French Mesotherapy for the Treatment of Pain

The clinical applications of mesotherapy outside the realm
of nonsurgical cosmetic medicine are almost entirely unheard
of in the United States. However, in France, the birthplace of
mesotherapy, it is first and foremost a pain and sports medicine
modality. Mesotherapy is of particular interest to clinicians due
to its safety, tolerability, cost effectiveness and seeming efficacy
when compared to conventional treatment protocols. This discussion
is intended to provide an overview of mesotherapy as it
is practiced in France for the treatment of chronic pain and
acute injury.
History of Mesotherapy
In 1952, Dr. Michel Pistor, a generalist practicing in rural France,
administered 10 mL of procaine intravenously in an attempt to abort
an acute asthma attack in a patient. While the treatment did not
ameliorate the patient’s respiratory status, upon follow-up, the patient
reported a significant improvement in his impaired hearing. Soon
thereafter, Dr. Pistor began experimenting with superficial injections
of procaine around the ears of hearing-impaired patients and experienced
some success. Soon his practice was full of hearing-impaired
patients seeking treatment. His results were mixed. However, many
of these patients saw improvement in seemingly unrelated conditions
such as eczema of the auditory canal and temporomandibular joint
(TMJ) pain. In addition, patients reported improvement in tinnitus,
which can be related to hearing impairment. 1
Dr. Pistor continued experimenting with superficial injections of
procaine for the treatment of a variety of disorders. On June 4, 1958,
he published an article describing his clinical success with this novel
procedure in which he stated, “the action on the tissues originating
from the mesoderm is so extensive that these treatments should be
called mesotherapy” (author’s translation). This was the first time
the term “mesotherapy” appeared in print. Dr. Pistor described mesotherapy
as “smallest dose, infrequently, in the correct location.” 2
The mesoderm is one of the three embryologic, histological classifications--
endoderm, mesoderm and ectoderm. The cells of the endoderm
develop primarily into the internal organs while the cells of the
mesoderm level develop into dermis and hypodermis, fatty tissues
and the musculoskeletal system. The ectoderm becomes, among other
tissues, the brain and epidermis. The term “mesotherapy” therefore
refers to injections into the dermis and hypodermis, which originate
PHARMACY
A CLINICIAN’S VIEWPOINT
French Mesotherapy
for the Treatment of Pain
Harry Adelson, ND 2005
from the mesoderm. As will be discussed later, one mesotherapy
technique developed after Dr. Pistor’s 1958 paper involves injecting
the epidermis, which originates from the ectoderm. However, it is
important to note that the mesoderm exists only in embryos; there is
no mesoderm layer of the human skin--a statement commonly made
in error by English language mesotherapists. One is not “injecting
into the mesoderm.” Rather, one is injecting into those structures that
have arisen from mesoderm.
The first international conference on mesotherapy took place in
1976—also the year in which mesotherapy was first used in inpatient
settings in France. In 1981, Dr. Jacques Le Coz introduced
mesotherapy into the orthopedic clinic at the Institue Nationale du
Sports (National Institute of Sports) in Paris. In 1987, the French
Academy of Medicine officially recognized mesotherapy as a legitimate
treatment modality within conventional medicine. 3
Currently in France, although still viewed as experimental and
unproven, mesotherapy is recognized as a legitimate treatment
modality by the French Academy of Medicine and is reimbursable
by that country’s national social security medical coverage. It has
been integrated into France’s largest sports medicine facility 4 and
is practiced in a number of pain management centers in France 5 as
well as in North Africa 6 . Apart from the French Society of Mesotherapy,
some of the more established national mesotherapy associations
or societies can be found in Algeria, Argentina, Belgium,
Brazil, Colombia, Great Britain, Germany, Greece, Israel, Italy,
Mexico, Portugal, Russia, Switzerland, Spain, Tunisia, Turkey
and Venezuela. The popularity of cosmetic mesotherapy is currently
exploding in Asia, with new national associations and societies
being formed every year.
Basic tenants of mesotherapy
Mesotherapy is characterized by its unique styles of injection-various
superficial injections using specialized short needles and specific
techniques directly over the sites of the affected structures. 7 The
proposed mechanism of action of mesotherapy is that solutions that
are injected intracutaneously remain in the area longer than they would
if delivered via deeper injection because they are cleared more
slowly by the general circulation. In addition, it is felt that these
superficially injected solutions continue to penetrate into the deeper
tissues. Kaplan and Raincourt injected radioisotope-marked calci-
21

A CLINICIAN’S VIEWPOINT
tonin and found, upon serial scans, that the more superficial the
injections, the longer the solution remained in the area. 8 Le Coz and
DuPont conducted an experiment on patients scheduled to undergo
arthroscopic surgery of the knee. The subjects were divided into
three groups. The first group received intraepidermic papules of a
diluted NSAID, the second group received subcutaneous injections
of the same solution using 4-mm needles, and the third received
deep intramuscular injections of the same solution. At 1 and 3 hours
post injection, venous blood draws were performed to determine
serum levels of the NSAID. It was found that uniformly, the shallower
the injection, the lower the level of the substance present in
venous circulation at both 1 and 3 hours post injection. During
arthroscopy, synovial biopsies were performed and all groups were
found to have NSAID present, though tissue concentration levels
were not determined. 9 Mesotherapy therefore appears to be a novel
technique for administering medicines locally to the area of the
pathology with the skin acting as a natural time-release system.
There are currently three principal mesotherapy injecting techniques--point
by point, nappage (French for “covering”) and epidermic.
Point by point was first described in the context of mesotherapy
by Dr. Pistor. It is very simply the injection of 0.02 cc to 0.05 cc of
solution after perpendicularly inserting a 4-mm,
6-mm or 12-mm needle its entire depth. Point-by-point injections
are generally given 1 cm to 2 cm apart and sparingly. Nappage,
first described by Bourguignon and Ravily 10 , is a more superficial
technique that takes practice to master. With the syringe held at a
45-degree angle from the skin and while applying light, constant
positive pressure on the syringe’s plunger, the practitioner rapidly
flicks the wrist (which can mimic shaking a salt shaker or the
action of a sewing machine) while covering a large area of skin.
Generally a 4-mm needle is used and is not fully inserted, perhaps
only 0.5 mm to 2 mm deep, and only a drop of solution is introduced
at each site at approximately 0.25-cm to 0.5-cm intervals.
In this way, one is able to infuse a large area of skin with the
solution while achieving a profound cutanous stimulation that
mimics certain ancient acupuncture practices. When done correctly,
the practitioner performs a “sweep” of nappage. Pinpoint bleeding
occurs 5 to 10 seconds later. Nappage is without a doubt the
least comfortable technique for the patient. The third technique is
epidermic, first described by Perrin. 11 As the name implies, this is
the most superficial of the techniques. When performed correctly,
the basal layer is not penetrated. Dr. Perrin developed this technique
in 1989 so that he could perform mesotherapy on children
without pain, after a minor mishap treating his daughter for a
sinus infection. A 13-mm (or ½-inch) 27- to 31-gauge needle is
positioned at a very steep angle to the surface of the skin, then,
with the bevel oriented away from the skin, it is dragged along the
skin while light, positive pressure is applied to the syringe’s
plunger. The needle will bend slightly from the angle and the pressure.
When treating certain anatomical contours such as the cervical
spine and the occipital ridge, the practitioner may bend the
needle before treating in order to maintain a correct needle position.
Most practitioners will use a slight bouncing action described
as “Parkinsonian.” The epidermic technique is intended to pro-
duce a shallow groove in the uppermost layers of keratinized epithelial
cells which in turn is covered with a bead of solution. When
performed correctly, there is no bleeding or scratching but one is
able to see the solution quickly absorb into the skin. Epidermic
technique is done in a grid pattern at 1-cm intervals over the entire
affected area. When either nappage or epidermic technique is
performed, the patient must be advised to avoid “spray-on tanning”
for a minimum of 24 hours post treatment.
Local anesthetics are used in the vast majority of mesotherapy
protocols--either lidocaine 1% or procaine 1%--always without epinephrine.
Local anesthetics are used for their anesthetic properties
that are believed to be longer acting when injected
mesotherapeutically. As is taught by the French Society of Mesotherapy,
lidocaine is generally indicated for the treatment of acute
conditions, while procaine is indicated for chronic conditions because
of its additional vasodilatory properties. 12
In France, mesotherapists commonly use the vasodilatory medication
Fonzylane (buflomédil) when treating pain. Trental®
(pentoxifylline), also commonly used in France, is an FDA-approved
medication that is not a true vasodilator but may be used
in the place of buflomédil in the United States. The approved use
for pentoxifylline is for the treatment of intermittent claudication.
The drug improves microcirculation by decreasing the blood’s viscosity
and by improving erythrocyte flexibility. Pentoxifylline
has been shown to increase leukocyte deformability and inhibit
neutrophil adhesion and activation. Tissue oxygen levels have been
shown to significantly increase with therapeutic doses of
pentoxifylline in patients with peripheral arterial disease. 13
Mesotherapists believe that by increasing microcirculation of localized
tissue beds, the elimination of metabolic waste is facilitated.
Injecting pentoxifylline mesotherapeutically is believed to
exercise the drug’s therapeutic effect for a longer period of time
compared to other routes of administration. 14
Pentoxifylline has been shown in animal studies to demonstrate
antinociceptive activity. It is a tumor necrosis factor-alpha and
interleukin-1-beta antagonist. 15 It has been shown to be an interleukin-
1alpha receptor agonist which therefore limits inflammatory hyperalgesia.
16 Local administration of pentoxifylline causes inhibition of
proinflammatory cytokine synthesis and antagonizes hyperalgesia in
formalin-injected rats. 17
Of particular interest is French mesotherapists’ liberal use of
salmon calcitonin (sCT) for the treatment of a broad range of
chronic pain disorders. Salmon calcitonin is best known as an
antiosteoporotic agent administered as a nasal spray, but its analgesic
effects in the treatment of acute osteoporotic fracture
have been well documented. 18-21 Researchers have examined
the anti-nocioceptive properties of sCT for a range of disorders
including advanced metastatic malignancy 22-24 , reflex sympathetic
dystrophy 25 , phantom limb pain 26-28 and diffuse sclerosing
osteomyelitis of the humerus 29 . One animal study demonstrated
sCT’s abilty to potentiate the analgesic effect of amitriptyline
and paroxetine 30 .
22 AMERICAN JOURNAL OF MESOTHERAPY

The mechanisms of analgesic action of sCT are believed to be
multifactorial. An anti-inflammatory action has been suggested 31 .
Studies in animals and in humans demonstrate that, in some but
not all cases, calcitonin increases plasma beta-endorphin levels
32 . It is possible that specific binding sites for salmon calcitonin
exist in the brain 33 .
It‘s worth mentioning that while the clinical use of sCT appears
safe, it is not without risk of side effects or adverse reactions. Nausea
without vomiting and mild local inflammatory reactions at the site of
injection are encountered in approximately 10% of patients receiving
sCT and transient severe nausea and vomiting occurs in approximately
1 in 300 patients. Flushing of the face or hands, skin rashes,
nocturia, pruritus of the ear lobes, feverish sensation, pain in the
eyes, poor appetite, abdominal pain, edema of the feet and salty taste
have been reported in patients treated with salmon calcitonin. Administration
of sCT has been reported in isolated cases to cause
hypersensitivity reaction 34 .
The majority of scientific data on mesotherapy in sports medicine
and for the treatment of pain are currently written in French and
consist of clinical case studies. These papers are published in the
journal of the French Society of Mesotherapy, which is not Medline
indexed but which has been published for
30 years. One such clinical case study showed mesotherapy to
be beneficial in the treatment of 65 patients suffering from chronic
thoracic back pain due to arthritis, spinal stenosis and sprain/strain
that was inadequately controlled using conventional methods,
namely, NSAIDs, narcotic analgesics, muscle relaxants and physiotherapy
35 . Another clinician describes his results after treating 267
cases of degenerative arthritic pain and suggests that mesotherapy
appears to be an effective and reasonable treatment option, especially
in light of the complete absence of adverse events or reactions
in the treatment group 36 . One paper describes the mesotherapeutic
treatment of 210 patients with soft tissue musculoskeletal pain not
satisfactorily controlled with conventional methods. These patients
were treated mesotherapeutically with local anesthetics, NSAIDs,
sCT and a nonsedating, centrally acting muscle relaxant
(thiocolchicoside). The results suggest mesotherapy to be a reasonably
effective treatment option, especially in light of poor patient
tolerance of the commonly used interventive option--injection of
corticosteroids 37 . Another paper which describes the use of mesotherapy
in 132 cases of patients with back and neck pain that had
not been ameliorated by at least 3 months of conventional treatment
also shows mesotherapy to be a promising treatment option in
terms of safety and efficacy 38 . Mesotherapy has been shown to be
helpful in a variety of commonly seen sports medicine conditions
such as Achilles tendonitis 39 . Lambert describes his success in treating
48 cases of Osgood-Schlatter’s 40 .
A systematic review and descriptive analysis of the current data
and better constructed, large scale trails are needed. However, mesotherapy
appears to be a promising modality in the treatment of a
variety of painful disorders. It is of particular interest because of its
excellent safety profile, tolerability to the patient, cost effectiveness
and seeming efficacy.
A CLINICIAN’S VIEWPOINT
1. Le Coz, Mesotherapie in Medecine Generale, Masson, 1993.
2. Le Coz, Mesotherapie in Medecine Generale, Masson, 1993.
3. Le Coz, Mesotherapie in Medecine Generale, Masson, 1993.
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7. Le Coz, Mesotherapie in Medecine Generale, Masson, 1993.
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levels in the inflamed tissue of the rat paw. Anesth Analg. 2004 Jun;98(6):1566-73.
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24. Szanto J, Jozsef S, Rado J, Juhos E, Hindy I, Eckhardt S. Pain killing with calcitonin
in patients with malignant tumours. Oncology. 1986;43(2):69-72.
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conditions., Bone. 2002 May;30(5 Suppl):84S-86S.
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Apr;33(4):499-501.
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novel treatment with calcitonin. J Rheumatol. 1993 Jun;20(6):1073-6.
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34. Mosby's Drug Consult, Mosby, Inc. An Elsevier Science Company, St. Louis, Missouri
35. Smail, H. Douleurs thoraciques anterieures d’origine vertebrale, 9th international mesotherapy
conference held by the French Society of Mesotherapy, Paris, October 20-22nd, 2000.
36. Leah da Silva, J., Mesquita, M.E. resultants de l’evaluation de deux annees de
traitemment de la douleur par mesotherapie dans les rhumatismes degeneratifs
chroniques, 9th international mesotherapy conference held by the French Society
of Mesotherapy, Paris, October 20-22nd, 2000.
37. Chos, D. Enquete retrospective des tendino-myalgies du rachis rencontrees dans
une consultation de rhumatologue dans le cadre d’n centre anti douleur. 9th international
mesotherapy conference held by the French Society of Mesotherapy, Paris,
October 20-22nd, 2000.
38. Messedi-Kamoun, N., Ben Salah F.Z., Dziri, C. La Mesotherapie dans les douleurs
rachidiennes experience Tunisienne a propos de 132 cas. 9th international mesotherapy
conference held by the French Society of Mesotherapy, Paris, October 20-
22nd, 2000.
39. Bourit, G. Guerin, P. Propositions therapeutiques dans la pathologie du tendon
calcaneen, 9th international mesotherapy conference held by the French Society of
Mesotherapy, Paris, October 20-22nd, 2000.
40. Yves Lambert, Place de las mesotherapie dans le concert therapeutique de la douleur
chronique, Lave Revue de Mesotherapie, vol 1, 2000.
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