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Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm

Authors Artzi O, Cohen JL, Dover JS, Suwanchinda A, Pavicic T, Landau M, Goodman GJ, Ghannam S, Al Niaimi F, van Loghem JAJ, Goldie K, Sattler S, Cassuto D, Lim TS, Wanitphakdeedecha R, Verner I, Fischer TC, Bucay V, Sprecher E, Shalmon D

Received 26 January 2020

Accepted for publication 18 April 2020

Published 18 May 2020 Volume 2020:13 Pages 371—378


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Editor who approved publication: Dr Jeffrey Weinberg

Ofir Artzi,1,2 Joel L Cohen,3 Jeffrey S Dover,4– 6 Atchima Suwanchinda,7,8 Tatjana Pavicic,9 Marina Landau,10 Greg J Goodman,11 Sahar Ghannam,12 Firas Al Niaimi,13 Jani AJ van Loghem,14 Kate Goldie,15 Sonja Sattler,16 Daniel Cassuto,17 Ting Song Lim,18 Rungsima Wanitphakdeedecha,19 Ines Verner,20,21 Tanja C Fischer,22,23 Vivian Bucay,24 Eli Sprecher,1,2,25 Dana Shalmon1,2

1Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3AboutSkin Dermatology and AboutSkin Research, , Greenwood Village and Lone Tree, CO, USA; 4SkinCare Physicians, Chestnut Hill, MA, USA; 5Dermatology, Yale University School of Medicine, New Haven, CT, USA; 6Dermatology, Brown Medical School, Rhode Island, USA; 7Department of Dermatology, School of Anti-Aging and Regenerative Medicine, Mae Fah Luang University, Bangkok, Thailand; 8Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 9Private Practice for Dermatology and Aesthetics Dr. Tatjana Pavicic, Munich 80539, Germany; 10Dermatology, Private Practice, Herzliya, Israel; 11Monash University, Clayton, Victoria, Australia; 12Associate Prof. of Dermatology, Alexandria University, Alexandria, Egypt; 13 152, Harley street, London, UK; 14UMA Institute, Amsterdam 1017, TX, Netherlands; 15Medical Director European Medical Aesthetics Ltd, London W1G 8QN, UK; 16Rosenpark Klinik, Darmstadt, Germany; 17Private Practice, Milan, Italy; 18Clique Clinic, Kuala Lumpur, Malaysia; 19Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; 20Verner Clinic, Tel Aviv, Israel; 21Department of Dermatology, University of Rome, Guglielmo Marconi, Italy; 22Skin and Laser Center, Potsdam, Germany; 23School of Medicine, University of Frankfurt, Germany; 24Bucay Center for Dermatology and Aesthetics, UTHSC, San Antonio, TX, USA; 25Department of Human Molecular Genetics & Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Correspondence: Ofir Artzi
Tel Aviv Sourasky Medical Center, Weizman 6, Tel Aviv, Israel
Tel +972-54-5968961
Fax +972-77-2001801

Background and Objectives: There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose.
Materials and Methods: A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists.
Results: Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3– 6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement.
Conclusion: A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.

Keywords: cosmetic techniques, dermal fillers/adverse effects, hyaluronic acid/adverse effects

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