==== Front Ger Med Sci Ger Med Sci GMS Ger Med Sci GMS German Medical Science 1612-3174 German Medical Science GMS Publishing House 000318 10.3205/000318 Doc04 urn:nbn:de:0183-0003186 Article Reconstruction of dermal layers evaluated by high-frequency ultrasound following treatment for skin fibrosis Mit Hochfrequenz-Ultraschall bewertete Rekonstruktion von Hautschichten nach Behandlung von HautfibrosenPereira de Godoy Lívia Maria 12 Pereira de Godoy Jose Maria *34 1 Instituto Lauro de Souza Lima, Bauru, Brazil 2 Clínica Godoy, São José do Rio Preto, Brazil 3 Departamento de Cardiologia e Cirurgia Cardiovascular, Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, Brazil 4 Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil *To whom correspondence should be addressed: Jose Maria Pereira de Godoy, Clínica Godoy, Rua Floriano Peixoto 2950, São José do Rio Preto, SP 15020-010, Brazil, Phone: +55 1732326362, E-mail: godoyjmp@gmail.com 26 5 2023 2023 21 Doc0413 3 2021 Copyright © 2023 Pereira de Godoy et al. 2023 https://creativecommons.org/licenses/by/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/. This article is available from https://www.egms.de/en/journals/gms/2023-21/000318.shtml Background: Lymphedema is a chronic, progressive clinical condition that evolves with intense fibrosis, the most advanced stage of which is stage III (lymphostatic fibrosclerosis). Aim: The aim of the present study was to show the possibility to reconstruct the dermal layers with the intensive treatment of fibrosis using the Godoy method. Case description: A 55-year-old patient with an eight-year history of edema of the lower limb of the leg had constant episodes of erysipelas, despite regular treatments. The edema progressed continually, associated with a change in the color of the skin and the formation of a crust. Intensive treatment (eight hours per day for three weeks) was proposed with the Godoy method. The ultrasound was performed and results revealed substantial improvement in the skin, with the onset of the reconstruction of the dermal layers. Conclusion: It is possible to reconstruct the layers of the skin in fibrotic conditions caused by lymphedema. Zusammenfassung Hintergrund: Das Lymphödem ist ein chronischer, fortschreitender klinischer Zustand, der sich mit einer starken Fibrose entwickelt, deren fortgeschrittenstes Stadium das Stadium III (lymphatische Fibrosklerose) ist. Ziel: Ziel der vorliegenden Studie war es, die Möglichkeit der Rekonstruktion der Hautschichten bei intensiver Behandlung der Fibrose nach der Godoy-Methode aufzuzeigen. Fallbericht: Ein 55-jähriger Patient, der seit acht Jahren an einem Ödem der unteren Extremität litt, hatte trotz regelmäßiger Behandlung immer wieder Schübe von Erysipel. Das Ödem schritt kontinuierlich voran, verbunden mit einer Veränderung der Hautfarbe und der Bildung einer Kruste. Eine intensive Behandlung (acht Stunden pro Tag für drei Wochen) nach der Godoy-Methode wurde vorgeschlagen. Wir haben eine Ultraschalluntersuchung durchgeführt, deren Ergebnisse eine deutliche Verbesserung der Haut und den Beginn des Wiederaufbaus der Hautschichten zeigten. Schlussfolgerung: Es ist möglich, die Hautschichten bei fibrotischen Zuständen, die durch Lymphödeme verursacht werden, zu rekonstruieren. reconstruction of dermal layers high-frequency ultrasound treatment for skin fibrosis ==== Body pmcIntroduction Lymphedema is a chronic, progressive, clinical condition that evolves with intense fibrosis, the most advanced stage of which is stage III (lymphostatic fibrosclerosis) [1], [2]. In more developed countries, lower limb lymphedema may be primary (congenital) or secondary to the surgical and radiotherapeutic treatments of tumors. In countries such as India this condition is mainly secondary to filariasis, but other infectious causes are frequent [1], [2], [3]. With regards to treatment, a considerable advance emerged with novel concepts and forms of treatment developed by Godoy & Godoy, which enable approximately a 50% reduction in the volume of the affected limb after five days of intensive treatment and the eventual normalization or near normalization in all clinical stages, including lymphostatic fibrosclerosis [4], [5], [6]. High-frequency ultrasound enables viewing the epidermis, dermis and hypodermis, the precise measurement of the thickness of the skin as well as the assessment of edema, fibrosis and atrophy of the skin [7]. One study reports that this imaging method can precisely detect lymphatic vessels for efficient lymphatic microsurgery without the prior need for lymphangiography [8]. A noninvasive, quantitative comparison of dermal fibrosis using optical coherence tomography (OCT) and high-frequency ultrasound (HFUS) revealed that both methods achieve the precise measurement of structural and physiological changes in the skin, but epidermal and dermal structures are better distinguished using OCT [8]. There are no studies in the literature showing the restoration of the dermis in patients with skin fibrosis. The aim of the present study was to show the possibility of the restoration of the dermal layers with the intensive treatment of fibrosis using the Godoy method. Case description A 55-year-old patient with an eight-year history of edema of the lower limb of the leg had constant episodes of erysipelas, despite regular treatments (Figure 1 (Fig. 1)). The edema progressed continually, associated with a change in the color of the skin and the formation of a crust (Figure 2 (Fig. 2)). However, the patient underwent no specific treatment for lymphedema until obtaining access to the Clínica Godoy-Brazil. The physical examination revealed lymphedema that limited the mobility of the ankle and a hardened crust below the knee (Figure 2 (Fig. 2)). Intensive treatment (eight hours per day for three weeks) was proposed with the Godoy method. Treatment involved mechanical lymphatic therapy using the RAGodoy® device eight hours per day and cervical lymphatic stimulation using the Godoy and Godoy technique 15 minutes per day. The skin was protected with an Unna boot. A hand-crafted non-elastic stocking made with grosgrain fabric was placed over the affected limb. The stocking was crafted to fit the measurements of the limb and adjusted based on the reduction in volume. The reduction in volume of the limb was constant with treatment (Figure 3 (Fig. 3)). The skin received moisturizing and peeling occurred (Figure 4 (Fig. 4)). At this point, HFUS was performed, which revealed the disarrangement of the structures of the dermal layers and intensive fibrosis (Figure 5 (Fig. 5)). Treatment led to considerable improvement in the skin to standards close to normality (Figure 6 (Fig. 6)) and a new ultrasound was performed (Figure 7 (Fig. 7)). The results revealed substantial improvement in the skin, with the onset of the restoration of the dermal layers. At this point, the patient began to undergo outpatient treatment, maintaining the moisturizing of the skin and use of the grosgrain stocking. Discussion The present study described the reversal of skin fibrosis to nearly clinical normality and the restoration of the skin layers following intensive lymphatic treatment using the Godoy method in a patient with lymphedema that led to the formation of an intense crust. No studies in the literature describe the use of this therapeutic strategy or show similar results. The clinical reversal of fibrosis is a constant finding in the treatment of lymphedema, as the intensive Godoy method enables approximately a 50% reduction in the volume of the affected limb in five days of treatment, achieving a 70 to 90% reduction in volume in the second week [4], [5], [6]. The intensity of such reductions depends on the volume of the limb and the fibrotic process. However, the aim is to achieve normality or near normality, as described in the present case study. The first phase of treatment is to achieve the clinical reversal of fibrosis associated with lymphedema in all clinical stages, including stage lymphostatic fibrosclerosis. In this phase, we are seeking to assess the structural changes of the skin in the fibrotic process and its reversal. High-frequency ultrasound is a noninvasive exam with good definition that allows to determine whether important changes have occurred in the skin layers [9]. As a noninvasive exam, high-frequency ultrasound is an important tool for the assessment of the dermis in these patients during treatment. A comparison with the results of the biopsies constitutes the most recent phase of our study [10], [11]. However, the results demonstrated the possibility of the reversal of fibrosis in patients with more advanced phases of lymphedema. Another important detail in this case was the resolution of the intense crust on the patient’s leg. Therefore, this study offers a line of investigation to detect the structures composing the skin that interfere with these changes. Biopsy is fundamental to gaining a better understanding of why this patient had such considerable crust formation. Conclusion It is possible to reconstruct the layers of the skin in fibrotic conditions caused by lymphedema. Notes Authors’ ORCIDs Lívia Maria Pereira de Godoy: 0000-0002-1036-8779 Jose Maria Pereira de Godoy: 0000-0001-5424-7787 Acknowledgment The authors would like to acknowledge Dr. Miriam Tarraf Fernandes and Dr. Julio Roberto Fernandes for their contribution to the performance and interpretation of ultrasound assessments. Ethics approval The study was approved by the Ethical Committee of Faculdade de Medicina de Sao Jose do Rio Preto-FAMERP-Brazil # 4.397.868. Competing interests The authors declare that they have no competing interests. Figure 1 Initial treatment Figure 2 Skin with an intense formation of crust Figure 3 After treatment Figure 4 Considerable peeling of the skin, which remains dry and dehydrated despite constant moisturizing Figure 5 High-frequency ultrasound. Left side of the image: normal right lower limb; right side of the image: left lower limb with lymphedema and disarrangement of skin structures Figure 6 Skin with substantial improvement, achieving near clinical normality Figure 7 Post-treatment ultrasound showing the onset of the reconstruction of the skin layers ==== Refs 1 Lee BB Antignani PL Baroncelli TA Boccardo FM Brorson H Campisi C Damstra RJ Flour M Giannoukas A Laredo J Liu NF Michelini S Piller N Rockson SG Scuderi A Szolnoky G Yamamoto T IUA-ISVI consensus for diagnosis guideline of chronic lymphedema of the limbs Int Angiol Aug 2015 34 4 311 332 24699525 2 Forte AJ Boczar D Huayllani MT Lu X Ciudad P Lymphoscintigraphy for Evaluation of Lymphedema Treatment: A Systematic Review Cureus 12 Dec 2019 11 12 e6363 10.7759/cureus.6363 31886094 3 Keo HH Gretener SB Staub D Clinical and diagnostic aspects of lymphedema Vasa Jul 2017 46 4 255 261 10.1024/0301-1526/a000622 28281399 4 Pereira de Godoy JM Pereira de Godoy HJ Pereira de Godoy AC Graciano de Marqui T Guerreiro Godoy MF Lymphedema and the mobilization of intracellular and extracellular fluids with intensive treatment Acta Phlebol 2019 20 57 60 10.23736/S1593-232X.19.00446-6 5 Pereira de Godoy JM Gonçalves IP Barufi S Godoy Mde F Large reduction in volume with the intensive treatment of lymphedema: reduction of fluids? Int J Angiol Sep 2012 21 3 171 174 10.1055/s-0032-1325167 23997564 6 Pereira de Godoy JM Guerreiro Godoy MF Barufi S Pereira de Godoy HJ Intensive Treatment of Lower-Limb Lymphedema and Variations in Volume Before and After: A Follow-Up Cureus 1 Oct 2020 12 10 e10756 10.7759/cureus.10756 33033665 7 Naredo E Pascau J Damjanov N Lepri G Gordaliza PM Janta I Ovalles-Bonilla JG López-Longo FJ Matucci-Cerinic M Performance of ultra-high-frequency ultrasound in the evaluation of skin involvement in systemic sclerosis: a preliminary report Rheumatology (Oxford) Jul 2020 59 7 1671 1678 10.1093/rheumatology/kez439 31665474 8 Czedik-Eysenberg M Steinbacher J Obermayer B Yoshimatsu H Hara H Mihara M Tzou CJ Meng S Exclusive use of ultrasound for locating optimal LVA sites-A descriptive data analysis J Surg Oncol Jan 2020 121 1 51 56 10.1002/jso.25728 31612513 9 Ud-Din S Foden P Stocking K Mazhari M Al-Habba S Baguneid M McGeorge D Bayat A Objective assessment of dermal fibrosis in cutaneous scarring, using optical coherence tomography, high-frequency ultrasound and immunohistomorphometry of human skin Br J Dermatol Oct 2019 181 4 722 732 10.1111/bjd.17739 30729516 10 Pereira de Godoy JM Guerreiro Godoy MF Pereira de Godoy HJ De Santi Neto D Stimulation of Synthesis and Lysis of Extracellular Matrix Proteins in Fibrosis Associated with Lymphedema Dermatopathology (Basel) Dec 2021 9 1 1 10 10.3390/dermatopathology9010001 35076482 11 Pereira de Godoy JM Pereira de Godoy LM de Fatima Guerreiro Godoy M Neto DS Physiological Stimulation of the Synthesis of Preelastic Fibers in the Dermis of a Patient with Fibrosis Case Rep Med 2021 2021 2666867 10.1155/2021/2666867 35003267