Herpes Zoster as a Differential Diagnosis for Ischemia after Facial Hyaluronic Acid Filler.

The use of hyaluronic acid (HA) fillers for facial rejuvenation has grown widely and is now one of the most performed noninvasive cosmetic procedures. Viral infections can occur, albeit rarely. This report describes a 65-year-old female patient with significant fat tissue loss in the malar region who developed herpes zoster after receiving HA filler for facial volumization. We performed volumization with a total of 2mL of HA in one session. Two days after the procedure, the patient began feeling mild pain in the malar region bilaterally and in the right side of the nasolabial fold. Upon physical examination, vesicles and erythema were observed. Due to the possibility of herpes zoster virus (HZV) infection, the patient was treated with valacyclovir. Ultrasonography with arterial and venous Doppler study revealed normal blood flow in the angular artery path and adequate positioning of the filler. After seven days of valacyclovir, the patient had complete resolution of the lesions. Herpes virus reactivation can be caused by direct axon damage by the needle, by tissue manipulation, and by inflammatory reaction. Herpes simplex virus (HSV) is the virus most commonly involved and its incidence does not exceed 1.45 percent of the complication cases, and HZV is even rarer. Reactivation of HZV might mimic tissue ischemia. Ultrasonography is a noninvasive, fast, and useful tool to evaluate vascular impairment and the positioning of the filler.