Post-Hyaluronic Acid Filler Reaction Treated With Abrocitinib: A Case Report

ABSTRACT

Post-hyaluronic acid filler nodules are uncommon, unpredictable complications that present a challenge to clinical therapy. JDD authors Miyahra Haniko P. Lopez MD MBA, Sophie H. Guenin MSc, Jennifer Laborada BS, and Mark G. Lebwohl MD report a case of a female in her fifties who developed edema and nodules 6 weeks after hyaluronic acid (HA) filler injection. After minimal improvement with oral steroids and intralesional hyaluronidase, a trial of oral abrocitinib was initiated, which yielded significant clinical improvement. Thus, abrocitinib may be a novel therapeutic option for delayed-onset nodules following injection of hyaluronic acid.

INTRODUCTION

The use of soft tissue fillers is an increasingly popular means of rejuvenation; it was the second most common minimally invasive cosmetic procedure worldwide in 2020.¹ Although fillers have a favorable safety profile,² adverse events may still occur. One such event is the occurrence of delayed onset nodules. Although more common with permanent fillers such as polymethylmethacrylate or silicone, nodules have also been reported with non-permanent hyaluronic acid fillers.^3,4

Historically, the risk of delayed onset nodules in the hands of a well-trained injector is low^2,4-6 with the incidence for granulomatous reactions ranging from 0.02%-0.4%.⁷ However, there is a reported increase in nodule formation with the use of newer fillers with proprietary cross-linking technology.^8-11

Recent publications suggest that targeting the Janus kinase (JAK) and signal transducer and activator of transcription (STAT) pathway decreases inflammation, leading to disease improvement in granulomatous diseases. One such medication is abrocitinib, a JAK inhibitor approved in the US for the treatment of refractory, moderate to severe atopic dermatitis in adults.¹² In this case report, we document clinical improvement of delayed-onset nodules from filler with the use of oral abrocitinib.

CASE REPORT

A 55-year-old woman presented with a chief complaint of swelling over her cheeks and jawline 6 weeks after hyaluronic acid filler injections (Juvederm Voluma) to her zygomatic arches. The patient reported previous hyaluronic acid filler injections without complications. Past medical history included atopic dermatitis particularly affecting her face, as well as Hashimoto’s thyroiditis. Prior to consulting dermatology, the patient underwent three courses of oral antibiotics (cephalexin, amoxicillin clavulanate, and clarithromycin) as well as two separate week-long courses of a methylprednisolone taper. She reported rapid improvement during steroid therapy but with rebound swelling upon completion of each taper. Concomitantly, five courses of hyaluronidase injections were also attempted, which softened and decreased the size of some but not all of the nodules. Oral antihistamines were of no benefit.

On physical examination, the patient had erythematous patches on bilateral eyelids and malar cheeks, mild swelling of the zygomatic arches and lower cheeks, and multiple firm, palpable nodules of varying sizes over the upper, mid, and lower cheeks. The patient also had dermographism at the time of her visit, and eyelid swelling.

After baseline examinations to rule out active infection, the patient was started on abrocitinib 100 mg/tab daily, fexofenadine (Allegra) 180 mg/tab twice daily, and fluticasone 0.0005% ointment for pruritus. The patient reported marked improvement in itch and reduction in swelling within 14 days of starting the abrocitinib. At the 2-month follow-up, the edema had resolved with further improvement in some of the nodules as well as pruritus (Figure 1). There was visible reduction in the width of the patient’s face and swelling at both the zygomatic arches and in the submalar regions of her face (Figure 1).

DISCUSSION

Late-onset nodules post-filler injections are an uncommon and unpredictable complication. The pathophysiology for this phenomenon remains unclear — multiple mechanisms have been implicated including protein impurities left over from the bacterial fermentation process⁹ and biofilm formation.^7,13 Recently, it has been proposed that the breakdown of the cross-linking components used to stabilize the filler may lead to an immunologic reaction and subsequent granuloma formation.^8,10,11,14

Although nodules may resolve over time without intervention, the typical standard of care for persistent nodules includes oral and intralesional steroids, antibiotic therapy, and hyaluronidase injections. Other novel measures to manage nodules include the use of lasers¹⁵ as well as energy-based devices.¹⁶ Definitive management of recalcitrant nodules includes surgical removal or incision and drainage.^2,7

Abrocitinib reversibly inhibits the Janus kinase 1 (JAK1) enzyme by blocking the adenosine triphosphate binding site.¹² JAK inhibitors have been shown in recent reports to reduce inflammation and granuloma formation.^17,18 In an open-label clinical trial (n=15), 10 patients with cutaneous sarcoidosis demonstrated marked improvement in their skin, and even complete response (n=6), after 6 months of tofacitinib 5 mg twice daily.¹⁹ Similarly, significant improvement was seen in 5 patients on tofacitinib for severe, recalcitrant granuloma annulare.²⁰ Tofacinitib is also a therapeutic option for ulcerative colitis, gaining FDA approval in 2018. Other considerations included the patient’s desire for medical management as well as ease of oral intake. Abrocitinib has a low incidence of adverse effects, including hematologic toxicity and dose-dependent lipid abnormalities.

CONCLUSION

JAK inhibitors offer a promising targeted treatment for granulomatous disorders. However, to our knowledge, the use of JAK inhibitors for reactions to fillers has not been documented in the literature; thus, our case offers unique insight and the potential to expand our therapeutic armamentarium. Its oral route and short half-life make JAK-1 inhibitors an appealing novel therapeutic option. The study of its use in granulomatous diseases can progress our understanding of its therapeutic potential.

ACKNOWLEDGEMENT

JDD authors thank the patient for providing permission for this case report.

REFERENCES

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SOURCE

Lopez, Miyahra Haniko P., et al. “Post-Hyaluronic Acid Filler Reaction Treated With Abrocitinib: A Case Report.” Journal of Drugs in Dermatology: JDD 23.1 (2024): 1355-1356.

Content and images published with permission from the Journal of Drugs in Dermatology.

Adapted from original article for length and style.

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