Nonsurgical treatment of congenital ichthyosis cicatricial ectropion and eyelid retraction using Restylane hyaluronic acid

DEAR EDITOR, The ichthyosiform dermatoses are hereditary conditions in which genetic mutations alter the normal development and function of keratinocytes, causing a defect in skin desquamation. Secondary ectropion and cicatricial eyelid retraction are commonly seen, often causing significant functional and cosmetic sequelae. Due to the generalized nature of the skin involved, management options are limited. Here we report three patients with sight-threatening bilateral upperand lower-eyelid cicatricial ectropion, managed with off-label use of hyaluronic acid (HA). Case 1 is a 3-year-old boy with lamellar ichthyosis. At presentation to Queen Victoria Hospital his vision was 4/60 and hand movements, with dense punctate epithelial erosions and 5 mm of lagophthalmos on forced closure. He underwent nonsurgical eyelid expansion using HA. Similarly to previous descriptions, eyelid skin was prepared with chlorhexidine. Injections were performed under general anaesthesia. Restylane lidocaine (Galderma, Lausanne, Switzerland) HA was injected using the 30-gauge needle provided via multiple puncture sites. The upper eyelid was initially injected just above the superior border of the tarsal plate, with injections progressing lateral to medial (Fig. 1). The needle was advanced suborbicularis, injecting deep to this muscle with some passing deep to the orbital septum (although anterior to the levator aponeurosis). Approximately 0 2 mL was injected during each aliquot. When 0 5 mL had been administered, a bulge became visible. The brow was distracted superiorly and this was massaged against the orbital rim in order to mould the contour. Care was taken to avoid any pressure against the globe. A similar technique was used on the lower eyelids, with 1 mL injected into each. Closure of eyes was achieved immediately, and at 4 months his vision (Kay picture cards) had improved to 6/15