Treatment of Delayed-onset Inflammatory Reactions to Hyaluronic Acid Filler: An Algorithmic Approach

Late-Onset Reactions after Hyaluronic Acid Dermal Fillers: A Consensus Recommendation on Etiology, Prevention and Management

Hyaluronic acid (HA) dermal fillers, generally considered low-risk, can lead to rare late-onset reactions (LORs) manifesting between 3 and 4 months postinjection, occasionally even as early as 24 h postinjection. The Complication Assessment and Risk Evaluation (CARE) board was established to review these reactions. In this publication, the authors aims to explore the etiological hypotheses underlying LORs, associated risk factors, prevention, and management approaches suggested by the CARE board. The CARE board identified three etiological hypotheses contributing to LORs. Firstly, the physicochemical structure of the filler, particularly low molecular weight HA, which may trigger an immune response. Secondly, infection, potentially introduced during injection or by dormant biofilm activation. Lastly, an imbalance in the host immune system, caused by factors like autoimmune diseases or viral infections, may lead to extended foreign body reactions, delayed type IV hypersensitivity, or adjuvant-based reactions. Based on these hypotheses, the board categorized various risk factors as patient-related (e.g., recent dental treatment, current medical status, active autoimmune disease), product-related (e.g., molecular weight), and procedure-related (e.g., aseptic technique and trauma). To reduce the risk of LORs, the CARE board recommends diligent patient selection, including comprehensive medical history assessment and informed consent. Practitioners should maintain an effective aseptic technique, and choose an appropriate product and injection depth for the anatomical location. Post-procedure, patients should receive education on proper filler care. Management of LORs depends on the suspected etiology, and the CARE board has proposed an algorithm to determine the most appropriate treatment. Hyaluronidase is recommended for noninflammatory reactions in the absence of active infection, while watchful waiting and/or steroid treatment may be preferred for inflammatory reactions. Hyaluronidase is not recommended as a first-line treatment for infections, which require drainage, bacterial culture, and antibiotic treatment. However, the board emphasizes the need for individualized evaluation and treatment in all cases.

Ultrasound-guided Treatment of Polycaprolactone Granuloma

Foreign body granulomas associated with polycaprolactone (PCL) filler injections are rare, yet challenging to manage. Multiple management modalities have been described. Here, we present a literature review and describe a case of histologically confirmed PCL-related granuloma, treated using ultrasound-guided injections of triamcinolone, hyaluronidase, and 5-fluorouracil combined with oral prednisolone and doxycycline.

Etiology of Delayed Inflammatory Reaction Induced by Hyaluronic Acid Filler

The etiology and pathophysiology of delayed inflammatory reactions caused by hyaluronic acid fillers have not yet been elucidated. Previous studies have suggested that the etiology can be attributed to the hyaluronic acid filler itself, patient's immunological status, infection, and injection technique. Hyaluronic acid fillers are composed of high-molecular weight hyaluronic acids that are chemically cross-linked using substances such as 1,4-butanediol diglycidyl ether (BDDE). The mechanism by which BDDE cross-links the two hyaluronic acid disaccharides is still unclear and it may exist as a fully reacted cross-linker, pendant cross-linker, deactivated cross-linker, and residual cross-linker. The hyaluronic acid filler also contains impurities such as silicone oil and aluminum during the manufacturing process. Impurities can induce a foreign body reaction when the hyaluronic acid filler is injected into the body. Aseptic hyaluronic acid filler injections should be performed while considering the possibility of biofilm formation or delayed inflammatory reaction. Delayed inflammatory reactions tend to occur when patients experience flu-like illnesses; thus, the patient's immunological status plays an important role in delayed inflammatory reactions. Large-bolus hyaluronic acid filler injections can induce foreign body reactions and carry a relatively high risk of granuloma formation.

Infraorbital mass long after dermal filler injection: A report of two cases

BACKGROUND

Hyaluronic acid fillers have been increasingly used throughout the world in the management of aging skin in the periocular region and other areas.

OBJECTIVE

To evaluate very late-term orbital mass formation secondary to Hyaluronic acid filler injection into the inferior eyelid.

METHODS

We report two cases that presented with a subcutaneous palpable mass localized at the right medial lower infraorbital area. Following clinical and radiological examination, surgical excision was required for the differential diagnosis of tumor.

RESULTS

After pathologic examination and the finding of a foreign-body granulomatous reaction, both patients recalled that hyaluronic acid filler had once been injected into their lower eyelids approximately 10 years prior. This is consistent with the fact that dermal-filler-related granuloma formation may occur even years later in the differential diagnosis of mass lesions.

CONCLUSION

It is suggested that patients be informed about the possible but rare mass effect in the infraorbital region. Clinicians should also attend to delayed hypersensitivity reactions, since patients may not recall details due to the length of time since injection.

Recent Advances of Hyaluronan for Skin Delivery: From Structure to Fabrication Strategies and Applications

Hyaluronan (HA) plays a fundamental role in maintaining the homeostasis on skin health. Furthermore, the effect of HA in skin inflammatory diseases is worth studying in the next future. HA and its conjugates change the solubility of active pharmaceutical ingredients, improve emulsion properties, prolong stability, reduce immunogenicity, and provide targeting. HA penetrates to deeper layers of the skin via several mechanisms, which depend on the macromolecular structure and composition of the formulation. The cellular and molecular mechanisms involved in epidermal dysfunction and skin aging are not well understood. Nevertheless, HA is known to selectively activate CD44-mediated keratinocyte signaling that regulates its proliferation, migration, and differentiation. The molecular size of HA is critical for molecular mechanisms and interactions with receptors. High molecular weight HA is used in emulsions and low molecular weight is used to form nanostructured lipid carriers, polymeric micelles, bioconjugates, and nanoparticles. In the fabrication of microneedles, HA is combined with other polymers to enhance mechanical properties for piercing the skin. Hence, this review aims to provide an overview of the current state of the art and last reported ways of processing, and applications in skin drug delivery, which will advocate for their broadened use in the future.