Med Lasers 2024; 13(1): 66-69  https://doi.org/10.25289/ML.24.006
The pinhole method as a novel approach to remove residual hyaluronidase powder: a case report
Jiwon Lee1, Sang Ju Lee2, Han Kyoung Cho1
1Department of Dermatology, Myongji Hospital, Goyang, Republic of Korea
2Yonsei Star Skin & Laser Clinic, Seoul, Republic of Korea
Correspondence to: Han Kyoung Cho
E-mail: trpchk@hanmail.net
ORCID: https://orcid.org/0000-0001-6074-013X
Received: March 6, 2024; Accepted: March 20, 2024; Published online: March 30, 2024.
© Korean Society for Laser Medicine and Surgery. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
With the increasing use of hyaluronic acid (HA) fillers in aesthetic medicine, hyaluronidase has been widely used for the correction of HA fillers and the treatment of related complications. A 24-year-old female presented with a whitish papule beneath her right eye. She had previously undergone triamcinolone and HA filler injections with subsequent hyaluronidase treatment. Despite an initial suspicion of triamcinolone residue, observation revealed the persistence of the lesion. A single session of treatment with the pinhole method using a carbon dioxide laser successfully removed the residual hyaluronidase powder, without complications, and the lesion completely resolved after 7 months. By creating microscopic holes and inducing dermal remodeling, the pinhole method is effective in treating various skin lesions. This case highlights the importance of thorough mixing of hyaluronidase solutions and demonstrates the utility of the pinhole method in treating such cases, suggesting its broader applicability in dermatological interventions.
Keywords: Carbon dioxide lasers; Dermal fillers; Hyaluronic acid; Hyaluronidase
INTRODUCTION

Periocular aging is characterized by thinning of the periorbital tissues, sagging upper eyelid skin, and pseudoherniation of lower eyelid fat [1]. Cosmetic dermal fillers, especially hyaluronic acid (HA), have gained popularity in the last two decades to address volume deficit in these aging tissues [1,2]. HA fillers have good utility and an excellent safety profile, although unwanted results such as overcorrection, asymmetries, and adverse events including infection, migration, and vascular occlusion may occur [1-3]. Hyaluronidase, an enzyme that destroys HA, is currently used for dissolving HA fillers and treating HA filler-related side effects [1-5].

The pinhole method consists of making multiple microscopic holes in the target lesion with a carbon dioxide (CO2) laser [6-8], and has been used to treat various types of scars. Previous studies have shown that it is convenient and safe, and results in less bleeding and oozing and a shorter recovery time [7]. We experienced a rare case of a 24-year-old female with a hyaluronidase powder remnant successfully removed using the pinhole method.

A written informed consent was obtained from the patient for the publication of this case report.

CASE REPORT

A 24-year-old female came to our clinic for a whitish papule under the right eye (Fig. 1A). She had undergone entropion repair the previous year, and received triamcinolone intralesional injection twice, one week apart, with the last dose one week before her visit. She also had HA filler injections in both lower eyelids, but due to the bluish hue at the injection site, she had hyaluronidase treatment two months before the visit. Since the most recent injection was triamcinolone, the patient was first observed for 4 weeks without treatment because of the possibility of remaining triamcinolone powder at the injection site. After four weeks, no change was observed; thus, the patient was treated with a single session of the pinhole method using a CO2 laser (Ultrapulse® Encore; Lumenis) with a 1.0 mm handpiece and parameters of 1.0 W, 10 ms exposure, and 100 ms delay in PreciseFX mode. Total three holes were made, each of them spaced 5 mm apart on the lesion and chalky materials were scraped out through these holes. There were no complications during the treatment. After the laser treatment, cold pack was applied for 10 minutes, then hydrocolloid dressing (DuoDERM® Extra Thin; Convatec) was done for 7 days. One month after the session, the size of the lesion decreased (Fig. 1B), and the lesion completely resolved seven months after the treatment (Fig. 1C).

Figure 1. (A) A 24-year-old female visited the clinic for a whitish papule (arrow) under the right eye. Total three holes were made with the pinhole method, each of them 5 mm apart. (B) One month after treatment with the pinhole method, the size of the lesion (arrow) decreased. (C) Seven months after the treatment, the lesion completely resolved.
DISCUSSION

The pinhole method involves using a CO2 laser to make microscopic holes that penetrate from the epidermis to the deeper dermis [6-11]. This method not only breaks down irregular and thick collagen bundles by physical breakage and thermal damage, but also induces regeneration and remodeling of dermal connective tissues, improving skin texture [6-9]. In addition, the operator can adjust the penetration depth and interval depending on the lesion with the pinhole method, thus it has advantage treating disoriented, irregular skin lesions than fractional CO2 lasers which have equivalent penetration depth and restricted beam sizes [9,10]. Previous studies have used the pinhole method to treat various types of scars, anetoderma, syringomas, sebaceous hyperplasia, and elastosis perforans serpiginosa [6-8,10,11]. In this case, we minimized scarring, bleeding, and oozing by puncturing microscopic holes in the lesion and removing its contents, rather than removing the entire lesion.

HA fillers are the most commonly used dermal fillers worldwide due to their safety, longevity, lack of immunogenicity, and biodegradability [12]. With their skyrocketing popularity, complications are inevitable, including nodule formation, overcorrection, undercorrection, migration, infection, and vascular occlusion [1-3]. Hyaluronidase, an enzyme that breaks down HA, has been approved for facilitating the absorption and dispersion of contrast dyes or drugs in subcutaneous tissues [3,4]. Its current off-label uses include dissolving HA fillers and treating HA filler-associated side effects [4]. Hyaluronidase is an endoglycosidase that breaks down HA by cleaving its glycosidic bonds and other mucopolysaccharides in the connective tissue [2-4]. It also dissolves native HA, but the body restores native HA in 15 to 20 hours; thus, hyaluronidase has no long-term effects on skin quality [2]. Hyaluronidase is reconstituted in bacteriostatic normal saline, and should be gently swirled or mixed in the vial to dissolve the powder in the saline properly before every use [2,3]. Local allergic reactions are known side effects after hyaluronidase injections and the incidence is reported to be 0.05% to 0.69% [4,5]. Such reactions include pruritus, edema, generalized maculopapular rash, and urticaria, although most of the symptoms are rare, mild, and benign [4].

Triamcinolone is a mildly potent fluorinated prednisolone with both anti-inflammatory and immunosuppressant activity, and is widely used as injections for various cutaneous and noncutaneous indications. Triamcinolone acetonide is highly insoluble in water due to the formation of microcrystals by ester compounds through hydrolysis by cellular esterases to release the active moiety; it thus has a long-lasting effect. Because triamcinolone acetonide is a suspension, the bottle must be shaken vigorously after each step of use and before each use because it may appear white at the injection site if not mixed properly. In addition, intralesional steroid injection can cause local side effects such as atrophy, hypopigmentation, and telangiectasias [13].

In this case, the patient’s most recent injection was triamcinolone, and because triamcinolone is highly insoluble and can appear white on the skin if it is not mixed well, the patient was observed for 4 weeks. However, the lesion remained intact, was not accompanied by any side effects of local steroid injections such as atrophy, hypopigmentation, and telangiectasia. In addition, hyaluronidase has no long-term effect on skin quality since the body resotres native HA, we inferred that the lesion was hyaluronidase deposition, not triamcinolone. We have described a rare case of hyaluronidase remaining on the skin, suggesting that it should be thoroughly mixed with normal saline before every injection. In addition, the pinhole method was used to treat the lesion without any side effects such as scarring, bleeding, or oozing, suggesting its broader application to treat a variety of skin lesions.

SUPPLEMENTARY MATERIALS

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: SJL. Resources: SJL. Project administration: SJL, HKC. Visualization: SJL, JL. Supervision: SJL, HKC. Writing–original draft: JL. Writing–review & editing: all authors.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

DATA AVAILABILITY

None.

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