Facial Cosmetic Filler Injections as Possible Target for Systemic Sarcoidosis in Patients Treated with Interferon for Chronic Hepatitis C: Two Cases

[Lessons on reactions to aesthetic fillers]

Any product injected to fill wrinkles can behave like a foreign body and cause unsightly granulomatous reactions. The subject is constantly evolving, subject to the vagaries of the market. Hyaluronic acid is the most injected product because it is resorbable and probably the least "toxic". In the event of sarcoidosis or an immune disorder, and in the event of vaccination against Covid, granulomas can develop even after very old injections.

Optimal Practices in the Delivery of Aesthetic Medical Care to Patients on Immunosuppressants and Immunomodulators: A Systematic Review of the Literature

Nonsurgical aesthetic procedures have been steadily growing in popularity among patients of all ages and ethnicities. At present, the literature remains devoid of guidelines on optimal practices in the delivery of aesthetic medical care to patients on immunosuppressant medications. The authors of this review sought to determine the physiologic responses of immunocompromised patients related to outcomes and potential complications following nonsurgical aesthetic procedures, and to suggest recommendations for optimal management of these patients. A comprehensive systematic review of the literature was performed to identify clinical studies of patients who had undergone nonsurgical aesthetic procedures while immunosuppressed. Forty-three articles reporting on 1690 immunosuppressed patients who underwent filler injection were evaluated, of which the majority (99%; 1682/1690) were HIV patients, while the remaining 8 were medically immunosuppressed. The complication rate of filler in this population was 28% (481/1690), with subcutaneous nodules the most frequently reported adverse event. A detailed synthesis of complications and a review of the inflammatory responses and impact of immunosuppressants and HIV infection on filler complications is presented. The authors concluded that patients on immunomodulatory medications may be at increased risk of filler granuloma relative to the general population, while patients on immunosuppressants may be at increased risk of infectious complications. Rudimentary guidelines for optimal preprocedural patient assessment, aseptic technique, injection technique, and antibacterial and antiviral prophylaxis are reviewed. Ongoing advancements in our understanding of the mechanisms underlying these inflammatory processes will undoubtedly optimize management in this patient population.

LEVEL OF EVIDENCE: 3

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.

Good tolerance of hyaluronic acid filler injections during the COVID-19 pandemic

BACKGROUND

The aim of our study was to identify and evaluate the complications related to hyaluronic acid during the COVID-19 pandemic.

METHOD

Twelve dermatologists participated in this study. A cohort and a non-cohort follow-up were ensured.

RESULTS

(1) Cohort follow-up: 1041 patients. 8% had a COVID-19 infection, 27% had received COVID-19 vaccination. 2% had immediate side effects (edema, erythema, bruising). 0.5% had delayed side effects (two inflammatory nodules, one nodule without inflammation, one edema). None of these side effects occurred in the context of infection or COVID-19 vaccinations. (2) Non-cohort follow-up: 7900 syringes used. Two early side effects (inflammatory edema) were reported, of which one occurred 15 days after vaccination. Two cases of delayed side effects such as inflammation on the injected area and inflammatory nodules occurred of which one was in the context of vaccination and one during COVID-19 infection. We estimate the frequency of complications possibly attributable to the disease or to the COVID vaccination to be 0.06% in our population.

DISCUSSION

Complications of HA injections in the context of COVID-19 disease or vaccination appear to be very rare but the frequency could be underestimated because of the low rate of vaccination/infection in our population. Our study shows a very good tolerance of hyaluronic acid injections during the COVID-19 pandemic.

Dermal Filler Injections in Patients With Autoimmune and Inflammatory Rheumatic Diseases-The Patients' Perspective

BACKGROUND

Injecting dermal fillers in patients with autoimmune inflammatory rheumatic diseases (AIIRDs) is controversial.

OBJECTIVE

To evaluate the attitudes of patients with AIIRDs regarding the use of dermal fillers and the side effects of those who underwent them.

METHODS

Patients with AIIRDs who attended a rheumatology outpatient clinic between 2016 and 2018 filled in a questionnaire about their attitudes toward dermal filler injections. The questionnaire evaluated information received from professionals and the factors that influenced their decision of whether or not to undergo the procedures.

RESULTS

Overall, 194 patients with AIIRDs (mean age 56.5 ± 14.0, 99% women) responded. Forty-two of them had previously undergone the injections and intended to repeat them (Group A), 37 had not received filler injections but intended to do so (Group B), and 114 who had never undergone them did not intend to undergo them. The major motivation for undergoing filler injections was social. Patients treated with dermal fillers refrained from informing their rheumatologist about their injections. They were, however, highly satisfied with the procedure and reported negligible side effects.

CONCLUSION

The use of dermal fillers was apparently safe and well received by patients with AIIRDs. Physicians' recommendations to refrain from injecting them with dermal fillers should be reconsidered and evaluated in clinical studies.

Non-surgical Rhinoplasty and Use of Hyaluronic Acid Based Dermal Filler-User Experience in Few Subjects

This study was intended to assess the utility of hyaluronic acid dermal fillers in patients who do not wish surgery in addition to the patients with minor post-surgery asymmetries. This was a prospective study which included post-surgery patients for minor nasal asymmetries, patients unwilling for surgery and those waiting for revision surgery. It is of great use in candidates who do not wish surgery but had the desire for different nasal appearance especially for important life events like marriage etc. This study included 20 patients with follow up period of 18 months. The results were compared on Nasal Imperfection Scale and Rhinoplasty Outcome Evaluation along with pre and post injection photographs. Nasal Imperfection Scale difference of 5 and Rhinoplasty Outcome Evaluation Scale differential of 50 is considered to be significant, which was observed in all individual cases. The growing need of medical rhinoplasty by the patient as well as surgeons has led to the introduction of fillers. Hyaluronic acid fillers are safe, easy and effective dermal fillers for patients undergoing all the expected indications of medical rhinoplasty. There is also growing number of candidates who wish for a 'nose job' for desired changes without coming under surgeon's scalpel. Our clinical experience with 20 patients has been described with satisfactory results.

Drug-Induced Sarcoidosis-Like Reactions

A drug-induced sarcoidosis-like reaction (DISR) is a systemic granulomatous reaction that is indistinguishable from sarcoidosis and occurs in a temporal relationship with initiation of an offending drug. DISRs typically improve or resolve after withdrawal of the offending drug. Four common categories of drugs that have been associated with the development of a DISR are immune checkpoint inhibitors, highly active antiretroviral therapy, interferons, and tumor necrosis factor-α antagonists. Similar to sarcoidosis, DISRs do not necessarily require treatment because they may cause no significant symptoms, quality of life impairment, or organ dysfunction. When treatment of a DISR is required, standard antisarcoidosis regimens seem to be effective. Because a DISR tends to improve or resolve when the offending drug is discontinued, this is another effective treatment for a DISR. However, the offending drug need not be discontinued if it is useful, and antigranulomatous therapy can be added. In some situations, the development of a DISR may suggest a beneficial effect of the inducing drug. Understanding the mechanisms leading to DISRs may yield important insights into the immunopathogenesis of sarcoidosis.

Dermal fillers in aesthetics: an overview of adverse events and treatment approaches

BACKGROUND

The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase.

OBJECTIVE

To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance.

METHODS

Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors' extensive experience, recommendations for avoiding and managing complications are provided.

RESULTS

Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique.

CONCLUSION

For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.

[Cutaneous manifestations of sarcoidosis]

Sarcoidosis is a systemic granulomatous disorder of unknown aetiology. Its dermatological manifestations are extremely polymorphous. They are normally classed as either specific lesions, comprising granulomas, which are generally chronic, or non-specific lesions, principally acute erythema nodosum. These signs are seen in around 25% of sarcoidosis patients. The disease may be heralded by a skin disorder. Diagnosis of cutaneous sarcoidosis provides the clinician with three problems: screening for a visceral site of the disease, determination of the prognosis, and long-term management with regular monitoring coupled with suitable therapy in the event of cosmetic or functional impairment.

Granulomatous foreign-body reactions to permanent fillers: detection of CD123+ plasmacytoid dendritic cells

BACKGROUND

Soft-tissue augmentation with permanent fillers can lead to severe granulomatous foreign-body reactions (GFBRs), but the immune pathomechanism of this complication is still unknown. We performed conventional histologic examination and immunostaining for plasmacytoid dendritic cells (pDCs) in skin sections from patients with GFBR to 4 permanent filler agents, which have been widely used in recent decades.

METHODS

Twenty-one skin biopsies were studied from 19 patients with GFBR to polyalkylimide 4% gel (PAIG, n = 10), polyacrylamide 2.5% gel (PAAG, n = 2), hydroxyethyl methacrylate/ethyl methacrylate in hyaluronic acid (HEMA/EMA, n = 4), or liquid injectable silicone (n = 5). GFBRs were analyzed in hematoxylin and eosin stained sections and pDCs detected using CD123 antibodies. Anti-CD11c immunostaining was performed for comparison.

RESULTS

Grading of the inflammatory infiltrates observed histologically did not correlate with the clinical features of inflammation. Immunostaining for CD123 did not detect pDCs in 8 of 10 polyalkylimide gel, 1 of 2 polyacrylamide gel, and the 5 liquid injectable silicone biopsies. In contrast, all 4 HEMA/EMA biopsies contained collections of pDCs in lymphocytic infiltrates close to filler particles and adjacent sarcoidal granulomas.

CONCLUSIONS

Our data suggest that pDCs contribute to the sarcoidal granulomas associated with injected HEMA/EMA. Recruited pDCs may exert their pro-inflammatory effects by the release of interferon-α at the site of these filler deposits.

Late-onset inflammatory adverse reactions related to soft tissue filler injections

An ever-increasing number of persons seek medical solutions to improve the appearance of their aging skin or for aesthetic and cosmetic indications in diverse pathological conditions, such as malformations, trauma, cancer, and orthopedic, urological, or ophthalmological conditions. Currently, physicians have many different types of dermal and subdermal fillers, such as non-permanent, permanent, reversible, or non-reversible materials. Despite the claims of manufacturers and different authors that fillers are non-toxic and non-immunogenic or that complications are very uncommon, unwanted side effects do occur with all compounds used. Implanted, injected, and blood-contact biomaterials trigger a wide variety of adverse reactions, including inflammation, thrombosis, and excessive fibrosis. Usually, these adverse reactions are associated with the accumulation of large numbers of mononuclear cells. The adverse reactions related to fillers comprise a broad range of manifestations, which may appear early or late and range from local to systemic. Clinicians should be aware of them since the patient often denies the antecedent of injection or is unaware of the material employed. Most of these adverse effects seem to have an immunological basis, the fillers acting more as adjuvants than as direct T-cell activators, on a background of genetic predisposition. Their treatment has not been the subject of well-designed studies; management of both acute and systemic reactions is often difficult, and requires anti-inflammatory and occasionally immunosuppressive therapy. The clinical, pathological, and therapeutic aspects of inflammatory and immune-mediated late-onset adverse reactions related to soft tissue filler injections are thoroughly reviewed herein.

Dermal fillers in aesthetics: an overview of adverse events and treatment approaches

Background

The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase.

Objective

To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance.

Methods

Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors’ extensive experience, recommendations for avoiding and managing complications are provided.

Results

Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique.

Conclusion

For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.

Two cases of interferon-alpha-induced sarcoidosis Koebnerized along venous drainage lines: new pathogenic insights and review of the literature of interferon-induced sarcoidosis

Sarcoidosis is a systemic granulomatous disorder of unknown origin commonly affecting the lung, the lymphoid system and the skin. We report here two cases of cutaneous sarcoidosis in two former intravenous drug users following interferon (IFN)-α and ribavirin therapy for chronic hepatitis C. Both patients developed skin sarcoidosis along venous drainage lines of both forearms, coinciding with the areas of prior drug injections. The unique distribution of the skin lesions suggests that tissue damage induced by repeated percutaneous drug injections represents a trigger for the local skin manifestation of sarcoidosis. Interestingly, skin damage was recently found to induce the local expression IFN-α, a well-known trigger of sarcoidosis in predisposed individuals. Here we review the literature on sarcoidosis elicited in the context of IFN-α therapy and propose a new link between the endogenous expression of IFN-α and the induction of disease manifestations in injured skin.

[Injectable fillers: adverse reactions and their management]

Injectable fillers are one of the corner stones of aesthetic medicine. In general they are safe to use. However, adverse reactions may occur. These reactions may be acute, subacute or delayed, e.g. after decades. It is important to know these reactions and to be prepared so that they can be adequately treated, in view of the clinical symptoms, the injected material and if applicable other diseases/treatments that might trigger these reactions. Last but not least, all reactions should be reported either to specialized registries or regulatory agencies. Only then we are able to learn more about these reactions and their best possible treatment.

Lip nodules caused by hyaluronic acid filler injection: report of three cases

Many dermal fillers have been used for reducing facial skin lines and for providing lip augmentation, and hyaluronic acid (HA) is one of the most widely used agents. One of the main commercial forms of HA is Restylane (Q Med, Sweden) produced by microbiological engineering techniques. Although HA is non-immunogenic, hypersensitivity and Granulomatous foreign body reactions have been reported. Herein, we report three female patients (average age 56 years) who presented with firm nodular lesions of the lip and a history of injection with HA (Restylane, Q Med, Sweden). Histopathologically, all cases showed pools of amorphous hematoxyphilic material surrounded by bands of densely collagenized connective tissue with no inflammation or foreign body reaction. Histochemical stains confirmed the presence of acid mucopolysaccharides such as hyaluronic acid. We conclude HA (Restylane, Q Med, Sweden) is an inert filler that may persist at an injection site, resulting in a tumor-like nodule.

Early granulomatous foreign body reactions to a novel alginate dermal filler: the system's failure?

BACKGROUND

Cutaneous granulomas after a soft filler injection represent one of the worst scenarios for both patient and injector.

OBJECTIVES

To present clinical and histopathological features of granulomatous nodular reactions induced by a new alginate-based dermal filler (Novabel(®)), and put it in context of the process of injectable soft tissue fillers approval and promotion in the EU.

METHODS

A case series of four patients injected with Novabel(®) for volume restoration of the face and hands, who developed severe foreign body reactions.

RESULTS

Four patients injected with Novabel(®) into tear troughs and/or dorsa of hands developed severe granulomatous reactions within months after injections. As we injected with the new filler into a total of 10 patients, a high incidence of 40% of the disfiguring adverse effect was observed. The inadequate response of manufacturer to our reporting the side-effects along with the available data on registration process of dermal fillers confirmed that the area is not well-regulated.

CONCLUSIONS

The status of dermal fillers as class III medical devices, and the process of their approval and marketing in the EU need to be seriously reconsidered to avoid unnecessary and serious adverse reactions.

[Dermal fillers: types, indications, and complications]

There are many types of dermal fillers currently used for cosmetic and medical indications in routine clinical practice. Fillers can be classified as temporary, semipermanent, or permanent depending on the length of time the substance remains in tissue. They can also be classified by the composition of the product. Materials can be based on collagen (bovine, porcine, and human), hyaluronic acid, poly-L-lactic acid, calcium hydroxylapatite, polymethal methacrylates, and polyacrylamide gels, among others. Temporary fillers are the products most often used for cosmetic purposes, in particular hyaluronic acid. This is due to the ease of application of fillers based on this substance, the good results obtained, and their safety profile. This review presents an overview of the techniques used for the correct placement of dermal fillers and the most common clinical indications for these procedures. It also covers the nature, properties, and mechanisms of action of the principal temporary, semipermanent, and permanent dermal fillers as well as the indications for each type of material. Finally, we describe the most common complications encountered and their treatment.

Cutaneous Sarcoidosis: An Uncommon Side Effect of Pegylated Interferon and Ribavirin Use for Chronic Hepatitis C

The treatment of chronic hepatitis C (CHC) has evolved in the past 15 years and combination of pegylated interferon plus ribavirin is its current standard therapy. However, several side effects are commonly observed and frequently lead to transient or definitive interruption of treatment. Although sarcoidosis in its systemic or cutaneous form is a very rare side effect in such circumstances, some cases have been reported even with conventional interferon. This brief review of the literature and description of a case of sarcoidosis occurring in a tattoo and a scar patient's face, during treatment with pegylated interferon alpha-2b plus ribavirin, is an educative report directed in special to dermatologists. The lesion improved after drug interruption and recurred after retreatment with pegylated interferon alpha-2a. We conclude that this side effect must call the attention of doctors to seek for the diagnosis and therapy as soon as possible in such circumstances. No differences were noticed neither with alpha-2a nor alpha-2b pegylated interferon employment.

[What's new in aesthetic dermatology: filler and laser treatments]

In esthetic dermatology, filling and laser treatments are two essential techniques. Several recent studies on calcium hydroxyapatite in filling treatments and facial volumetry, in esthetics, but also in HIV patients, have been published. It was also tested in accentuated melomental folds where it is superior to hyaluronic acid. In aging of the skin of the dorsal aspect of the hands, hyaluronic acid provides slightly better results than collagen. Filler rhinoplasty can correct minor deformations of the nose. Lipofilling is advantageous for linear scleroderma of the face, at least in the forehead region, and adipocyte stem cells may be a future solution for facial aging or lipoatrophy. The risk of local and/or general sarcoid reactions related to interferon in patients having undergone filling injections has been reported. In the field of laser treatment, fractionated photothermolysis has motivated much more research and seem particularly valuable in treating acne scars, aging of the dorsal aspect of the hands, and, more anecdotally, in colloid milium and pearly penile papules. Laser is also useful in preventing surgical scars where a mini-diode can also be used. For axillary hyperhidrosis, subdermic Nd-YAG laser competes with botulinum toxin, with longer-lasting results. Solutions are appearing for treatment of red or white striae cutis distensae. Intense pulsed light is the reference technique for poikiloderma of Civatte, and seems effective, with new devices, for melasma. However, inappropriately used by nonphysicians, IPL can cause serious ocular accidents; one case of uveitis has been reported.