Comment on ‘‘Elevation of transaminases after MMP® session with methotrexate for alopecia areata treatment - how much do we know about the risks of systemic absorption of the technique?’’^☆

Dear Editor,

We read with interest Nogueira’s et al. recent case report.¹ This is an important contribution to the limited evidence about the safety of drug delivery techniques.

As an experienced and enthusiastic user of the MMP® technique, I have a few considerations:

1. Although evidence derived from case reports is considered low, nevertheless it is important to raise questions in different scenarios.

2. Changes in liver enzyme levels are common in clinical practice and can be caused by many factors including physical activity, use of drugs (e.g., acetaminophen) or alcohol, and viral infections.²

3. MMP® is a drug delivery technique that uses microneedles and dermo pigmentation equipment. Tattoos are unequivocal evidence of injection and absorption. The main advantages of this technique are the uniform drug distribution in the dermis, without bolus formation (Fig. 1), and increased substance dispersion due to shear stress and turbulent whirling³ caused by Newton’s law of attrition.

4. Drug absorption delivered through MMP® occurs predominantly through the lymphatic channels of the skin⁴ and not the subjacent blood vessels.

5. MMP® is the only drug delivery technique with published protocols that allow the quantification of the drug density injected in the dermis,⁵ offering safety parameters to the dermatologist.

6. Since the procedure was done in an ophiasis region (423cm²), using a saline solution (estimated density 1.000.000μg/mL) and the medication contained 25mg/mL of the active ingredient, based on published protocols we calculate that 390.907μg (0.390907 mg) of the methotrexate solution was injected in the dermis⁵ (Video 1), which corresponds to 9.8 mg of methotrexate.

Figure 1
Drug delivery with MMP® technique. This is a cross section of the reticular dermis demonstrating ink between the collagen fibers, without bolus formation

Considering the aforementioned facts, and the lack of other reports of possible drug toxicity related to methotrexate MMP® drug delivery, we must consider an alternative hypothesis for the findings described by Nogueira et al.¹ It is possible that this patient’s mild transient increase in transaminases may have occurred by chance or have been caused by other factors unrelated to methotrexate MMP® drug delivery?

Acknowledgments

Dr. Nilceo Michalany for microphotography documentation. Dr. Sergio Hirata, advisor of my doctoral thesis.

• ☆
  Study conducted at the DermoCentro Clinic, São José dos Campos, SP, Brazil.
• Financial support
  TRADERM, a company that commercializes tattoo supplies.

Appendix A Supplementary data

Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.abd.2023.05.002.

References

• ¹
  Nogueira BL, Bonamigo RR, Heck R. Elevation of transaminases after MMP® session with methotrexate for alopecia areata treatment-how much do we know about the risks of systemic absorption of the technique? An Bras Dermatol. 2023;98:390–1.
• ²
  Giannini EG, Testa R, Savarino V. Liver enzyme alteration: a guide for clinicians. Cmaj. 2005;172:367–79.
• ³
  Arbache S, de Mendonca MT, Arbache ST, Hirata SH. Treatment of idiopathic guttate hypomelanosis with a tattoo device versus a handheld needle. JAAD Int. 2021;3:14–6.
• ⁴
  Hellerich U. Tattoo pigment in regional lymph nodes-an identifying marker? Arch Kriminol. 1992;190:163–70.
• ⁵
  Arbache S, da Costa Mattos E, Diniz MF, Paiva PYA, Roth D, Arbache ST, et al. How much medication is delivered in a novel drug delivery technique that uses a tattoo machine? Int J Dermatol. 2019;58:750–5.

Publication Dates

• Publication in this collection
  22 Jan 2024
• Date of issue
  Jan-Feb 2024

History

• Received
  05 May 2023
• online
  05 Oct 2023