brys2019

Prévia do material em texto

LETTERS AND COMMUNICATIONS
Early-Onset Sweet-like Dermatitis After Facial Hyaluronic Acid Filler Injection
Dermal filler placement represents one of the most
common minimally invasive cosmetic procedures
performed in the United States, second only to
neurotoxin injection. More than 2 million filler
injections were performed in 2017, with filler use
increasing annually given a favorable safety profile
and relatively noninvasive nature.1 Given the
increasing prevalence of filler injections, practi-
tioners must be aware of potential pitfalls and
complications that may arise secondary to their
use.
Well-known early complications of filler use include
improper aesthetic placement, arterial occlusion, and
acute infection. Later complications of filler placement
include hypersensitivity reactions, granuloma forma-
tion,fillermigration, andbiofilm.These complications
as well as best practices for their avoidance and
treatment have been thoroughly reviewed elsewhere.2
With the recent exponential expansion in the number
of hyaluronic acid (HA) and other filler products with
nuanced chemical structures, particular attention
should be given to potential newly recognized adverse
effects.
Herein, we present the first reported case of an early-
onset, Sweet-like dermatitis after HA filler placement.
Our case demonstrates that a pathergy-like reaction
may be a rare, but possible, early adverse event after
filler injection. Our case raises several questions
regarding the overall potential for a pathergy-like
reaction, potential predisposing factors, and whether
certain products may be more likely to result in this
complication.
A 57-year-old woman with no known medical
history taking no medications presented for her
first cosmetic evaluation. She was in her usual state
of health, with the exception of low-grade fevers,
cough, and nasopharyngitis for several days pre-
ceding her consultation. Neurotoxin and filler
injections were performed at the time of her visit
with no immediate complications. 15U of onabo-
tulinum toxin A was injected into the corrugators,
followed by 3U to each orbicularis oculi, 5U to the
mentalis, and 4U to the superior orbicularis oris. A
total of 1 mL of Restylane Silk was injected to the
etched perioral lines and the oral commissures. One
milliliter of Restylane Refyne was subsequently
injected to the nasolabial folds and oral commis-
sures. Finally, 2 mL of Voluma XC was placed
along the lateral zygoma with a 27-G 1/2$ needle
and to the anterior midcheek with a 25-G TSK
cannula.
Twenty-four to 48 hours after her injection, the
patient noted asymptomatic, uniform, erythematous
papules at sites of filler injection in the infraorbital
cheeks, upper and lower cutaneous lip, and nasola-
bial folds but not at sites of neurotoxin injection in the
corrugators, orbicularis oculi, mentalis, or orbicu-
laris oris (Figure 1). Bacterial and viral cultures were
performed at that time andwere negative. The patient
was empirically treated with prednisone and valacy-
clovir with rapid improvement within 10 days
(Figures 2 and 3). No recurrences were noted after
tapering of prednisone or upon 2-month follow-up.
The patientwas noted to have a complete blood count
within normal limits approximately 10 weeks before
her cosmetic procedure.
Several diagnostic criteria for Sweet syndrome were
met, including the abrupt onset of erythematous
papulonodules, association with a preceding illness,
and rapid response to systemic corticosteroid. Given
the aforementioned features and clinical improve-
ment, diagnostic confirmation by skin biopsy was not
performed.
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1076-0512 · Dermatol Surg 2019;00:1–3 ·
1
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Discussion
Pathergy is a known phenomenon of cutaneous
inflammation occurring after injury in the setting of
various systemic conditions. Most commonly,
pathergy is associated with neutrophilic dermatoses,
such as acute febrile neutrophilic dermatosis (Sweet
syndrome), pyoderma gangrenosum, or Behçet’s dis-
ease. In predisposed individuals, such as patients
with a history of Sweet syndrome and an ongoing
febrile illness, filler injection may theoretically serve
as a sufficient stimulus to induce a pathergy-like
response. To date, however, this complication has not
been reported.
Our patient’s preceding febrile illness may have
resulted in a predisposition for the development
of a Sweet-like dermatitis after HA filler injection.
Similar histories are often seen in patients who
develop Sweet syndrome not associated with
malignancy. As demonstrated in this case, treat-
ment with oral corticosteroids is often sufficient in
management of an acute complication. Recalci-
trant neutrophilic dermatoses, although never
previously reported after dermal filler placement,
may require alternative systemic medications, such
as dapsone or other nonsteroidal inflammatory
agents.3
It should be noted that in this case, lesions only
occurred at sites where HA filler, but not neurotoxin,
was injected. Notably, the reaction appeared most
exuberant in areas of Voluma XC injection, whereas
no reaction was seen at the oral commissures, and a
less severe reactionwas seen in the nasolabial folds and
etched perioral lines where Restalyne Refyne and Silk
products were used. One possible explanation for this
observation is the relatively greater trauma induced by
the placement of more viscous/distending HA filler
products as compared to the trauma of injecting
neurotoxin.
Alternatively, it is possible that the observed reac-
tion represents an atypical presentation of inflam-
matory nodule formation or an unusual
hypersensitivity reaction to HA filler. Hypersensi-
tivity reactions can be seen with any HA formula-
tion; however, these are more common with
Vycross/tightly cross-linked high and low molecu-
lar weight hyaluronic acid technology. Immuno-
logic assaults such as dental work or bacterial
illness have been reported as triggering events in
retrospective reviews of delayed adverse events
secondary to treatment with Vycross technology.
Although delayed hypersensitivity reactions are
Figure 2. Early improved within 2 days of initiating pred-
nisone.
Figure 1. First available photograph of the patient’s reaction to filler placement. Note lack of involvement of areas where
onabotulinum toxin A was injected and general increased involvement of bilateral cheeks.
LETTERS AND COMMUNICAT IONS
DERMATOLOG IC SURGERY2
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
possible, Humphrey and colleagues reviewed 4,500
patients treated with Vycross products, and delayed
swelling and nodule formation occurred at amedian
of 4 months after treatment with an incidence of
0.98% per patient.4,5 The appearance of asymp-
tomatic inflammatory nodules within 24 to 48
hours of HA injection as observed in this case is
clinically and pathophysiologically inconsistent
with this process. Finally, given negative bacterial
and viral cultures, an acute-onset infectious etiol-
ogy was considered unlikely. Taken together,
practitioners should be aware for the potential of a
Sweet-like dermatitis after filler placement, as well
as its diagnosis and appropriate management.
References
1. American society of plastic surgeons 2017 plastic surgery statistics
report. Available from: https://www.plasticsurgery.
org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-
2017.pdf. Accessed January 12, 2019.
2. Signorini M, Liew S, Sundaram H, Goodman GJ, et al. Global
aesthetics consensus: avoidance and management of complications
from hyaluronic acid fillers- evidence- and opinion-based review
and consensus recommendations. Plast Reconstr Surg2016;137:
961–71.
3. Nelson CA, Stephen S, Ashchyan HJ, James WD, et al. Neutrophilic
dermatoses: pathogenesis, Sweet syndrome, neutrophilic eccrine
hidradenitis, and Behcet disease. J Am Acad Dermatol 2018;79:987–
1006.
4. Humphrey S, Jones DH. Retrospective review of delayed adverse events
secondary to treatment with a smooth, cohesive 20mg/ml hyaluronic
acid filler in 4500 patients J Am Acad Dermatol In press.
5. Belezany K, Carruthers JD, Carruthers A, Mummert ME, et al. Delayed-
onset nodules secondary to a smooth cohesive 20 mg/ml hyaluronic acid
filler: cause and management. Dermatol Surg 2015;41:929–39.
Adam K. Brys, MD
Department of Dermatology
Duke University Medical Center
Durham, North Carolina
Sue Ellen Cox, MD
Aesthetic Solutions
Chapel Hill, North Carolina
The authors have indicated no significant interest with
commercial supporters.
Figure 3. Substantial improvement after 10 days of pred-
nisone.
LETTERS AND COMMUN ICAT IONS
0 0 : 0 0 :MONTH 201 9 3
© 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf
https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf
https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf