Overview of dermatological ozone applications and A rare complication of dermal ozone treatment: Isolated orbital emphysema with cutaneous injection

Year 2018, Volume: 3 Issue: 2, 38 - 49, 20.06.2018

Selami Baş Erkan Yula

Abstract

Background: Ozone treatment that effects immune system has become more
popular as a supplemental or alternative therapy due to development of
sensitive medical ozone generators, starting formal ozone training programs and
some established general application protocols. 
Although, ozone treatment is a safe method, especially in dermal
injections, inexperienced practitioners can cause various complications. In
this report, we discussed a rare complication of ozone treatment titled
isolated orbital emphysema with dermal injection and a short overview of dermatological
ozone applications.

Case: A 35
years old male volunteer without any systematic disease was applied
subcutaneous ozone injection at a concentration of 10 µg/ml to induce collagen
synthesis for thin wrinkles on the forehead, while he was getting the ozone
therapy course as a trainee. During the injection to the right of glabella, 3
ml of ozone gas at a concentration of 10 µg/ml was injected while it was
supposed to be 0.5 ml. Due to periorbital anatomical structure, the
subcutaneous air intrusion towards the right eye occurred, leading to immediate
emphysematous swelling in the right eye lid and orbital region, and ptosis in
the eye lid. Understanding the injection was subcutaneous, direct massaging
towards inside out around the eye was performed to collect the gas to the
periphery. When the patient's condition was assessed, no pain, blurred vision
and other symptoms were noted, except feeling of pressure. However, on the same
day we administer oral high dose vitamin C and multi-mineral combination to
increase the patient's antioxidant resistance. Also, oral hydration and keeping
warm of the periocular area recommended. It was determined that no developing
any visual complaints during 48 and 72 hour follow-up.

In this case, we believe that intervention
with manual massage around the eye, using ozone gas at low concentration and
the injected amount of gas is not relatively extreme lead to the absence of
complications.

Conclusion:
Although, ozone is very reliable and the therapeutic index is quite broad, the
ozone gas application to critical anatomical localizations such as the orbital
region we believe that these kinds of interventions should not be done except
experienced practitioners who are dominant in the anatomical structure and
practice the application technique well.

Keywords

ozone, dermal ozone, ozone treatment, complication

Dermatolojik ozon uygulamalarına bakış ve Nadir bir dermal ozon tedavisi komplikasyonu olgusu: Dermal enjeksiyonla oluşan izole orbital amfizem

Abstract

Amaç: İmmün sistemi etkileyen bir yöntem olan ozon tedavisi, hassas medikal ozon jeneratörlerinin gelişmesi, ozon uygulama için çeşitli eğitim programlarının düzenlenmeye başlanması ve bazı genel uygulama protokollerinin oluşturulmayla etkin bir şekilde tamamlayıcı veya alternatif bir tedavi olarak kullanılması yaygınlaşmaktadır. Her ne kadar oldukça güvenli bir yöntem olsa da özellikle dermal enjeksiyonlarda deneyimsiz uygulayıcılar çeşitli komplikasyonlara yol açabilmektedir. Bu olgu sunumunda dermal enjeksiyonla oluşan izole orbital amfizem olgusu paylaşılmakta ve kısaca dermatolojik ozon uygulamalarına değinilmektedir.

Olgu: 35 yaşında herhangi bir sistemik hastalığı olmayan erkek gönüllüye, kursiyer olarak katıldığı ozon terapi kursunda alın bölgesindeki ince kırışıklar için kollojen sentezinin indüksiyonu amacıyla subkutan 10 μg/ml dozunda ozon enjeksiyonunun yapılması istenir. Fakat uygulayıcının glabellanın sağ kısmına doğru yaptığı enjeksiyon sırasında intradermal 0.5 ml yapması gereken bölgeye subkutan yaklaşık 3 ml, 10 μg/ml konsantrasyonda ozon gazı enjekte edilir. Periorbital anatomik yapı nedeniyle subkutan havanın hastanın sağ gözüne doğru ilerlemesi sonucu sağ göz kapağı ve orbital bölge dakikalar içerisinde amfizematöz şişliğe uğradı ve göz kapağında hafif pitoz meydana geldi. Enjeksiyonun subkutan yapıldığının anlaşılması ile gaz toplanmasını perifere toplamak için derhal göz etrafına içerden dışarı doğru masaj yapıldı. Hastanın görme durumu değerlendirildiğinde bası hissi dışında herhangi bir şikayetinin olmadığı, ağrı, bulanık görme veya diğer semptomların gelişmediği tespit edildi. Buna rağmen hastanın antioksidan direncini artırmak için aynı gün oral yüksek doz C vitamini ve multiminarel kombine preparat başlandı. Oral hidrasyon ve lezyona uğrayan bölgenin sıcak tutulması önerildi. Hastanın 48 ve 72 saatlik takibinde görme ile ilgili herhangi bir şikâyet gelişmediği tespit edildi. Bu vakada neyse ki düşük konsantrasyonda ozon gazı kullanılmasının, enjekte edilen miktarın görece olarak aşırı olmamasının ve göz etrafına manuel masaj ile müdahale edilmesinin ciddi bir komplikasyon gelişmesine engel olduğu kanaatindeyiz.

Sonuç: Her ne kadar ozon oldukça güvenilir ve terapotik indeksi geniş bir etken madde olsa da orbital bölge gibi kritik anatomik lokalizasyonlara ozon gazı uygulamasında anatomik yapıya hâkimiyeti olan, uygulama tekniğini iyi gerçekleştiren deneyimli uygulayıcılar dışında bu tür müdahalelerin yapılmaması gerektiği kanaatindeyiz.

Keywords

ozone treatment, complication, Isolated orbital emphysema

References

• 1. Bocci VA. Scientific and Medical Aspects of Ozone Therapy. State of the Art. Archives of Medical Research. 2006; 37 :425–435.
• 2. Geleneksel ve tamamlayici tip uygulamalari yönetmeliği [Regulation of Conventional and Complementary Medical Practices], 27.10.2014 Resmi Gazete Sayısı: 29158.
• 3. Smith NL, Wilson AL, Gandhi J, Vatsia S, Khan SA. Ozone therapy: an overview of pharmacodynamics, current research, and clinical utility. Medical Gas Research. 2017; 7(3): 212-219.
• 4. Bocci V, Valacchi G, Corradeschi F, Fanetti G. Studies on the biological effects of ozone: 8. Effects on the total antioxidant status and on interleukin-8 production. Mediators Inflamm. 1998;7:313-317.
• 5. Elvis AM, Ekta JS. Ozone therapy: A clinical review. J Nat Sc Biol Med 2011; 2(1): 66-70.
• 6. Andreula CF, Simonett i L, De Santis F, Agati R, Ricci R, Leonardi M. Minimally invasive oxygen-ozone therapy for lumbar disk herniation. AJNR Am J Neuroradiol. 2003; 24: 996-1000.
• 7. Martínez-Sánchez G, Al-Dalain SM, Menéndez S, Re L, Giuliani A, Candelario-Jalil E, et al. Therapeutic effi cacy of ozone in patients with diabetic foot. Eur J Pharmacol. 2005; 523: 151-61.
• 8. Zanardi I, Borrelli E, Valacchi G, Travagli V, Bocci V. Ozone: a multifaceted molecule with unexpected therapeutic activity. Curr Med Chem. 2016; 23: 304-314.
• 9. Azarpazhooh A, Limeback H. The application of ozone in dentistry: a systematic review of literature. J Dent. 2008; 36: 104-116.
• 10. Kal A, Kal O, Akillioglu I, et al. The protective effect of prophylactic ozone administration against retinal ischemia-reperfusion injury. Cutan Ocul Toxicol. 2017; 36: 39-47.
• 11. Bocci VA, Zanardi I, Travagli V. Ozone acting on human blood yields a hormetic dose-response relationship. J Transl Med. 2011; 9: 66.
• 12. Gulmen S, Kurtoglu T, Meteoglu I, Kaya S, Okutan H. Ozone therapy as an adjunct to vancomycin enhances bacterial elimination in methicillin resistant Staphylococcus aureus mediastinitis. J Surg Res. 2013; 185: 64-69.
• 13. Bertolotti A, Izzo A, Grigolato PG, Iabichella ML. The use of ozone therapy in Buruli ulcer had an excellent outcome. BMJ Case Rep. 2013; 2013:bcr2012008249.
• 14. Giunta R, Coppola A, Luongo C, et al. Ozonized autohemotransfusion improves hemorheological parameters and oxygen delivery to tissues in patients with peripheral occlusive arterial disease. Ann Hematol. 2001; 80: 745-748.
• 15. Molinari F, Simonetti V, Franzini M, et al. Ozone autohemotherapy induces long-term cerebral metabolic changes in multiple sclerosis patients. Int J Immunopathol Pharmacol. 2014; 27: 379-389.
• 16. Clavo B, Suarez G, Aguilar Y, et al. Brain ischemia and hypometabolism treated by ozone therapy. Forsch Komplementmed. 2011; 18: 283-287.
• 17. Magalhaes FN, Dotta L, Sasse A, Teixera MJ, Fonoff ET. Ozone therapy as a treatment for low back pain secondary to herniated disc: a systematic review and meta-analysis of randomized controlled trials. Pain Physician. 2012; 15: E115-129
• 18. Neimark AI, Nepomnyashchikh LM, Lushnikova EL, Bakarev MA, Abdullaev NA, Sizov KA. Microcirculation and structural reorganization of the bladder mucosa in chronic cystitis under conditions of ozone therapy. Bull Exp Biol Med. 2014;156:399-405.
• 19. Gu XB, Yang XJ, Zhu HY, Xu YQ, Liu XY. Effect of medical ozone therapy on renal blood flow and renal function of patients with chronic severe hepatitis. Chin Med J (Engl). 2010; 123: 2510-2513.
• 20. Borges GÁ, Elias ST, da Silva SM, Magalhães PO, Macedo SB, Ribeiro AP, Guerra EN. In vitro evaluation of wound healing and antimicrobial potential of ozone therapy. J Craniomaxillofac Surg. 2017;45(3):364–370.
• 21. Dıraçoğlu D. Ozone-oxygen therapies in musculoskeletal diseases. Turk J Phys Med Rehab. 2016; 62(2): 183-191.
• 22. https://www.austinozone.com/wp-content/uploads/Ozone-Therapy-in-the-Dermatology.pdf Erişim tarihi: 03.03.2018
• 23. Travagli V, Zanardi I,Valacchi G, Bocci V. Ozone and Ozonated Oils in Skin Diseases: A Review. Mediators Inflamm. 2010; 2010: 610418. Mediators Inflamm. 2010; 2010: 610418.
• 24. http://ozonetherapy.org/04.06.2007/ozonoterapiya-stimulyacii-broncho-patalogii/ Erişim tarihi 05.03.2018
• 25. Gordillo GM, Roy S, Khanna S, et al. Topical oxygen therapy induces vascular endothelial growth factor expression and improves closure of clinically presented chronic wounds. Clinical and Experimental Pharmacology and Physiology. 2008; 35(8): 957-964.
• 26. Fitzpatrick E, Holland OJ, Vanderlelie JJ. Ozone therapy for the treatment of chronic wounds: A systematic review. Int Wound J. 2018; 1-12.
• 27. Martusevich AK, Peretyagin SP, Ruchin MV, Struchkov AA. Ozone therapy in patients with burn disease. J Biomedical Science and Engineering, 2018; 11(2): 27-35.
• 28. Menéndez S, Re L, Falcón L, et al. Safety of topical Oleozon® in the treatment of tinea pedis: phase IV clinical trial. International Journal of Ozone Therapy. 2008;7(1):55–59.
• 29. Menéndez S, Falcón L, Maqueira Y. Therapeutic efficacy of topically Oleozon® in patients suffering from onychomycosis. Mycoses. 2011 Sep;54(5):e272-7.
• 30. Guerrer LV, Cunha KC, Nogueira MC, Cardoso CC, Soares MM, Almeida MT. "In vitro" antifungal activity of ozonized sunflower oil on yeasts from onychomycosis. Braz J Microbiol. 2012; 43(4): 1315-1318.
• 31. Ozone therapy in painful lipodystrophies. A preliminary study Olga Cardoso, Pierluigi Rossi, Antonio Galoforo, Guido Collodo. Ozone Therapy. 2018; 3: 7510.
• 32. Izzo A, Bertolotti A. Oxygen-Ozone Therapy: a Hope Turns into Reality II part. Int Journal of Ozone Therapy. 2007; 6: 43-48.
• 33. Cuccio G, Franzini M. Oxygen-ozone therapy in the treatment of tissue adipose diseases. Ozone Therapy. 2016; 1: 6270.
• 34. Sırıto MA. Oxygen-Ozone therapy for local adipose deposits and oedematous fibrosclerotic panniculopathy. Rivista Italiana di Ossigeno-Ozonoterapia 2006; 5:37-39.
• 35. Ruhi Cakir. Ozone Therapy and Combined PRP Applications, Oncothermia Journal, 2014; 10: 35-39.
• 36. Nikulin NK, Bitkina OA, Philippova LI, Kopytova TV. Dynamics of Lipid Peroxidation Indices under Influence of Ozone Therapy in Patients with Complicated Forms of Rosacea and Acne Disease. IOA 17th World Ozone Congress, Strasbourg 2005. III.3.6.1-5.
• 37. https://www.medozons.com/ozone-therapy/ozone-therapy-in-different-fields-of-medicine/dermatology.html Erişim Tarihi: 02.02.2018
• 38. Jiang F, Deng D, Li X, Wang W, Xie H, Wu Y, Luan C, Yang B. [Curative effect of ozone hydrotherapy for pemphigus]. Journal of central south university (medical scıences). 2018; 43(2): 152-156.
• 39. Khatri I, Moger G, Kumar NA. Evaluation of effect of topical ozone therapy on salivary Candidal carriage in oral candidiasis. Indian J Dent Res. 2015; 26(2): 158-162.
• 40. Crastechını E, Koga-Ito CY, Machado SF et al. Effect of ozonized olive oil on oral levels of Candida spp. in patients with denture stomatitis. Braz Dent Sci. 2018; 21(1): 111-118.
• 41. Kazancioglu HO, Erisen M. Comparison of Low-Level Laser Therapy versus Ozone Therapy in the Treatment of Oral Lichen Planus. Ann Dermatol. 2015; 27(5): 485-491.
• 42. Kutlubay Z, Engin B, Serdaroğlu S, Tüzün Y. Dermatolojide Ozon Tedavisi. Dermatoz. 2010 ; 1(4) : 209-216.
• 43. https://medicalozone.info/medical-ozone-cosmetology/ Erişim Tarihi: 03.04.2018
• 44. Travagli V, Zanardi I, Bocci V. Topical applications of ozone and ozonated oils as anti-infective agents: an insight into the patent claims. Recent Patents on Anti-Infective Drug Discovery. 2009; 4(2): 130–142.
• 45. Günaydın Y, Sevim H, Tanyolaç D, Gürpınar ÖA. Ozonated Olive Oil with a High Peroxide Value for Topical Applications: In-Vitro Cytotoxicity Analysis with L929 Cells. Ozone: Science & Engineering. 2017; 40(1): 37-43.
• 46. Serio F, Pizzolante G, Cozzolino G, D’Alba M, Bagordo F, Giorgi MD, et al. A New Formulation Based on Ozonated Sunflower Seed Oil: In Vitro Antibacterial and Safety Evaluation. Ozone: Science & Engineering. 2017; 39(3); 139-147.
• 47. de Souza YM, Fontes B, Martins JO, SannomiyaP, Brito GS, Younes RN, Rasslan S. Evaluation of the effects of ozone therapy in the treatment of intra-abdominal infection in rats. Clinics. 2010; 65(2): 195-202.
• 48. Bocci V, Paulesu L. Studies on the biological effects of ozone: induction of interferon on human leucocytes. Haematologica.1990;75:510-5.
• 49. Zimran A, Wasser G, Forman L, Gelbart T, Beutler E. Effect of ozone on red blood cell enzymes and intermediates. Acta Haematol. 2000;102:148-51.