Effects of mesotherapy introduction of compound glycyrrhizin injection on the treatment of moderate to severe acne

Compound glycyrrhizin has achieved outstanding results in the treatment of various skin diseases. However, the use of mesotherapy to inject compound glycyrrhizin into the skin to treat acne is still understudied.

application of fusidic acid cream. However, the drug treatment effect of acne is often poor due to poor tolerance, skin sensitivity, and other reasons in some patients. 4 Compound glycyrrhizin is a compound preparation mainly composed of glycyrrhizic acid, glycine, and cysteine. 5 Compound glycyrrhizin has anti-inflammatory and antiviral effects. 6 Accumulating evidence has shown that compound glycyrrhizin can regulate immunity, improve liver function, alleviate tissue damage, and regulate hormone levels. 7 Compound glycyrrhizin also has the antiandrogen activity of estrogen, which regulates the proliferation of mitogen and lymphocytes by inhibiting the permeability of hyperactive capillaries. 8 In addition, previous studies have shown that compound glycyrrhizin plays an anti-inflammatory role by inhibiting the activity of phospholipase. 9 Compound glycyrrhizin regulates immune function by slowing down the metabolism rate of cholesterol in the liver, activating natural killer cells of T cells, and inducing the secretion of interferon. 10 Mesotherapy is to break through the epidermal barrier by direct injection or microporous introduction and directly introduce the cosmetic active ingredients into the dermis or deeper subcutaneous areas. 11 Mesotherapy accelerates the metabolism of the skin and improve the skin quality from the inside out. 12 The therapeutic principle of mesotherapy is a physical method that causes the skin healing process of trauma. 13 Mesotherapy uses the process of trauma and repair to achieve the purpose of treating many stubborn skin diseases. 14 At the same time, mesotherapy increases the absorption rate of drugs due to the proper destruction of the epidermis, so that drug therapy can achieve higher efficiency. 15 Whether mesotherapy combined with compound glycyrrhizin has curative effect on facial inflammatory dermatosis has been rarely reported. This study aimed to explore the clinical effect of mesotherapy combined with compound glycyrrhizic acid on moderate to severe facial acne. We hope that our research can provide more theoretical basis for the clinical treatment of acne.

| Participants
This study was approved by the ethics committee of Xingtai People's Hospital. Informed written consents were derived from all the participants.
A total of 108 patients were included in this study, and they were divided into control groups and observation groups according to the random number table. The control group adopts the treatment method of pyromycin gel. The research group adopts the treatment method of external use of clinomycin gel + mid-layer therapy to introduce compound licoroate injection. We chose a 0.5 mm roller microneedle to import compound licorzide injection.
Micro-needle is used to stimulate the skin to make a large amount of micro-pipeline to promote drug absorption and reach the affected area.

| Diagnostic criteria
The diagnosis of this study was based on the diagnostic criteria of There were nodules, cysts, and scars, except for acne, inflammatory papules, and pustules. The pain was obvious. The total number of lesions was more than 100, among which nodules and cysts were more than three.

| Treatment
The clindamycin phosphate gel (Dalin) was purchased from Suzhou

| Measurement of skin transepidermal water loss value
A noninvasive skin tester (CK Company) was used to measure the transepidermal water loss (TEWL) value of the cheek skin of the patient. The room temperature of the test room was maintained at 20°C, and the skin was kept in the natural state for 20 min after cleaning. The measurement was repeated three times for each test site, and the value was read and recorded. TEWL value was used to determine the epidermal permeability barrier status and evaluate the skin barrier function. The increase of TEWL indicated the increase of skin water loss, barrier damage, and skin irritation. A decrease in the value of TEWL indicated that skin water loss was reduced and the barrier was being restored. lobe and the clavicle. The operating specifications were followed, and each part was measured three times and the average value was taken. The higher the skin moisture content, the more robust the skin water barrier, the better the effect.

| Assessment of acne severity
Global acne grading system (GAGS) was used to evaluate the severity of acne, and the skin lesion scores were calculated before treatment and 4 and 8 weeks after treatment. The skin of the patient was divided into six regions, and the factor score of each region was 2 points for the forehead, 2 points for the right cheek, 2 points for the left cheek, 1 point for the nose, 1 point for the lower chin, and 3 points for the chest and upper back. Skin lesion score of each area: 0 = no skin lesion, 1 ≥ 1 acne, 2 ≥ 1 papule, 3 ≥ 1 pustules, and 4 ≥ 1 nodule. The total score of this area = factor score × skin score, with l-18 as mild, 19-30 as moderate, 31-38 as severe, and more than 39 as very severe.

| Inflammatory cytokines
Fasting blood was collected from patients before and after treatment, and serum was obtained by centrifugation. Commercial ELISA kits were used to measure serum concentrations of TNFα and IFNγ.

| Clinical characteristics of the acne patients
Demographic and clinical characteristics of the acne patients received clindamycin phosphate gel treatment (Control) or clindamycin phosphate gel combined with mesoderm introduction of compound glycyrrhizin injection treatment (Observation) were shown in Table 1. There was no significant difference of the gender, age, duration of illness, and Pillsbury scale between the control and observation groups.

| Clinical effectiveness of control and observation groups
The treatment effects of clindamycin gel treatment in the control group and mesodermal treatment in the observation group are shown in Table 2. The representative images before and after the treatment has been included in Figure S1. Cure: reduction of lesion area ≥90%; Significant effect: the lesion area was reduced by 60%-89%; Effective: skin lesion area reduced by 30%-59%; and Invalid: Reduction of lesion area ≤29%. It can be seen that there are significant differences between the two groups. The effect of clindamycin gel + mesotherapy was better than the traditional treatment group.

| Adverse reactions in control group and observation group
The adverse reactions of clindamycin gel treatment in the control group and mesodermal treatment in the observation group are shown in Table 3. The pigmentation, scar hyperplasia, pruritus, and burning sensation of the two groups of patients after treatment were statistically analyzed. There were more adverse reactions in the control group than in the observation group. The combined treatment group with clindamycin gel plus mesotherapy was able to significantly reduce adverse reactions compared with the control group.

| Acne severity evaluation
In order to evaluate the severity of acne in the two groups, the GAGS was used to evaluate the severity of acne. Skin lesion scores were calculated before treatment and 4 and 8 weeks after treatment. There was no significant difference in the total score of GAGS between the two groups before treatment. However, there were significant differences between the two groups at 4 and 8 weeks after treatment. The effect of clindamycin gel plus mesotherapy combined with compound glycyrrhizin injection was better than the control group (Figure 1).

F I G U R E 1
Comparison of global acne grading system (GAGS) in acne patients between the treatment of clindamycin phosphate gel (Control) or clindamycin phosphate gel combined with mesoderm introduction of compound glycyrrhizin injection (Observation) at the time of pre-, 4 and 8 weeks posttreatment. Data are shown with mean ± SD. **p < 0.01, ***p < 0.001 and ns means no significance. Two-way ANOVA followed Turkey's multiple comparisons test.

| Physiological parameters of skin in acne patients
In order to analyze the effect of different treatments on the skin quality of the participants, we performed physiological tests on the acne skin of the two groups, mainly including TEWL and cuticle water content. We show that both treatments can effectively reduce skin moisture loss and increase skin keratin moisture content in patients with acne. However, combined treatment group can improve the water retention of patients more effectively than the control group (Figure 2A,B).

| The inflammatory response of the patients
To test the inhibitory effect of different treatments on the inflammatory response in acne patients, serum concentrations of inflammatory cytokines were measured in both groups. The levels of TNFα ( Figure 3A) and IFNγ ( Figure 3B) were significantly decreased after treatment, indicating that the treatment in both groups could effectively inhibit the level of acne-related inflammation. However, combined treatment group could alleviate the inflammation of patients more effectively than the control group ( Figure 3A,B).

| DISCUSS ION
Acne vulgaris is a chronic inflammatory disease of the hair follicle sebaceous glands, which is manifested as acne, papules, and pustules. 16 Patients with moderate to severe acne are prone to recurrent attacks and difficult to cure, which can bring negative effects to their mental health. 17 The research on the mechanism of acne and the exploration of new therapies has become a hot topic in the discipline. 18 Previous studies have revealed that plant extracts and preparations have been successfully used in different acne pathological conditions. 19 In addition, the combination of intense pulsed light therapy and chemical drug intervention has also been proved to be of great significance for the remission of acne symptoms. 20 Clindamycin is one of the first-choice drugs for acne. However, single treatment has a slow effect and a long course of treatment. 21 Glucocorticoids can inhibit salivary secretion, and long-term use of glucocorticoids has many adverse reactions, including dry skin, mucosa, and mouth, which is not conducive to the prognosis of patients. 22 In order to improve the onset time of acne medication and reduce the incidence of complications, antibiotics and glucocorticoids for the treatment of acne are often used in combination with other drugs. 23 In addition, some recent studies have suggested that the pathogenesis of acne is related to many factors, such as excessive sebum secretion caused by androgen and abnormal stimulation of sebaceous duct keratinization, lumen blockage, acne propionate infection, genetic background, and so on. 24 Androgen, especially dihydrotestosterone, is the initiating factor of acne. According to the different targets in the androgen metabolic pathway, antiandrogen therapy for acne tends to be divided into the following four categories: ovaries-derived androgen blockers, adrenal androgen blockers, androgen receptor antagonists, and enzyme inhibitors. 25 However, the side effects of antiandrogen therapy for acne should not be ignored. Therefore, it is necessary to identify more effective and safer treatments of acne.
In this study, we showed that using mesotherapy to inject a spe- Compound glycyrrhizin contains glycyrrhizin, glycine, and cysteine. 5 This product has anti-inflammatory, antiviral, anti-allergic, immunomodulatory, and hormone-like effects. 26 In recent years, its clinical application is extensive. At present, the drug has been used for skin diseases closely related to autoimmune reaction, including F I G U R E 2 Comparisons of transepidermal water loss (TEWL, A) and water content in corneum (B) in acne patients between the treatment of clindamycin phosphate gel (Control) or clindamycin phosphate gel combined with mesoderm introduction of compound glycyrrhizin injection (Observation) at the time of pre-and 8 weeks posttreatment. Data are shown with mean ± SD. *p < 0.05, **p < 0.01, ***p < 0.001 and ns means no significance. Two-way ANOVA followed Turkey's multiple comparisons test. viral herpes and dermatitis, drug rash, connective tissue diseases, such as hand, foot, and mouth disease, facial glucocorticoid dependent dermatitis, and vitiligo. 27 Compound glycyrrhizin is used to treat skin diseases, especially some diseases that are ineffective after long-term treatment with conventional drugs. 28 It is reported that compound glycyrrhizin has a good therapeutic effect on a variety of skin diseases, with satisfactory short-term and long-term therapeutic effects, long remission period, and low recurrence rate. 29 For example, the treatment of pustular psoriasis with compound glycyrrhizin combined with azithromycin has a significant effect, and the pustules in most patients have basically subsided within 3-6 days after treatment. Therefore, compound glycyrrhizin has become a safe and effective drug in the clinical treatment of pustular psoriasis. 30 In the treatment of pemphigus, compound glycyrrhizin can shorten the healing time and reduce the dosage of glucocorticoid. In the treatment of herpes zoster, compound glycyrrhizin has a corticosteroid like effect, which plays a role in regulating immunity and killing viruses. However, the utilization rate of compound glycyrrhizin is low and the liver and kidney are damaged greatly. Therefore, it is very significant to improve the medication strategy of compound glycyrrhizin for the treatment of clinical skin diseases. In this study, we innovatively used mesotherapy to inject compound glycyrrhizin into the skin of acne patients, which improved the treatment efficiency and reduced adverse reactions.
Mesotherapy, which originated in Europe, is a minimally invasive technique. Mesotherapy is performed by puncturing the skin and injecting intradermal or subcutaneous trace amounts of a mixture of natural plant extracts, homeopathic factors, drugs, vitamins, and trace amounts of bioactive substances. 14 The use of mesotherapy in esthetic medicine and plastic surgery is accepted and increasingly popular, and its range of applications is growing at an extremely rapid rate. 31 Although the purported rejuvenation and fat-melting injections are attractive, more research is needed on the safety and efficacy of these new cosmetic methods. In this study, we used mesotherapy to treat moderate to severe facial acne by intradermal injection of compound glycyrrhizin. 32 Our mesotherapy uses direct injection or micropore introduction to break through the epidermal barrier and directly introduce compound glycyrrhizin deep into the dermis or deeper subcutaneous parts, so as to accelerate skin metabolism and improve skin quality from the inside out. We use this process of trauma and repair to achieve our therapeutic goals, and at the same time, due to the appropriate destruction of the epidermis, increase the absorption of drugs, so that our treatment achieves a double effect.

| CON CLUS ION
In conclusion, we used mesotherapy to treat moderate to severe facial acne by injecting compound glycyrrhizin into the skin. Our study demonstrates that the introduction of compound glycyrrhizin deep into the dermis or deeper subcutaneously via mesotherapy can act as a protective skin barrier and inhibit skin water loss compared with traditional clindamycin treatment. Our acting has also shown that compound glycyrrhizin injection-mesotherapy, is more effective in suppressing inflammation in acne patients with fewer side effects.

FU N D I N G I N FO R M ATI O N
This study was supported by Xingtai Key Research Project (2021ZC132).

CO N FLI C T O F I NTE R E S T S TATE M E NT
None declared.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

F I G U R E 3
Comparisons of serum TNFα (A) and IFNγ (B) in acne patients between the treatment of clindamycin phosphate gel (Control) or clindamycin phosphate gel combined with mesoderm introduction of compound glycyrrhizin injection (Observation) at the time of preand 8 weeks posttreatment. Data are shown with mean ± SD. *p < 0.05, **p < 0.01, ***p < 0.001 and ns means no significance. Two-way ANOVA followed Turkey's multiple comparisons test.