upregulation of HA synthases (HAS) up to 1.8-fold change in HA- and HYAL-treated NHDF. HA and HYAL significantly accelerated wound closure in an in vitro model for cutaneous wound healing. HYAL induced HAS1 and HAS2 mRNA gene expression in NHDF. Interestingly, low concentrations of HYAL (0.015 U/ml) resulted in a significantly higher induction of HAS compared to moderate (0.15 and 1.5 U/ml) and high concentrations (15 U/ml) of HYAL. This observation corresponded to increased concentrations of HA measured by ELISA in conditioned supernatants of HYAL-treated NHDF with the highest concentrations observed for 0.015 U/ml of HYAL. Finally, immunohistochemical analysis of human skin samples incubated with HYAL for up to 48 h ex vivo demonstrated that low concentrations of HYAL (0.015 U/ml) led to a pronounced accumulation of HA, whereas high concentrations of HYAL (15 U/ml) reduced dermal HA-levels. Conclusion HYAL is a bioactive enzyme that exerts multiple effects on the HA-metabolism as well as on the structural cells of the skin. Our results indicate that HYAL promotes wound healing and exerts a dose-dependent induction of HA-synthesis in structural cells of the skin. Herein, interestingly the most significant induction of HAS and HA were observed for the lowest concentration of HYAL.
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Affiliation(s)
| | - Holger Schrumpf
- Department of Dermatology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Katharina Gorges
- Department of Pharmacology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Oliver Reiners
- Department of Pharmacology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Jens W Fischer
- Department of Pharmacology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Bernhard Homey
- Department of Dermatology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Peter Arne Gerber
- Department of Dermatology, University Hospital Duesseldorf, Duesseldorf, Germany. .,Dermatologie am Luegplatz, Duesseldorf, Germany.
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Liu J, Xin WQ, Liu LT, Chen CF, Wu L, Hu XP. Majocchi's granuloma caused by Trichophyton rubrum after facial injection with hyaluronic acid: A case report. World J Clin Cases 2020; 8:3853-3858. [PMID: 32953864 PMCID: PMC7479567 DOI: 10.12998/wjcc.v8.i17.3853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/02/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Facial cosmetic procedures become popular for people with a desire to have a younger appearance, and cosmetic technology has developed rapidly over the past several decades. However, increasing complications related to cosmetic injections have been reported, and infection is one of the most serious problems and can cause anxiety and facial injury. We here report a case of Majocchi's granuloma (MG) caused by Trichophyton rubrum after facial injection of hyaluronic acid.
CASE SUMMARY A 37-year-old woman presented to our hospital with a history of red papules, nodules, and abscesses on her left zygomatic arch for 2 mo. She had received a cosmetic injection of hyaluronic acid on the left side of her face prior to the appearance of the lesions. MG caused by Trichophyton rubrum after facial injection of hyaluronic acid was diagnosed based on morphology and molecular biological identification. In vitro antifungal susceptibility testing was conducted according to the Clinical and Laboratory Standards Institute M38-A2 method. Minimal inhibitory concentrations were used to evaluate the antifungal susceptibility. The antifungal agents and their minimal inhibitory concentrations for the strain were terbinafine (< 0.5 μg/mL), itraconazole (0.06 μg/mL), amphotericin B (0.25 μg/mL), fluconazole (32 μg/mL), voriconazole (0.125 μg/mL), posaconazole (0.125 μg/mL), and isavuconazole (0.06 μg/mL). We initially administered 250 mg/d oral terbinafine for 2 mo, but the patient still had painful papules, nodules and abscesses on her face. Then, we adjusted the treatment to itraconazole 400 mg/d for 8 wk based on the in vitro antifungal susceptibility testing results. The skin lesions improved significantly, and there was no recurrence during follow-up.
CONCLUSION This case revealed that facial injection of hyaluronic acid may cause serious MG. Antifungal susceptibility testing should be considered in the treatment of MG caused by Trichophyton rubrum.
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Affiliation(s)
- Jie Liu
- Department of Dermatology, Skin Research Institute of Peking University Shenzhen Hospital, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Wen-Qiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Lan-Ting Liu
- Department of Dermatology, Skin Research Institute of Peking University Shenzhen Hospital, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Chao-Feng Chen
- Department of Dermatology, Skin Research Institute of Peking University Shenzhen Hospital, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Lin Wu
- Department of Dermatology, Skin Research Institute of Peking University Shenzhen Hospital, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
| | - Xiao-Ping Hu
- Department of Dermatology, Skin Research Institute of Peking University Shenzhen Hospital, Peking University Shenzhen Hospital, Shenzhen 518036, Guangdong Province, China
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Clinical Applications of Hyaluronidase. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1148:255-277. [PMID: 31482503 DOI: 10.1007/978-981-13-7709-9_12] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hyaluronidases are enzymes that degrade hyaluronic acid, which constitutes an essential part of the extracellular matrix. Initially discovered in bacteria, hyaluronidases are known to be widely distributed in nature and have been found in many classes including insects, snakes, fish and mammals. In the human, six different hyaluronidases, HYAL1-4, HYAL-P1 and PH-20, have been identified. PH-20 exerts the strongest biologic activity, is found in high concentrations in the testicles and can be localized on the head and the acrosome of human spermatozoa. Today, animal-derived bovine or ovine testicular hyaluronidases as well as synthetic hyaluronidases are clinically applied as adjuncts to increase the bioavailability of drugs, for the therapy of extravasations, or for the management of complications associated with the aesthetic injection of hyaluronic acid-based fillers. Further applications in the fields of surgery, aesthetic medicine, immunology, oncology, and many others can be expected for years to come. Here, we give an overview over the molecular and cellular mode of action of hyaluronidase and the hyaluronic acid metabolism, as well as over current and potential future clinical applications of hyaluronidase.
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Buhren BA, Schrumpf H, Bölke E, Kammers K, Gerber PA. Standardized in vitro analysis of the degradability of hyaluronic acid fillers by hyaluronidase. Eur J Med Res 2018; 23:37. [PMID: 30122153 PMCID: PMC6100712 DOI: 10.1186/s40001-018-0334-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/31/2018] [Indexed: 12/13/2022] Open
Abstract
Background Hyaluronidase is a hyaluronic acid (HA) metabolizing enzyme, which is approved as an adjuvant for infiltration anesthesia. The “off-label” use of hyaluronidase is regarded as gold standard for the management of HA-filler-associated complications. Yet, up to date there are only few studies that have systematically assessed the degradability of different HA-fillers by hyaluronidase. Objective To analyze the interactions of HA-fillers and hyaluronidase in a time-dependent manner using a novel standardized in vitro approach. Methods Comparable HA-fillers, Belotero Balance Lidocaine (BEL; Merz), Emervel classic (EMV; Galderma) and Juvederm Ultra 3 (JUV; Allergan), were incubated with a fluorescent dye and bovine hyaluronidase (HYAL; Hylase “Dessau”, Riemser) or control (NaCl) and monitored by time-lapse videomicroscopy. The degradation of HA-fillers was assessed as decrease in fluorescence intensity of HA-filler plus hyaluronidase vs. HA-filler plus control, quantified by computer-assisted image analysis (ImageJ). Results Hyaluronidase showed a significant degradation of the HA-fillers BEL and EMV. Degradation was measurable at 5 h (BEL) and 7 h (EMV), respectively; significance was reached at 14 h (BEL) and 13 h (EMV). No effect of hyaluronidase was observed for JUV. Conclusion Time-lapse microscopy enables systematically, standardized, comparative in vitro analyses of the interactions of hyaluronidase and HA-fillers.
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Affiliation(s)
- Bettina Alexandra Buhren
- Departments of Dermatology, Medical Faculty, Research Laboratory for Dermatology and Immunology, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Holger Schrumpf
- Departments of Dermatology, Medical Faculty, Research Laboratory for Dermatology and Immunology, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Edwin Bölke
- Departments of Radiation Oncology, Medical Faculty, Research Laboratory for Dermatology and Immunology, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter Arne Gerber
- Departments of Dermatology, Medical Faculty, Research Laboratory for Dermatology and Immunology, Heinrich-Heine-University Duesseldorf, University Hospital Duesseldorf, Duesseldorf, Germany.
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Buhren BA, Schrumpf H, Hoff NP, Bölke E, Hilton S, Gerber PA. Hyaluronidase: from clinical applications to molecular and cellular mechanisms. Eur J Med Res 2016; 21:5. [PMID: 26873038 PMCID: PMC4752759 DOI: 10.1186/s40001-016-0201-5] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/05/2016] [Indexed: 12/22/2022] Open
Abstract
Over the past 60 years, hyaluronidase has been successfully utilized in ophthalmic surgery and is now being implemented in dermatosurgery as well as in other surgical disciplines. The enzyme is considered a “spreading factor” as it decomplexes hyaluronic acid (also called hyaluronan, HA), an essential component of the extracellular matrix (ECM). When applied as an adjuvant, hyaluronidase enhances the diffusion capacity and bioavailability of injected drugs. Therefore, the enzyme has been used as a local adjuvant to increase the diffusion capacity of local anesthetics, increasing the analgesic efficacy, and the anesthetized area particularly in the first minutes following injection, resulting in diminished intra- and postoperative pain. In aesthetic medicine, the off-label use of hyaluronidase is considered the gold standard for the management of HA-filler-associated complications. Here, we review the clinical use, underlying biological mechanisms, and future directions for the application of hyaluronidase in surgical and aesthetic medicine.
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Affiliation(s)
| | - Holger Schrumpf
- Department of Dermatology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Norman-Philipp Hoff
- Department of Dermatology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Said Hilton
- Medical Skin Center Dr. Hilton & Partners, Düsseldorf, Germany.
| | - Peter Arne Gerber
- Department of Dermatology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
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