Aesthetic Treatment Considerations in Patients with Cutaneous Autoimmune Disease

J Clin Aesthet Dermatol. 2025;18(7):26–29.

by Rafael Mojica, DO; Grace Hingtgen, BS; Sami K. Saikaly, MD; and Taylor Gray, DO

*Dr. Mojica and Ms. Hingtgen share co-first authorship of this article.

Drs. Mojica, Saikaly, and Gray are with the Department of Dermatology at the University of Florida College of Medicine in Gainesville, Florida. Ms. Hingtgen is with the University of Florida College of Medicine in Gainesville, Florida.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.

Abstract: Objective: The increasing prevalence of autoimmune disease alongside the growing popularity of cosmetic treatments has placed physicians in a unique position to understand how utilizing such treatments can serve as both beneficial and potentially harmful interventions. The objective of this study was to analyze available literature and identify areas where additional research is needed to guide use of facial aesthetic treatments in patients with cutaneous autoimmune disease. Methods: A literature search was performed on PubMed and Google Scholar for articles describing aesthetic treatments in the setting of autoimmune disease. Additional articles were found through examining the reference sections of resulting articles. Results: This analysis revealed numerous gaps in the literature regarding therapeutic use of aesthetic treatments in the management of autoimmune disease. Several case reports and smaller studies suggested positive outcomes with some interventions, however larger-scale studies are needed to create generalizable guidelines for physicians regarding usage of aesthetic treatments as a therapeutic modality. Limitations: Many studies regarding both efficacy and adverse outcomes of aesthetic treatments excluded patients with cutaneous manifestations of autoimmune disease. Few articles specifically sought to analyze how individual treatments can be used for therapeutic outcomes in this patient population. Conclusion: Many cosmetic treatments can serve a therapeutic role in the management of autoimmune conditions with cutaneous manifestations. Treatments such as neurotoxin, filler, light-based devices, autologous platelet-rich plasma, microneedling, and chemical peels may be selectively chosen for use in management of certain autoimmune conditions. Keywords: Autoimmune disease, cosmetic treatments, hyaluronic acid, injectables, botulinum toxin, microneedling, chemical peels, CO₂ laser, platelet-rich plasma

Introduction

Autoimmunity is an increasingly prevalent health phenomenon that demands consideration in medical therapy. Approximately one in ten persons are affected by autoimmune disease, with the overall prevalence rising.¹ There is a spectrum of autoimmunity varying from the asymptomatic presence of self-reactive immune elements to clinically evident manifestations of disease. Despite the increased prevalence of autoimmune disease, there is no standardized defining criteria; however, it is widely accepted that the growing number is due to unidentified gene-environment interactions. With autoimmunity on the rise, enhanced understanding of how aesthetic treatments can serve as both beneficial treatment options and potentially harmful interventions is needed. This is especially true as women, who are already more likely to undergo aesthetic procedures, are more likely than men to suffer from autoimmune disease.^2,3 This article aims to highlight currently available guidelines and areas where further research is needed for facial aesthetic treatments in patients with cutaneous diseases in which there is suspected autoimmune component of disease pathophysiology. Specifically, we will discuss the following conditions: cutaneous lupus erythematosus (CLE), systemic sclerosis, morphea, Sjögren’s syndrome, pemphigus vulgaris, alopecia areata, and vitiligo.

Methods

A literature search was performed on PubMed and Google Scholar for articles describing aesthetic treatments in the setting of autoimmune disease. The keywords used in this search, either alone or in combination, are as follows: “autoimmune disease,” “cosmetic,” “hyaluronic acid injection,” “filler,” “calcium hydroxyapatite,” “PLLA,” “hyaluronidase,” “neurotoxin,” “botulinum injection,” “microneedling,” “glycolic acid,” “chemical peels,” “CO₂ laser,” “carbon dioxide laser,” “laser hair removal,” “Kybella,” “intralipotherapy,” “threadlift,” “platelet rich plasma,” “PRP,” “conditioned plasma,” “fat grafting,” “fat injection,” “Vycross,” “pulsed dye laser,” “intense pulsed light therapy,” “laser,” and “therapeutic use.” Additional articles were found through examining the reference sections of searched articles.

Types of Treatments

Neurotoxin. Botulinum toxin is the most common cosmetic treatment performed. Use of botulinum toxin increased by 40 percent from 2020 to 2021 in the United States and is used more than three million times per year worldwide.^4,5 The cosmetic effect of botulinum toxin is elicited by inhibiting presynaptic neurotransmitter (acetylcholine) release from motor neurons. This results in partial paralysis or atrophy, thereby relaxing the effector muscle and minimizing appearance of dynamic rhytides. Most documented reactions to botulinum toxin are neurologic in nature and it seems botulinum toxin has little negative impacts on those with pre-existing cutaneous autoimmune disease.

Botulinum toxin may be used therapeutically for individuals with scleroderma and Sjögren’s syndrome. Eight two-unit injections spaced evenly around the mouth have been shown to improve objective and subjective measures for individuals with oral aperture constriction secondary to scleroderma for approximately two months.⁶ While more data is needed, botulinum toxin may also provide relief for select patients who suffer from Raynaud’s phenomenon.⁷ Furthermore, botulinum toxin injection has been used to treat recurrent parotitis and dry eye experienced by individuals with Sjögren’s syndrome.^8,9

Currently available research supports use of botulinum toxin for cosmetic benefit in patients with facial cutaneous autoimmune disease. Further research is needed to explore the potential disease-specific therapeutic benefit which neurotoxin could provide.

Filler. Injectable fillers have increased in use by 42 percent from 2020 to 2021 and are frequently used for soft tissue augmentation to address volume loss and static rhytides.⁴ Currently available fillers can be divided into two subtypes—physical fillers and bio-stimulatory fillers. Physical fillers include hyaluronic acid (HA) and collagen-based fillers that temporarily replenish volume and evanesce over time.¹⁰ In comparison, bio-stimulatory fillers like poly-L-lactic acid (PLLA) and calcium hydroxyapatite (CaHA) create an environment which generates intrinsic collagen production via stimulation of the body’s inflammatory response, leading to fibroplasia and Type I collagen formation.¹⁰ Autologous fat grafting is another aesthetic treatment used for volume replenishment and soft tissue augmentation that is favored for its biocompatibility and lack of immune response.¹¹

Filler-related adverse events can be divided into early and delayed events. Early events include injection site reactions, infection, swelling, hypersensitivity, skin discoloration, and vascular occlusion which can result in skin necrosis or permanent blindness. Delayed events include infection, foreign body granulomas, delayed-type hypersensitivity reactions, and persistent discoloration/scarring. Given autoimmune disease is characterized by a reduced tolerance of autoantigens, potentially inducing an antibody response through injectable fillers may lead to local or systemic inflammation or injury.¹² While HA is generally non-immunogenic on its own as it is chemically identical across different species, additives and activation of inflammatory modulators may lead to exacerbated effects, especially in those with pre-existing autoimmunity.¹³ Two complications which are still poorly understood include delayed-onset nodules (DONs) and autoimmune syndrome induced by adjuvants (ASIA).¹² It was previously recommended to avoid Vycross™ HA fillers (Volbella®, Vollure®, and Voluma®) in patients with history of autoimmune or inflammatory diseases, as nodules which are potentially more resistant to treatment have been noted as a side effect.¹³ However, more recent studies do not demonstrate that nodules occur more commonly with fillers made with Vycross™ technology.¹⁴ Both local and systemic inflammatory features have also been documented related to injection of biomaterials such as HA, acrylamides, and methacrylate compounds.¹⁵

Despite the potential side effects, injectable fillers may be utilized safely for aesthetic treatments in patients with controlled autoimmune disease. Physical fillers may be preferred to PLLA and CaHA, as they are more temporary and propagate less of an endogenous response. HA and fat grafting have been used successfully to treat patients with scleroderma for disease-specific concerns such as oral aperture as well as unrelated cosmetic concerns.¹¹

Additionally, the literature suggests that HA fillers do not lead to or accelerate development of autoimmune responses when compared to age-matched controls, negating the need for any type of screening beyond review of systems when consulting with otherwise healthy patients interested in aesthetic enhancement with filler.¹⁶

Finally, hyaluronidase, an enzyme which breaks down HA, has been used successfully for treatment of microstomia in patients with systemic sclerosis.¹¹ Use of hyaluronidase appears to be safe, with the most common side effect being allergic reactions in rare instances. If a patient has a suspected or known bee or wasp sting allergy, intradermal skin testing can be performed to confirm an allergy to hyaluronidase.

Light-based devices. CO₂ laser resurfacing. Laser skin resurfacing is typically used for improvement of rhytides, photoaging, and acne or other scars.¹⁷ Specifically, fractional CO₂ laser therapy splits the light beam into smaller microbeams that are preferentially absorbed by intracellular water to ablate the superficial tissue and promote collagen remodeling in the dermis.¹⁷ It has several therapeutic uses for autoimmune conditions. In a study by Hu et al¹⁸ that included 25 patients with vitiligo, CO₂ fractional laser treatments was shown to have a clinically apparent improvement in repigmentation in 72 percent (n=18) of these patients, with statistically significant decreases in inflammatory cytokines interleukin (IL)-4, IL-10, IL-17, and IL-23.¹⁸

Fractional CO₂ can also be used for therapeutic management of connective tissue disorders to enhance range of motion and minimize contractures with immediate post-therapeutic improvements.¹⁹ A prospective study also found fractional CO₂ serves as a safe and effective intervention for the improvement of microstomia.²⁰ There is still a limited number of reports for CTDs, as this is a relatively new treatment option and lasers have progressed significantly over the last few years.

The variety of therapeutic uses extends to pemphigus vulgaris as well. Patients with oral lesions have been successfully treated with single sessions of non-ablative, non-thermal CO₂ laser therapy in which the light beam was used over a layer of gel with high water content to decrease absorption and therefore diminish tissue injury.²¹ Success measured by pain relief which was seen almost immediately and lack of aggravation of existing lesions or production of new lesions.²¹ These studies determined the fractional laser treatment to be safe with no long-term side effects. However, caution should still be taken when using lasers for autoimmune patients, as areas of skin with pre-existing damage may interfere with the re-epithelialization process required for optimal resurfacing results.¹⁷

CO₂ lasers have largely been avoided in patients with chronic CLE due to risk of photosensitivity reactions.²² However, given the limited amount of information available at present, it is still recommended to exercise caution in this population to avoid reactivating disease.

Laser hair removal. Lasers used for hair removal are sought due to their potentially permanent effect and use for larger surface areas. Laser therapy functions via epilation which involves destruction of the hair shaft, follicle, and bulb to prevent regrowth.²³ The light induces photothermolysis which causes thermal injury as it is absorbed by melanin, an endogenous chromophore, found within the hair bulb and shaft.²³ The ideal wavelength is between 690nm and 1000nm as oxyhemoglobin and water, the competing chromophores in the skin and hair, have a decreased absorption in this range.²⁴ Side effects are more often seen in patients with darker skin types and can lead to dyspigmentation, blisters, erythema, burns, or other skin damage depending on the type of laser which is utilized.²³ There is currently limited literature concerning the risks of laser hair removal in autoimmune patients, but there has been reported induction of vitiligo and other inflammatory reactions, such as Kikuchi disease, secondary to laser hair removal.^25,26 More research is needed to understand the interaction of hair removal lasers in cosmetic treatment of patients with pre-existing autoimmune disease.

Pulsed-dye laser (PDL), intense pulsed light (IPL), and low level laser therapy (LLLT). Pulsed dye laser and intense pulsed light are both effective in treating facial erythema and vascular lesions. PDL utilizes a singular wavelength and can be used to treat one condition at a time, while IPL is polymorphic and utilizes multiple wavelengths to treat various skin conditions at once.²⁷ Side effects of these procedures include post-inflammatory hyperpigmentation and purpura.²⁷ PDL can provide significant benefit in individuals with CLE, such as improvement of telangiectasias, chronic erythema, and other cutaneous lesions.²² It also has efficacy for use on vascular lesions in morphea or systemic sclerosis. However, patients with morphea and systemic sclerosis could require a higher volume of treatment sessions to treat telangiectasias when compared to non-disease telangiectasias.¹¹ There are limitations in the generalizability of literature findings as many patients had reportedly inactive (non-flaring) disease.¹¹ With this in mind, it is important to have a board-certified physician involved in treatment in the case of subsequent complications. IPL therapy has shown efficacy for telangiectasias in morphea, microstomia in systemic sclerosis, dry eye disease in Sjögren’s disease, among others.^11,28 Low-level laser therapy is generally used to help decrease irritation and inflammation related to acne, rosacea, or other immune processes within the skin. It has promise in serving as a non-invasive option, with minimal side effects, as an immune modulator for patients with autoimmune disease affecting the skin and joints.²⁹ It has been shown in small trials to aid in treating psoriasis when used in conjunction with other therapies.³⁰

While many therapeutic uses have been identified in the realm of laser therapy for autoimmune diseases, they do not come without risks. PDL, IPL, LLLT, and other light therapies should be carefully used in patients with photo-sensitive skin disease, as laser therapy has the potential to cause exacerbation of scars. Although rare, granulomatous reactions have been documented following IPL, likely due to underlying immune dysfunction.³¹ Overall, barring rare inflammatory reactions such as this, PDL, IPL, and LLLT can be considered to be relatively safe for both aesthetic and therapeutic use in the presence of autoimmune disease.

Autologous platelet-rich plasma. Platelet-rich plasma (PRP) is a derivative of autologous blood consisting of plasma with a higher-than-normal platelet concentration, a full range of clotting factors, and several growth factors.³² The alpha granules within the PRP contain various growth factors that function to induce cell proliferation, angiogenesis, and chemotaxis with the goal of hair restoration and skin rejuvenation.³²

PRP for the use of folliculogenesis in alopecia areata has shown to be efficacious in clinical trials.³² However, these studies were relatively small, with the largest study only incorporating 90 patients; the underlying pathophysiology of its benefit is still not fully understood.³² Larger RCTs evaluating long-term improvement are needed to determine true efficacy as a standard treatment option for alopecia areata. PRP’s density of growth factors may also aid in repigmentation for patients with vitiligo secondary to enhanced proliferation of melanocytes.³²

Despite the autologous nature of PRP, relative lack of immunogenicity, and benign side effect profile there are still special considerations that need to be made prior to initiating treatment. One report provides evidence of a patient with prior history of alopecia areata who subsequently developed serum sickness disease following a PRP procedure.³³ While this procedure is considered safe in otherwise healthy patients, the injection of autologous biologic materials in patients with pre-existing autoimmune disease must be done under a watchful eye.

Microneedling. Microneedling is most often used for the treatment of scars, including those arising from acne, surgical procedures, burns, or other causes. Overall, it is minimally invasive with relatively low downtime. The other benefit of microneedling is use in targeting specific areas of pathology without risk of dissemination to other undesired areas.

The most common adverse events seen with microneedling include infection and trauma secondary to excessive provider force.³⁴ There are no specific contraindications related to underlying autoimmune disease documented in the literature. Rather, microneedling is increasingly used as a therapeutic agent for patients with alopecia areata and vitiligo. A study analyzing the clinical and biochemical effects of microneedling on mice showed evidence of improved hair growth and enhanced expression of hair growth genes, including Wnt3a, β-catenin, VEGF, and Wnt10b.³⁵ Microneedling has also been shown to be beneficial for treatment of vitiligo when used in conjunction with other treatments, such as topical 5-fluorouracil or topical tacrolimus.³⁶

While microneedling can be safely utilized in the setting of autoimmune cutaneous conditions, this technique should only be employed in a clean environment by highly trained individuals utilizing proper microneedling depths for each anatomic area. Care should also be taken in conditions that can Koebnerize as well.

Chemical peeling. Chemical peels are relatively inexpensive cosmetic treatments that can be used for a variety of conditions, including acne, scarring, and pigmentary conditions such as melasma and photoaging. There are several different types of peels which are categorized based on depth of penetration.³⁷ Peels should be selected based on the patient’s unique concerns. There is little data available on the use of peels in individuals with CTD; more research is needed to elucidate what role, if any, chemical peeling may have in this patient population.

Other treatments. Other facial aesthetic interventions currently available include intralipotherapy (deoxycholic acid) and thread lifts. There is currently no data available to evaluate their safety or efficacy in patients with autoimmune connective tissue disorders.

Conclusion

Despite expanding use of aesthetic procedures for both cosmetic and therapeutic benefits over the last decade, there is still a lack of evidence on the potential harms and efficacy of many aesthetic procedures in patients with special considerations. Cutaneous diseases with an autoimmune component, including CTDs, vitiligo, alopecia areata, and pemphigus vulgaris all require special consideration. Further research is needed to clarify how cosmetic treatment modalities can benefit these patients.

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