Dermatologist Debriefs

The Autoimmune Guide to Safe Aesthetic Treatments

• Stefanie Williams

Share episode

Autoimmune conditions are rising globally, but what does this mean for those seeking cosmetic enhancement? In this episode, Dr. Stefanie breaks down which aesthetic treatments are genuinely safe and which carry hidden risks for an overactive immune system. From Botox variants to the delayed reactions fillers can trigger months later, this is essential listening for anyone navigating beauty treatments with frontal fibrosing alopecia, lupus, or other autoimmune conditions.

SPEAKER_00:

Dermatologist debriefs. Join no-nonsense dermatologist Dr. Stephanie Williams as she debunks myths and shares her professional insights. Separating facts from fiction in just a few minutes.

SPEAKER_01:

Hello, this is Dr. Stephanie. So last week I was asked by a colleague what cosmetic treatments are safe to do for patients with frontal fibrosing alopecia, also called FFA. And to clarify, FFA is a scarring form of hair loss that primarily affects the frontal hairline, creating a kind of band-like recession of the hairline. It's considered a variant of Lycan Planopillaris, an autoimmune condition, where the body's immune system mistakenly attacks and ultimately destroys hair follicles. So that made me think that it would be maybe a good idea to speak about cosmetic treatments in patients with autoimmune conditions in general, because it's not just relevant for FFA patients but also all sorts of other autoimmune diseases too. Autoimmune diseases are on the rise globally, and with that are requests for cosmetic procedures among those patients. But this can really be a challenge for practitioners to balance safety and aesthetic goals. And these patients require tailored considerations due to higher risk of immune-mediated reactions to cosmetic treatments. So let's have a think about which treatments may be relatively safe for those patients to do and which patients may be less safe. Let's start with one of the most common treatments we do in aesthetic practice, which are muscle relaxing injections, also known as Botox. Botox is of course just one of many brand names, and the active ingredient is called butulinium toxin. So this active ingredient is generally considered safe for patients with well-controlled autoimmune diseases, as long as the disease is stable and not in a flare. However, as with any treatment, this should of course always be carried out with informed consent. And while most patients know this procedure under the original brand name Botox, there is a newer variant of Botulin toxin available. This is a German brand called Beaucouture, and compared to the original US brand, some view this as potentially safer for autoimmune patients because it may be less immunogenic. And the reason for that is that Beaucouture is a purified solution that only contains the naked neurotoxin, so to say. It is in fact free from complexing proteins that aren't actually needed for its therapeutic action. And these complexing proteins are thought to potentially contribute to immune reactions and in theory could therefore increase the risk for autoimmune patients to have an immune response to the ingredient or let's say to the help ingredients in the solution. So this lower total protein load makes it appealing for patients at higher risk of immune reactions, such as those with autoimmune diseases. However, to my knowledge, there are no studies published yet to confirm this either way. But overall, in my own professional experience, both brands are generally fine, including for patients with autoimmune conditions. And personally, I've never had any issues after either in my own clinic with regards to immune reactions. So let's talk about the next group of cosmetic treatments, cosmetic injectables, to be specific, one that's equally as popular, and that's dermal fillers. So these injectable fillers are actually a little higher risk for autoimmune patients compared to butulinium toxin, and that's because fillers, like for example, hyaluronic acid fillers, carry a slightly higher risk of delayed immune reactions like granulomas, with reported cases emerging up to a year or later after the actual treatment. And that can happen even following a negative patch test. Granulomas are lumps formed in the immune system walls of foreign substances, in this case the filimaterial, by surrounding them with a specialized tissue, resulting in firm lumps that can persist, sometimes become even painful or disfiguring. And not all filibrons are equal here. Some HA formulations may carry higher risk of immune reactions in autoimmune patients than others. And then there are of course non-HA fillers, for example, containing polylactic acid, PLLA, or calcium hydroxylapatite. One of the brands is called Radius that you may have heard of. But there are others. So I would personally avoid these in autoimmune patients. Unfortunately, patch testing prior to filler injection does not reliably predict delayed reactions. And of course, they can also be confounded by current immunomodulatory medications such as corticosteroids or cytotoxic drugs. So once those are stopped, there is always a possibility that only then an immune reaction may occur, and that can be months and months later. So overall, my advice to autoimmune patients is to avoid all fillers during active flare-up of disease. But in patients with stable, well-controlled disease, there may be an option to be treated with fillus. I would definitely stick to HA fillus and discuss very carefully that there is a possibility of late reactions, and we can't really predict long-term reactions. So autoimmune patients, especially if they've got quite significant autoimmune conditions, may even want to stay away from all dermal fillers. Ultimately, it comes down to your and your doctor's risk appetite or risk aversion, as well as the choice of filler material, as well as the brand, because different HA brands have a different potential to elicit immune reactions. Personally, I'm quite risk-adverse as a doctor when it comes to cosmetic treatments because these are all obviously elective, and so in many cases, I would discuss this with the patient and advise against it. As a rule of thumb, you can imagine that anything injected into the skin that your body may think of as a foreign material, rightly or wrongly, carries a risk of reactions for autoimmune patients. So that also includes skin boosters, whether they contain hyaluronic acid or polynucleotides or polylactic acid or other ingredients. Out of those three groups that I just mentioned, I would be most reluctant to inject the last two, so polynucleotides and PLLA, as the polynucleotides are of marine origin and can more often cause immune reactions in my experience. Whereas hyaluronic acid, if it's well formulated, has a relatively lower risk of that. And then there is another skin booster that has an even lower risk. It's called Sunicos Performa, which contains a blend of amino acids, and those are body identical. But arguably the least problematic with regards to potential autoimmune reactions are so-called autologist treatments. So these are treatments that use the patient's own cells, tissues, or blood products for therapy. One example is fat transfer, where doctors take the patient's own fat tissue from somewhere on the body and transfer it into the face, for example, the cheeks. That's a little more invasive than most of the treatments I do, and but it's an orthologist product, so that's something you may want to discuss with your plastic surgeon. But there are also less invasive ortologist cosmetic treatments, including PRP, platelet-rich plasma, or exochine by orthogen, either as an injection or needled into the skin. These are solutions rich in growth factors that are derived from the patient's own blood, and because of that it has a reduced immunogenic potential. And for clarification, while orthogen's exokine treatment comes from the patient's own blood, commercially available exosomes are actually not orthologous. So in summary, autologous regenerative treatments are a really good option for autoimmune patients, in my view. For example, plain medical needling, where we do a micro needling procedure using simple sterile saline solution as a gliding medium, or energy-based treatments. And some of those energy-based treatments I'm particularly fond of, and that don't introduce any foreign materials into the patient's skin are focused ultrasound like L-therapy and soft wave, and also radio frequency needling. And then there's a very gentle, no-downtime regenerative laser which is called clear lift, and that again does not introduce any foreign substances into the patient's skin because it works with acoustic waves rather than chemical materials. Similarly, pigment and vascular lasers and IPL are also generally considered safe for patients prone to autoimmune reactions, as is LED and low-level laser light. And chemical peels are also mostly fine. But just to clarify, I am speaking specifically about potential autoimmune reactions today. There are, of course, other reasons certain cosmetic treatments may not be suitable for certain conditions. For example, I would definitely advise against medical needling for vitiligo patients due to the risk of Kubner phenomenon where the disease can be activated via mechanical trauma. And another consideration with regards to cosmetic treatments for autoimmune patients is their treatment, their systemic treatment for the autoimmune condition. So these patients are often on immune suppressive treatments such as corticosteroids or cytotoxic drugs or biologicals, which may increase the risk of skin infections, which is also something we have to take into account. So, in summary, my advice is to treat only during periods of remission of the autoimmune condition and to always avoid cosmetic interventions during acute exacerbations of autoimmune disease. And then we want to avoid introducing materials into the skin that stay in our skin for long periods of time, such as fillers, which may then stimulate the immune system, and the immune system may mistake it as an unwanted foreign body, which can potentially happen even months or more than a year later, and it may then respond with granuloma formation, which is something we really don't want to happen. So, as a general rule, stick to treatments that don't introduce foreign materials into the skin if you are one of those patients, and make sure you discuss this very closely with your cosmetic doctor. I hope this makes sense, and I will speak to you again next week.