Hyaluronic acid skin fillers: adverse reactions and skin testing

Use of Hyaluronidase in the Treatment of Granulomatous Hyaluronic Acid Reactions or Unwanted Hyaluronic Acid Misplacement

BACKGROUND

In the past, reactions or misplacement of soft tissue fillers has been fraught with anxiety because time has been the main thrust for improvement in spite of ancillary treatments. Hyaluronidase is an enzyme that dissolves hyaluronic acid in the skin and also assists in the management of granulomatous foreign-body reactions to hyaluronic acid. These reactions may be caused by allergy to the material or immunologic response to the protein contaminants in the hyaluronic acid preparations. Dissolution of material in erroneous placement of material and in allergic reactions can be a time saver and a deterrent to patient dissatisfaction.

OBJECTIVE

To evaluate the use of hyaluronidase in the treatment of both allergic reactions and the erroneous misplacement of hyaluronic acid in the skin.

METHODS

A case of persistent granulomatous reaction to injectable hyaluronic acid and a case of hyaluronic acid erroneous misplacement with their successful subsequent treatments using intracutaneous hyaluronidase are reported, along with illustrative examples of hyaluronidase use.

RESULTS

The use of hyaluronidase reduced the patient discomfort within 24 to 48 hours, deterring any patient anxiety or patient dissatisfaction.

CONCLUSIONS

Hyaluronidase has a place in the treatment of allergic reactions to hyaluronic acid [corrected] and in the erroneous misplacement of the material.

Hyaluronic acid and its use as a "rejuvenation" agent in cosmetic dermatology

Since 1996, hyaluronic acid (HA) has been launched onto the market in Europe. Since then, different companies proposed their HAs. Biomatrix (NJ, USA) proposes an animal-derived HA (from rooster comb). Q-Med AB (Uppsala, Sweden) and LEA-DERM (Paris, France) are the main companies to have a nonanimal HA. HA is produced by bacterial fermentation from a specific strain of streptococci. HA has no species specificity and theoretically has no risk of allergy. No skin testing is necessary before injecting because HA is a biodegradable agent. To be utilized as a filler agent for improving wrinkles, scars, or increasing volumes, HA must be stabilized to obtain a sufficient half-life. Process of stabilization varies, according to each manufacturer. This explains the differences in longevity and in viscosity of the different products. Several HAs are suitable to fine lines, to deep wrinkles/folds, or to increase volume. A new indication for "rejuvenation" is injection into the superficial dermis and epidermis. The HA (stabilized or not) is not used to fill in but rather to hydrate and finally to rejuvenate the skin. This procedure must be repeated at intervals of a few weeks or months. If HA is the safest filler agent in cosmetic indications today, some rare side effects may appear and must be known to inform patients. Most of these complications are not severe and will disappear when the product is degraded.

Sterility of stored nonanimal, stabilized hyaluronic acid gel syringes after patient injection

BACKGROUND

Restylane (Restylane; Q-Medical, Uppsala, Sweden) is a nonanimal stabilized hyaluronic acid (NASHA) that has become increasingly popular for soft tissue augmentation and volume correction because of its greater longevity and lower rate of hypersensitivity reactions when compared with collagen. Despite manufacturer warnings, the remaining material in the syringe is commonly stored for subsequent treatment in the same patient.

OBJECTIVE

Our purpose was to determine the incidence of bacterial contamination of NASHA stored after initial patient injection.

METHODS

After use of a specific sterile sequence, NASHA from previously used syringes stored at room temperature for 2 to 9 months was cultured under aerobic (n = 20) and anaerobic conditions (n = 10).

RESULTS

No bacteria were cultured from any of the samples.

LIMITATIONS

Limitations of this study include sample size and storage period for a maximum of 9 months.

CONCLUSIONS

NASHA remaining in syringes after patient injection was not contaminated with bacteria. Our study raises the possibility that re-use of the remaining portion of material in the syringe may be safe and is more economical than discarding it.

The histological aspects of fillers complications

The histological aspects of resorbable heterologous fillers (bovine collagen, acid hyaluronique), autologous fillers (lipofilling, dermis-fat graft), biodegradable fillers (New-Fill), and permanent fillers (silicone, Artecoll, Evolution, Aquamid, DermaLive, DermaDeep, Bioplastique, Paraffin) are described. This article relates the morphological aspect of these materials, the normal tissue reaction after injection, and its chronological evolution as the morphological aspects from the different side effects, more frequently observed for the permanent fillers. They mainly consist of granulomatous reactions which may appear long after injection.

Scar sarcoidosis after hyaluronic acid injection

A 54-year-old woman presented with a 5-month history of tender nodules in both nasolabial folds that had developed 4 months after the injection of hyaluronic acid (HA) (Restylane) for wrinkles. The patient was treated with 1.5 mg/day betamethasone for 6 days and her lesions disappeared within 1 week. About 8 days after stopping therapy, however, new nodules developed at the same site, on previously healthy buttocks, and on old scars. On examination, nodules of about 0.5-1 cm in size were palpable at the nasolabial folds, and red nodules were present on the buttocks (Fig. 1) and on two old scars. Laboratory tests disclosed an increased protein C reaction (7.9 mg/L; normal value, < 5 mg/L) and acetyl-converting enzyme test (14.5 U/L; normal value, < 9 U/L). A chest X-ray was normal. Lung function tests showed a decreased lung CO diffusion, and chest axial tomography disclosed fibrosis, increased parenchyma density, and calcifications, findings suggestive of a diagnosis of lung sarcoidosis. An X-ray of the hands showed some bone cysts. Interestingly, two granulomatous lesions were observed at the sites of venipuncture. Histology of a gluteal lesion biopsy showed a deep granuloma with epithelioid and Langhans cells in the absence of necrobiosis. Sarcoidosis was diagnosed and the patient was given 50 mg/day prednisone with clear clinical improvement of cutaneous lesions in about 6 months. Decreased parenchyma density was also observed by chest axial tomography.

Injectable Skin Fillers

The list of injectable skin fillers available for soft tissue augmentation is constantly growing, giving aesthetic surgeons more options in the treatment of scars, lines, and wrinkles. Each type of filler is distinct with regard to intended use, placement technique, duration in tissue, ease of use, and cost. Physicians who are well acquainted with the strengths and weaknesses of each class of filler will be best equipped to use this rapidly expanding class of agents in serving their patients. The authors review the most commonly used injectable skin fillers and discuss their differences in terms of composition, source (eg, human, animal), intended use, placement technique, tissue duration (nonpermanent, semipermanent, or permanent), side effects, and specific advantages and disadvantages.

The Evolution of Soft Tissue Fillers in Clinical Practice

To remain experts in skin care and treatment, every dermatologist must be aware of the evolving role of soft tissue fillers in dermatology. Patients with facial scarring, lipodystrophy, contour abnormalities, and age- and sun-induced rhytids can be successfully treated. A literature review, industry recommendations, and the authors' experience serve to highlight fillers most appropriate for each patient's complaint. Newer agents, including the hyaluronic acids and human collagens, and long-lasting materials, such as polymethlymethracrylate and calcium hydroxlyapatite, are reviewed. This discussion of the specific risks, indications, and technical pearls for the various fillers will allow clinicians to accurately advise or treat patients.

[Soft tissue filling with hyaluronic acid]

PHYSIOLOGY AND PHARMACOLOGY: Hyaluronan was discovered by Karl Meyer in 1934 in the vitreous humor of cattle eye. Hyaluronic acid, (AH), is a natural polysaccharide and a ubiquitous component of the extra cellular matrix. It is largely biocompatible and has a short half life. In the early 1990's, preceded by the use of bovine collagen, AH started to be employed in the fields of Dermatology and Plastic Surgery; currently it is a major intervention product in both soft tissue augmentation and facial volume loss treatments. Often well tolerated, AH, has high water retention properties and is an effective tissue volumizer. Industry first attempted to extract AH from rooster comb, then through bacterial fermentation and succeeded in increasing its lifespan by cross linking. However, industrially produced AH can contain residues from the manufacturing process. It thus appears critical to us to be informed of the process used in manufacturing AH including the reticulant utilized. Manufacturers should be legally required to publish this data as well as to conduct physiochemical follow-up studies over the short, mid and long terms.

LEGAL CONSIDERATIONS

In Europe, CE marking is a prerequisite to market injectable products. However, a CE marking does not necessarily imply that the product's efficacy and side effects have been assessed objectively in clinical studies. However, this marking is expected to fall into line with the US legislation, where the marketing of any medicinal product is subject to FDA approval, based on comprehensive animal and clinical studies and on more systematic and better centralised side effect reporting. We have examined most of the products used in Europe and internationally in 2004, whether of animal or bacterial origin, reticulated or non-reticulated, and used to restore, increase volume or as a product vector. Before injecting these products, it is essential to have a thorough understanding of their absolute and relative contraindications and anaesthetic requirements, differences between types of wrinkles to fill in and indicated techniques, differences between concerned regions or tissues, and the impact of associated cosmetic treatments. These resorbable injectable products have mild and, more importantly, short-lived side effects. However, in patients with a relative contraindication, a double test is justified, as allergic reactions are known to occur in 1 to 3% of patients. It is also advisable not to inject HA in a site previously injected with a non-resorbable product. More precise statistics on results and side effects based on double-blind randomised studies are still wanting, due to the lack of legal requirement and effective centralisation of data. Therefore, all side effects must be reported to improve our knowledge as well as the safety of injections.

CONCLUSION

Although their duration of effect is limited, HA products are the most commonly used fillers, before collagens. Many questions have yet to be answered, but they produce very significant results in filling procedures. Both clinicians and patients praise these products for their tolerance, resorbable nature, and limited side effects.

Localized granulomatous reaction to a semi-permanent hyaluronic acid and acrylic hydrogel cosmetic filler

Dermalive, an injectable skin filler composed of a combination of synthetic hyaluronic acid and acrylic hydrogel particles was recently developed for soft tissue augmentation. Dermalive produces longer term results than temporary injectable fillers and is associated with a reportedly low incidence of adverse reactions. We describe a marked local reaction to the injection of Dermalive in the nasolabial fold developing within 4 months with histological confirmation of a granulomatous response. To our knowledge there has been only one previous report of a local granulomatous reaction to Dermalive.

Evaluation of the safety of a non-animal stabilized hyaluronic acid (NASHA - Q-Medical, Sweden) in European countries: a retrospective study from 1997 to 2001

BACKGROUND

In Europe, several filler devices are currently on the market for use in aesthetic dermatology and some of them cause severe, permanent, adverse reactions. Since 1996 a non-animal stabilized hyaluronic acid (NASHA) from Q-Medical, Sweden, has been introduced and is becoming a leading product in aesthetic dermatology. Hyaluronic acid has no species specificity and skin testing is not recommended before treatment.

OBJECTIVE

Our purpose was to evaluate the incidence of adverse reactions from 1997 to 2001 and the safety of NASHA after injections into the skin for aesthetic reasons.

METHOD

Surveys were sent to physicians in European countries that agreed to participate. This is a retrospective study. A total of 12 344 syringes were sold by the Q-Medical to these physicians and we evaluated the total number of patients treated to 35% of this number (4320). We separated immediate hypersensitivity reactions from delayed reactions and analysed infectious and other types of reactions.

RESULTS

From 1997 until 2001, 34 cases of hypersensitivity were reported: 16 cases of immediate hypersensitivity and 18 cases of delayed. The global risk of sensitivity is 0.8%. Since 2000, the amount of protein in the raw product has decreased and the incidence of hypersensitivity reactions is around 0.6%. As 50% of these reactions are immediate and resolved within less than 3 weeks, the risk of strong but transient, delayed reaction is around 0.3%. Four cases of abscess were reported. They were all sterile. No bacterial infection was found. Herpetic recurrence is possible after lip augmentation according to the technique of injection. No systemic reactions were reported.

CONCLUSION

NASHA is a very useful and safe filler product. Skin testing does not seem to be necessary.

Management of complications after implantation of fillers

Soft tissue augmentation is widely practised by a variety of different practitioners. A new classification of filler substances and procedures, taking into account long-term safety and reversibility of side effects, is proposed: i non-permanent and biodegradable, ii semi-permanent and biodegradable, iii permanent and reversible, iv permanent and non-reversible. Complications and adverse effects occur with all fillers and all filler procedures. Insufficient experience is an important contributory factor. Underreporting is probably common. Commonest are haematomas, ecchymoses, infections, papulopustular or acneiform lesions, non-hypersensitivity related swelling and oedema, erythema, changes in pigmentation, palpability of the implant and necrosis of overlying tissue. Specific therapeutic approaches for these complications and practical recommendations to minimize or avoid them are discussed. Hypersensitivity reactions and granuloma formation are the most distressing adverse effects. They can occur with most fillers. Mostly these hypersensitivity reactions are local granulomas but, rarely, generalized reactions also occur. Case reports of systemic reactions after injection of hyaluronic acid are documented. Treatments include steroids, minocycline and immunomodulatory agents, such as cyclosporin, tacrolimus and ascomycin. In selected cases, surgical procedures are necessary to elimirate granulomatous reactions. Implant migration and facial lipoatrophy are encountered with certain compounds. Extreme caution is therefore advocated before using permanent and non-reversible products for soft tissue augmentation. Those who use fillers need to be familiar with the complications of fillers and with the treatment of those complications.

Granulomatous foreign body reaction against hyaluronic acid: report of a case after lip augmentation

BACKGROUND

Hyaluronic acid (HA) (Restylane and Hylaform) is becoming more widely used for cosmetic procedures such as lip augmentation and treatment of facial skin lines, as other products, mainly bovine collagen, have proved allergenic in many patients.

OBJECTIVE

To report a case of a 48-year-old woman who developed discrete nodules in the lips after HA injection for lip augmentation. The histologic analysis revealed the presence of a granulomatous reaction surrounding a blue amorphous material with the tinctorial features of HA.

CONCLUSION

To our knowledge, this is the third case of granulomatous body reaction against this substance, which was allegedly inert in humans. Although rare, this reaction can have important aesthetic implications, and the patients should be informed about their risks.

Hylan G-F 20 induces delayed foreign body inflammation in Guinea pigs and rabbits

Recent clinical evidence suggests that hylan, a modified hyaluronan, and related products potentially elicit foreign body granulomatous inflammation in human soft tissue. We investigated the biocompatibility of hylan G-F 20 (Synvisc) for up to 28 days after intradermal injection in guinea pigs and intramuscular injection in rabbits. Compared to saline and unmodified hyaluronan, hylan induced definitive macroscopic changes in guinea pigs by day 14 or later and in rabbits by 28 days after injection. Histologically, at the injection sites, there was severe granulomatous inflammation in guinea pigs and acute inflammation with minimal infiltration of macrophages and foreign body giant cells in rabbits. Furthermore, specific antibodies against hylan were demonstrated in guinea pigs by passive cutaneous anaphylaxis, and substantial deposits of IgG on hylan were evident by immunohistochemistry. The present results contradict previous reports on biocompatibility of hylan and suggest that hylan may potentially induce similar unfavorable reactions in humans.

Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation

BACKGROUND

Nonanimal hyaluronic acid gel was recently developed for soft tissue augmentation and volume expansion and has been shown to offer several advantages in comparison to other augmentation materials. There are rare reports of adverse events believed to be secondary to trace amounts of proteins in the hyaluronic acid raw material.

OBJECTIVE

To determine the safety profile of nonanimal stabilized hyaluronic acid gel (Restylane, Perlane, Restylane Fine Lines, Q-Med AB, Uppsala, Sweden) for soft tissue augmentation using a retrospective review of all adverse events data from Europe, Canada, Australia, South American, and Asia from 1999 and 2000.

RESULTS

Data from an estimated 144,000 patients treated in 1999 indicated the major reaction to injectable hyaluronic acid was localized hypersensitivity reactions, occurring in approximately 1 of every 1400 patients treated. In 1999 there was an adverse event reported for 1 of every 650 patients (0.15%) treated. These were temporary events that included redness, swelling, localized granulomatous reactions, bacterial infection, as well as acneiform and cystic lesions. For 2000 there was an estimated 262,000 patients treated with hyaluronic acid gel. The total number of adverse events was 144, corresponding to one adverse event for every 1800 patients (0.06%) treated. The major adverse event was again hypersensitivity, occurring in 1 of every 5000 patients treated.

CONCLUSION

According to the reported worldwide adverse events data, hypersensitivity to nonanimal hyaluronic acid gel is the major adverse event and is most likely secondary to impurities of bacterial fermentation. According to data from 2000, the incidence of hypersensitivity appears to be declining after the introduction of a more purified hyaluronic acid raw material.