Baranska-Rybak Wioletta, Lajo-Plaza José V, Walker Lee, Alizadeh Navid
Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland.
Centro Médico Lajo-Plaza, Madrid, Spain.
Dermatol Ther (Heidelb). 2024 Jul;14(7):1767-1785. doi: 10.1007/s13555-024-01202-3. Epub 2024 Jun 22.
Hyaluronic acid (HA) dermal fillers, generally considered low-risk, can lead to rare late-onset reactions (LORs) manifesting between 3 and 4 months postinjection, occasionally even as early as 24 h postinjection. The Complication Assessment and Risk Evaluation (CARE) board was established to review these reactions. In this publication, the authors aims to explore the etiological hypotheses underlying LORs, associated risk factors, prevention, and management approaches suggested by the CARE board. The CARE board identified three etiological hypotheses contributing to LORs. Firstly, the physicochemical structure of the filler, particularly low molecular weight HA, which may trigger an immune response. Secondly, infection, potentially introduced during injection or by dormant biofilm activation. Lastly, an imbalance in the host immune system, caused by factors like autoimmune diseases or viral infections, may lead to extended foreign body reactions, delayed type IV hypersensitivity, or adjuvant-based reactions. Based on these hypotheses, the board categorized various risk factors as patient-related (e.g., recent dental treatment, current medical status, active autoimmune disease), product-related (e.g., molecular weight), and procedure-related (e.g., aseptic technique and trauma). To reduce the risk of LORs, the CARE board recommends diligent patient selection, including comprehensive medical history assessment and informed consent. Practitioners should maintain an effective aseptic technique, and choose an appropriate product and injection depth for the anatomical location. Post-procedure, patients should receive education on proper filler care. Management of LORs depends on the suspected etiology, and the CARE board has proposed an algorithm to determine the most appropriate treatment. Hyaluronidase is recommended for noninflammatory reactions in the absence of active infection, while watchful waiting and/or steroid treatment may be preferred for inflammatory reactions. Hyaluronidase is not recommended as a first-line treatment for infections, which require drainage, bacterial culture, and antibiotic treatment. However, the board emphasizes the need for individualized evaluation and treatment in all cases.
透明质酸（HA）真皮填充剂通常被认为风险较低，但可导致罕见的迟发性反应（LORs），这些反应在注射后3至4个月出现，偶尔甚至早在注射后24小时就出现。成立了并发症评估与风险评估（CARE）委员会来审查这些反应。在本出版物中，作者旨在探讨LORs背后的病因假说、相关风险因素、预防措施以及CARE委员会建议的管理方法。CARE委员会确定了导致LORs的三个病因假说。首先，填充剂的物理化学结构，特别是低分子量HA，可能引发免疫反应。其次，感染可能在注射期间或通过休眠生物膜激活而引入。最后，由自身免疫性疾病或病毒感染等因素引起的宿主免疫系统失衡，可能导致延长的异物反应、迟发型IV型超敏反应或基于佐剂的反应。基于这些假说，委员会将各种风险因素分为患者相关因素（如近期牙科治疗、当前医疗状况、活动性自身免疫性疾病）、产品相关因素（如分子量）和操作相关因素（如无菌技术和创伤）。为降低LORs的风险，CARE委员会建议谨慎选择患者，包括全面评估病史并获得知情同意。从业者应保持有效的无菌技术，并根据解剖位置选择合适的产品和注射深度。术后，应向患者提供关于正确护理填充剂的教育。LORs的管理取决于疑似病因，CARE委员会提出了一种算法来确定最合适的治疗方法。对于无活动性感染的非炎症反应，建议使用透明质酸酶，而对于炎症反应，观察等待和/或类固醇治疗可能更可取。不建议将透明质酸酶作为感染的一线治疗方法，感染需要引流、细菌培养和抗生素治疗。然而，委员会强调在所有情况下都需要进行个体化评估和治疗。
