Hyaluronidase is an enzyme that degrades hyaluronan which is a major component of the extracellular matrix or ECM. It has been shown that the ECM is the source of fibrosis in many similar disorders to Ledderhose Disease. Hyaluronidase thus addresses the source of fibroma production. Once it has been used to shrink fibromas, it has no effect on new growth. It is not the same as collagenase (Xiapex/Xiaflex) which is used to break collagen cords or disrupt collagen plaques, in Dupuytren’s and Peyronie’s Disease.
Hyaluronidase acts to reduce scar tissue in a similar fashion to collagenase and has been available for a long time for use in humans. Hyaluronidase does not affect normal tissues like collagenase. Steroids such as triamcinalone acetonide can cause atrophy to normal tissues and need to be used in small quantities when being used with these injections.
Practitioners that have been using hyaluronidase for many years have experienced that about 50 percent of patients treated have no to mild recurrence. Another 40 percent have moderate recurrence and 10 percent, aggressive recurrence. As it is unknown in which group a patient would fall some also recommend the use of verapami alongside this treatment.
For those patients that do not respond to this treatment more invasive treatment options such as radiotherapy or potentially surgery are still available.
Our understanding from patients is that after referral to a foot-and-ankle surgeon or podiatrist who preforms injections and surgery’ hyaluronidase can be offered on the NHS, but not many surgeons are aware of the option so you may need to bring information with you.
According to the procedure reported by Dr Davis in the US you can expect the following:
The procedure varies based on location of the lesions but a common scenario is as follows:
We perform a posterior tibial nerve block. This is an injection into the nerve on the inside of the ankle that gives sensation to the bottom of the foot. The purpose of this is to completely numb the bottom of the foot rendering the procedure painless. Plantar fibromas are often fairly firm lesions so too small a needle cannot adequately penetrate the lesions which is why the block is important.
The lesion(s) are visualised via sonography (diagnostic ultrasound). The goal is to place the needle centrally within each lesion so that as much solution can fill the lesions as possible. If the injection is too deep, that is, under the lesion, then the effectiveness is reduced as the active ingredients are not adequately penetrating the lesion. If the injection is too superficial, then not only can effectiveness be reduced but leakage of the solution into the skin can cause atrophy.
The solution used is a combination of hyaluronidase, triamcinolone acetonide and a local anaesthetic, usually Marcaine. The amount and proportions thereof are a judgement call based on the size of each lesion and its firmness. A more firm lesion may benefit from a higher percentage of triamcinolone acetonide. The first injection may go in slowly, as the nodules tend to be quite dense. At later appointments the injection goes in faster and easier. https://www.ledderhosedisease.com
We generally see a softening of the nodule after three weeks, and a reduction in pain. The next injection is given at that stage (at 3 weeks), and by 6 weeks the nodule tends to have shrunk by 30-40%. Further injection tend to cause further shrinking.
How many nodules can be treated in one session
There is no limit to the number of nodules that can be treated at one time. Both feet can be treated at the same time. It would be normal to experience some discomfort once the numbness of each injection wears off so one needs to consider that.
Typical side effects
Short term: one to two days of tenderness and bruising
Down time is related to the number of lesions injected. It averages about 24 hours.
No long term adverse effects of treatment have been reported.
This treatment can be repeated after 3-4 weeks if the nodule doesn’t shrink enough, or if recurrence or new nodules heppen later on.
Other treatments used at the same time
Enzyme capsules or tablets can be prescribed to be taken as well, and after the injections many patients will use verapamil cream to try prevent recurrence.