Navigating the Risks of Hyaluronic Acid Fillers: Understanding and Managing Late-Onset Reactions

Thailand Aesthetics: Hyaluronic acid (HA) dermal fillers have become increasingly popular for cosmetic enhancements, offering a non-surgical solution to reduce wrinkles and add volume to the face. Despite their widespread use and general safety, a small percentage of patients experience late-onset reactions (LORs). These reactions can occur months after the injection, presenting a range of symptoms that can be concerning for both patients and practitioners. This Thailand Aesthetics report focuses on a study review by researchers from Medical University of Gdansk-Poland Centro Médico Lajo-Plaza, Madrid-Spain and Care Geneva Aesthetics-Switzerland that delves into the causes, risk factors, prevention strategies, and management approaches for LORs based on recommendations from the Complication Assessment and Risk Evaluation (CARE) board.


Navigating the Risks of Hyaluronic Acid Fillers: Understanding and Managing Late-Onset Reactions

Understanding Late-Onset Reactions
Late-onset reactions to HA fillers typically manifest between three and four months post-injection, though they can appear as early as 24 hours in some cases. The symptoms can include swelling, redness, pain, nodules, and even systemic symptoms such as fever and malaise. These reactions are classified as late-onset to distinguish them from immediate allergic reactions that occur within minutes to hours after the procedure.
 
Causes of Late-Onset Reactions
The CARE board has identified three primary hypotheses that may explain the occurrence of LORs:
 
-Physicochemical Structure of Fillers: Fillers with low molecular weight HA are more likely to trigger an immune response. This response is due to the small HA molecules being more easily recognized by the immune system as foreign, leading to inflammation.
 
-Infection: Infections can be introduced during the injection process or from dormant bacteria becoming active. The injection site can harbor bacteria that form biofilms, which are resistant to antibiotics and can reactivate, causing an inflammatory response.

-Immune System Imbalance: Patients with autoimmune diseases or those who have recently experienced viral infections may have an overactive immune response. This can lead to prolonged foreign body reactions, delayed type IV hypersensitivity, or adjuvant-based reactions.
 
Identifying Risk Factors
The CARE board categorizes risk factors for LORs into patient-related, product-related, and procedure-related factors:
 
Patient-Related Risks:
-Recent Dental Treatments: Procedures that involve the mouth can introduce bacteria that may later migrate to the filler site.
 
-Current Medical Conditions: Conditions such as autoimmune diseases can predispose patients to LORs. Medications that suppress the immune system can also increase the risk of infection.
 
-Medications and Previous Filler Treatments: Some medications and the type or history of previous filler treatments can affect the likelihood of LORs.
 
Product-Related Risks:
-Molecular Weight of the Filler: Fillers with low molecular weight HA are more likely to cause reactions due to their ability to provoke an immune response.
 
-Contaminants: Contaminants introduced during the manufacturing process can trigger reactions.
 
Procedure-Related Risks:
-Injection Techniques: The skill of the practitioner and adherence to aseptic techniques are crucial. Improper techniques can introduce bacteria or cause trauma that leads to inflammation.
 
Prevention Strategies
To minimize the risk of LORs, the CARE board recommends several preventive measures:
 
-Thorough Patient Screening: A comprehensive medical history should be taken to assess any potential risk factors, such as autoimmune conditions, recent infections, or allergies. Patients should also be questioned about any recent dental work or procedures that could impact their risk.
 
-Choosing the Right Product: Selecting fillers with the appropriate molecular weight and ensuring they are free from contaminants is essential. Products that are known to cause fewer reactions should be preferred.
 
-Proper Injection Techniques: Practitioners should be well-trained in injection techniques and maintain strict aseptic procedures. This includes using sterilized equipment and ensuring the injection site is clean to prevent introducing bacteria.
 
-Patient Education: Patients should be informed about the proper aftercare procedures to reduce the risk of complications. This includes avoiding touching the treated area, not applying makeup immediately after the procedure, and avoiding exposure to potential contaminants.
 
Managing Late-Onset Reactions
Despite best efforts, some patients may still develop LORs. The CARE board has developed an algorithm to assist in the management of these reactions based on their suspected causes:
 
-Non-inflammatory Reactions: For non-inflammatory nodules or other non-infectious reactions, hyaluronidase can be used to dissolve the filler. If the reaction does not respond to hyaluronidase, oral steroids may be considered.
 
-Inflammatory Reactions: In cases where inflammation is present but not due to infection, watchful waiting or treatment with oral steroids may be appropriate. The use of hyaluronidase in these cases should be avoided unless absolutely necessary.
 
-Infections: If an infection is suspected, drainage of any abscesses, bacterial culture, and appropriate antibiotic treatment are required. Hyaluronidase is not recommended as it can spread the infection.
 
Case Studies
To illustrate these principles, consider the following case studies:
 
Case 1: A patient experienced systemic symptoms and local swelling after HA filler injections. Initial treatments included steroids and hyaluronidase, but symptoms recurred, leading to a diagnosis of ASIA syndrome. The patient eventually responded well to steroid therapy alone.
 
Case 2: Another patient developed body-wide urticaria and was found to have high levels of antinuclear antibodies. This patient was treated with cyclosporin A and had no recurrence of symptoms at follow-up.
 
Case 3: A patient developed swelling and redness at the filler site following a COVID-19 vaccination. The symptoms were managed successfully with corticosteroids, and the patient experienced no further issues.
 
Conclusion
The CARE board's recommendations highlight the importance of thorough patient screening, careful product selection, and proper injection techniques to minimize the risk of LORs. When reactions do occur, a tailored approach based on the suspected cause is essential. By following these guidelines, practitioners can help ensure safer outcomes for their patients and manage any complications effectively.
 
The study review was published in the peer reviewed journal: Dermatology and Therapy.
https://link.springer.com/article/10.1007/s13555-024-01202-3
 
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