ABSTRACT
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 low2,4-6 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
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.
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
CONCLUSION
ACKNOWLEDGEMENT
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.
Adapted from original article for length and style.