The 2016 International League of Dermatological Societies' revised glossary for the description of cutaneous lesions

Foreign body reactions are regularly seen as a late complication of cosmetic treatment with synthetic dermal fillers. Often this foreign body reaction is triggered by a systemic infection, but other systemic triggers are also reported. In this case report, we present a woman in her 60s who was treated with ipilimumab for metastatic melanoma. After two courses of treatment she developed painless facial nodules. A foreign body reaction to dermal fillers was suspected because the patient had received cosmetic treatment with dermal fillers 25 years previously. This reaction was confirmed by excision and histological examination. In the absence of other known triggers, this case revealed immunotherapy (ipilimumab) and subsequent activation of the adaptive immune system as potential triggers of foreign body reactions to dermal fillers. Immunotherapy is increasingly used as anticancer treatment for an increasing number of tumour types. Furthermore, synthetic dermal fillers have frequently been used in the past. Therefore, physicians should be aware of this late‐occurring complication of synthetic filler treatment in patients who develop skin lesions during immunotherapy.     

Granuloma as a complication of polycaprolactone-based dermal filler injection: ultrasound and histopathology studies

In aesthetic medicine, there has been an ongoing search for an ideal dermal filler to offer zero complication rate. Polycaprolactone-based dermal filler (PCL) has been available since 2009.

The purpose of the paper was to present a case of granuloma as a complication of PCL injection, which has not been reported so far by other researchers. A 68-year-old female was injected with PCL. One year later, nodules accompanied by bluish skin discoloration developed within the injection site. Ultrasound and histopathology studies were performed. The examinations confirmed the presence of foreign body granuloma after PCL, which makes it the first reported case worldwide. The published data analyses showed general lack of studies and case reports to address this issue. The PCL, like an injection of any soft tissue filler, may lead to serious complications, such as granuloma formation. This makes further research legitimate and necessary.     

Granulomatous reaction to Belotero Balance: A case study

Objective: The most commonly used dermal fillers are hyaluronic acids (HAs), and in general, are well tolerated with mild to moderate risk of adverse events. The most frequently reported side effects are injection site erythema and bruising. We present the first case of a patient who developed a severe granulomatous foreign body reaction to the HA filler, Belotero Balance. In our review of the literature, a granulomatous reaction has never before been reported as a side effect of this particular HA filler (1). Case: On exam, the patient had firm erythematous, granulomatous plaques on her bilateral cheeks, with a tender, fluctuant nodule on her right cheek. Complete resolution of this delayed reaction was achieved after several injections of intralesional Kenalog (IL-K) 2.5 mg/cc, and further fine-tuning was achieved through laser resurfacing. Conclusion: Granulomatous reactions can occur with any HAs, though such incidents are not commonly reported. These delayed reactions are generally localized immunological reactions, though biofilm infections should be excluded where appropriate. It is only with long-term (5-year) longitudinal studies that accurate numbers of such reactions will be known.     

In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin

OBJECTIVE: To determine whether endogenous synthesis of new extracellular matrix may contribute to the degree and duration of clinical benefits derived from cross-linked hyaluronic acid dermal filler injections. DESIGN: In vivo biochemical analyses after filler injections. SETTING: Academic referral center. PARTICIPANTS: Eleven healthy volunteers (mean age, 74 years) with photodamaged forearm skin. Interventions Filler and vehicle (isotonic sodium chloride) injected into forearm skin and skin biopsy specimens taken 4 and 13 weeks later. MAIN OUTCOME MEASURES: De novo synthesis of collagen, the major structural protein of dermal extracellular matrix, was assessed using immunohistochemical analysis, quantitative polymerase chain reaction, and electron microscopy. RESULTS: Compared with controls, immunostaining in skin receiving cross-linked hyaluronic acid injections revealed increased collagen deposition around the filler. Staining for prolyl-4-hydroxylase and the C-terminal and N-terminal epitopes of type I procollagen was enhanced at 4 and 13 weeks after treatment (P<.05). Gene expression for types I and III procollagen as well as several profibrotic growth factors was also up-regulated at 4 and 13 weeks compared with controls (P<.05). Fibroblasts in filler-injected skin demonstrated a mechanically stretched appearance and a biosynthetic phenotype. In vitro, fibroblasts did not bind the filler, suggesting that cross-linked hyaluronic acid is not directly stimulatory. CONCLUSIONS: Injection of cross-linked hyaluronic acid stimulates collagen synthesis, partially restoring dermal matrix components that are lost in photodamaged skin. We hypothesize that this stimulatory effect may be induced by mechanical stretching of the dermis, which in turn leads to stretching and activation of dermal fibroblasts. These findings imply that cross-linked hyaluronic acid may be useful for stimulating collagen production therapeutically, particularly in the setting of atrophic skin conditions.     

Allergic reaction to hyaluronidase use after hyaluronic acid filler injection

Hyaluronic acid (HA) is biocompatible, easy to use and reversible. HA fillers are considered to be safe, although some complications can occur. At this time, hyaluronidase is used off-label for correction. A 41-year-old woman presented to our clinic for focal erythematous plaque on hyaluronidase injection site. She got the injection for correction of HA filler excess. The skin lesion continued for 7 days. Histopathologic findings were nonspecific. On intradermal skin test, allergic reaction to hyaluronidase were confirmed. Adverse effects of this hyaluronidase are uncommon with local injection site reactions most frequently reported. Allergy to hyaluronidase should be included in the differential diagnosis when focal erythema and swelling occur after hyaluronidase injection.     

Adverse reactions to injectable soft tissue fillers: Memorable cases and their clinico-pathological overview

Background: Filler injection is a minimally invasive procedure widely used for soft tissue augmentation. Although the safety profile is favorable, adverse events can occur, especially after illegal filler injection. Objectives: The authors present memorable cases of filler complications and review their clinico-pathological features and treatment strategies. Patients and methods: This is a retrospective, single-center case series. The authors identified eight patients with significant complications following filler injection. A medical record review was performed for clinical history, histopathological studies, and treatment. Results: Six female and two male subjects presented with significant filler complications. The time interval between filler injection and the development of a complication varied greatly among cases (immediately afterwards to 14 years following filler injection). Four of the patients received illegal filler injection where the injected material was either unknown (25%) or was told as paraffin (12.5%) or Vaseline^® (12.5%). Hyaluronic acid fillers were used in two patients (25%) and the rest were injected with porcine atelocollagen (12.5%) and polyacrylamide hydrogel (12.5%). The complications were classified as an allergic reaction (25%), filler material migration (12.5%), injection necrosis + embolism (25%), and foreign body granuloma (37.5%), based on their clinico-pathological features and were treated accordingly. Conclusion: Adverse effects are not uncommon following filler injection. Physicians should be aware of the potential side effects, recognize their presentations, and understand how to manage them.     

Successful hyaluronic acid filler injection in a chronic myeloid leukemia patient taking imatinib mesylate

Dermal fillers are highly favored around the globe as minimally invasive or nonsurgical procedures. Imatinib mesylate is the first-line treatment for patients diagnosed with chronic myeloid leukemia. However, some studies describe that imatinib mesylate may increase the tendency of skin fragility which can lead to easy bruising and hyperpigmentation after invasive skin procedures. Yet, to our knowledge, no studies have described any successful dermal filler injection performed on patients who are under imatinib mesylate treatment. Hence, we present a case successfully treated with hyaluronic acid filler injection on a patient under imatinib mesylate treatment. We carefully propose that hyaluronic acid filler can be an effective means of rejuvenation and cosmetic enhancement for those under imatinib mesylate treatment.     

Extensive necrosis after injection of hyaluronic acid filler: case report and review of the literature

Background Use of dermal fillers for soft tissue augmentation has become an integral part of aesthetic practices. Dermal fillers temporarily remove the appearance of rhytids and reduce the depth of skin folds. Even with the most experienced of injectors, adverse effects can and do occur ranging from mild bruising to severe injection necrosis. Aims Physicians should be able to treat the severe complication of vascular necrosis and detect impending necrosis after injection of a dermal filler, especially with hyaluronic acid fillers. Materials and Methods Case report of a patient who was followed for 6 months from time of injection of hyaluronic acid filler to complete healing of wound. Results Complete wound healing was achieved with early recognition and institution of treatment. Discussion We review a case report of injection necrosis and methods used to prevent and treat this complication. Conclusion Early recognition of vascular necrosis with specific protocol for treatment after injection necrosis with hyaluronic acid fillers improves the outcome of wound healing.     

Delayed skin necrosis following hyaluronic acid filler injection: A case report

Vascular compromise is a rare but serious complication of dermal filler injection. Vessel occlusion tends to have a more immediate onset of symptoms. We report a case of skin necrosis that started with pain, erythema and edema two days after hyaluronic acid filler on the forehead of a 57‐year‐old woman. The patient was treated with less than 24 hours the onset of symptoms, leaving discreet scar. The current theories that explain skin necrosis caused by HA fillers include angiospasm and embolization. The frontal region has many anastomoses, the embolized proximal vessel initially did not lead to symptoms. However, the HA inside the artery may have traveled over time and reached a terminal distal branch, which generated localized skin damage and pain. The urgent treatment of arterial occlusion and thromboembolism caused by HA injection is intralesional high‐dose hyaluronidase.     

色素异常性皮肤淀粉样变病一家系报道

患者,男,61岁。全身皮肤出现色素沉着及减退斑10年余。其父、兄与其有相同的皮疹特征。皮损组织病理示：表皮角化过度,部分上皮脚融合,棘层轻度增生,真皮浅层小血管可见淋巴细胞浸润,部分真皮乳头层可见嗜伊红团块状物质,其间可见裂隙。真皮乳头层团块状物质刚果红染色阳性。结合临床及实验室检查,诊断为色素异常性皮肤淀粉样变病。     

Alopecia with foreign body granulomas induced by Radiesse injection: A case report

Radiesse is a soft tissue filler which has been widely used for cosmetic enhancement. The safety of Radiesse has been thoroughly investigated via numerous studies. A late-onset complication of Radiesse injection consists of foreign body granulomas, with only three case reports in over 10 years of clinical use. Herein, we describe the case of a patient who experienced alopecia with foreign body granulomas at the injection region one month after receiving a Radiesse injection. To our knowledge, this is the first report in the English literature of alopecia as an adverse event associated with Radiesse injection. The present case reminded physicians to evaluate more cautiously the necessity of injecting filler into hair-bearing area for lifting purpose. This procedure may cause foreign body granulomatous reaction, which may result in hair loss at the injection region.     

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.     

A review of hydrolifting: A new modality for skin rejuvenation

Background: Hydrolifting is a newly developed modality of skin rejuvenation, which enhances overall facial volume augmentation and recovers skin thickness through multi-pass HA injection. Although it is commonly performed, only a few articles have reported on the rejuvenating effects of hydrolifting. Moreover, clear protocols and possible mechanisms of the procedure have not been elucidated. Objective: To define a novel technique for injecting HA and to clarify how to choose an appropriate HA filler based on the procedural purpose. Methods: This article is based on a review of the medical literature and the authors’ clinical experience in investigating and treating skin wrinkles with the hydrolifting method. Results: In hydrolifting, HA filler serves as a hydration source, dermal volumizer, and stimulator of dermal collagen and antioxidants. Hydrolifting is frequently indicated in minor wrinkles, minor volume depletion and rough skin texture. Conclusion: The hydrolifting method is a newly introduced antiaging treatment modality. It effectively covers the blind spots of conventional HA injection, such as infraorbital, perioral and hand dorsal wrinkles. However, further investigations are needed to reach a consensus on the basic concepts of treatment, choice of appropriate fillers and optimal technique in hydrolifting.     

复发前后皮损表现不同的性病型Reiter综合征

报告1例复发前后皮损表现不同的性病型Reiter综合征.患者男,50岁.在多次非婚性生活后,出现尿道炎、不对称性关节痛、结膜炎及全身皮损,诊断为性病型完全型Reiter综合征.在病情稳定1年余后,在多次非婚性生活后再次出现全身皮损,复发皮损与初发不同,因此该例诊断为性病型Reiter综合征复发.     

Rhinosporidiosis: gigantic cells with engulfed sporangia of Rhinosporidium seeberi in the case of dermosporidiosis

Rhinosporidiosis in an Indian male with a tumorous skin lesion is reported. Histopathology from the skin lesion revealed gigantic foreign body giant cells bloated with multiple, engulfed sporangia of rhinosporidiosis, which has not been reported earlier. The term "dermosporidiosis", should be used to denote such predominant skin lesions of rhinosporidiosis.     

Novel management of granuloma formation secondary to dermal filler: A multi-modality approach

Background

Dermal fillers for soft tissue augmentation have become increasingly popular among patients of all ages and ethnicities. With more widespread use, there has been an increased incidence of adverse reactions, one of which is the granulomatous foreign body reaction (GFBR).

Materials & Methods

We present a three patient case series in which GFBR secondary to dermal filler was successfully treated with a multi-leveled approach. The first modality involves intralesional injection of a mixture containing 1 cc of 5-fluorouracil (5-FU), 0.5 cc of dexamethasone sodium phosphate, and 0.1 cc of triamcinolone 10. The lesion is injected intradermally in small aliquots, similar to scar treatment. The patient then takes colchicine 1.2 mg loading dose on day 1, then 0.6 mg twice per day for 4 days concurrently with naproxen 500 mg orally once daily for 5–7 days. This process may be repeated in 6 weeks if the lesions have not resolved and PDL laser may be employed for residual post-inflammatory erythema.

Results

All three patients presented in this case series had significant aesthetic improvement in their dermal filler-derived foreign body granulomatous reactions.

Conclusion

GFBR provides both a medical and aesthetic issue for these patients including mental distress, pain, and dysfunction, therefore having an effective treatment for GFBR will affect medical management of these patients, improving patient outcomes and satisfaction. Our proposed regimen for GFBR has been shown to be highly efficacious and safe for these patients, providing a significant improvement in both function and cosmesis of the area.     

Filler migration to the forehead due to multiple filler injections in a patient addicted to cosmetic fillers

Filler migration is a potential complication following the injection of multiple fillers. With the increasing popularity of multiple filler injections, migrated granulomas should be an essential differential diagnosis for newly growing facial lumps. It is important for all physicians to be aware that complication induced by dermal fillers can occur in locations other than the planned injected sites. We described a case of filler migration to the forehead in a patient addicted to cosmetic fillers. To our knowledge, it has never been published in dermatology literature so far. A detailed history of cosmetic procedures from the patient addicted to filler injections is necessary for accurate diagnosis. Because account of previous cosmetic filler injections is not always reliable, an early skin biopsy with pathological examination is the gold standard for determining whether multiple filler injections have been performed.     

Temporal fossa defects: techniques for injecting hyaluronic acid filler and complications after hyaluronic acid filler injection

Facial changes with aging include thinning of the epidermis, loss of skin elasticity, atrophy of muscle, and subcutaneous fat and bony changes, all which result in a loss of volume. As temporal bones become more concave, and the temporalis atrophies and the temporal fat pad decreases, volume loss leads to an undesirable, gaunt appearance. By altering the temporal fossa and upper face with hyaluronic acid filler, those whose specialty is injecting filler can achieve a balanced and more youthful facial structure. Many techniques have been described to inject filler into the fossa including a “fanned” pattern of injections, highly diluted filler injection, and the method we describe using a three‐injection approach. Complications of filler in the temporal fossa include bruising, tenderness, swelling, Tyndall effect, overcorrection, and chewing discomfort. Although rare, more serious complications include infection, foreign body granuloma, intravascular necrosis, and blindness due to embolization into the ophthalmic artery. Using reversible hyaluronic acid fillers, hyaluronidase can be used to relieve any discomfort felt by the patient. Injectors must be aware of the complications that may occur and provide treatment readily to avoid morbidities associated with filler injection into this sensitive area.     

European evaluation of a new hyaluronic acid filler incorporating lidocaine

Background A new dermal filler has been developed with preincorporated lidocaine for the treatment of moderate/severe wrinkles. Aims Injector and patient evaluation of comfort and aesthetic results obtained with a new hyaluronic acid filler incorporating lidocaine (HAL) following treatment of nasolabial folds. Patients/Methods Three thousand five hundred and sixty‐six patients were recruited by 485 injectors across 16 countries. All patients had previously received facial fillers but now required further treatment. All patients received the new hyaluronic acid filler incorporating lidocaine. Results Injector assessment of HAL was that it was very easy to inject in > 75% of patients, and postinjection sculpting/massaging was very easy in most patients (> 70%). Both injectors and patients reported low patient pain levels, with patients experiencing less pain during all stages of the HAL injection procedure compared to previous dermal fillers. Over 95% of injectors rated the aesthetic effect of HAL as “excellent” or “good,” with 99.1% stating they would recommend treatment to a colleague and 99.4% recommending treatment to other patients. More than 90% of patients were happy with the treatment, and 99% would recommend HAL to friends. Conclusions The new hyaluronic acid filler incorporating lidocaine provides a more comfortable injection experience and improved aesthetic result for most patients compared with other dermal fillers used previously.     

A Case of Complication after Matridex? Injection

Matridex® is an injectable skin filler that''s composed of a mixture of cross linked hyaluronic acid and dextranomer particles, and it was recently developed for soft tissue augmentation. To the best of our knowledge, there have been few previous reports on complications associated with Matridex. We report here on a delayed inflammatory reaction to an injection of Matridex in the glabellar fold, and this developed five weeks after the injection and it lasted more than a year. The patient was treated with oral doxycycline and intralesional injection of triamcinolone acetonide; this resulted in almost complete resolution of the lesion. The patient should be informed of the potential complications with the use of injectable fillers before treatment, for it could lead to undesirable aesthetic consequences.