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LETTER
Infectious complications after hyaluronic acid injections—Two
case reports
Dear Editor
As the number of cosmetic procedures performed increases, there is
also an increase in the number of side effects. Among them are infec-
tious complications, which can be divided into early and late. Most
often, they are of bacterial or viral origin.
We present two case reports with infectious complications after
hyaluronic acid injections.
First patient, a 54-year-old female presented to the Emergency
Department (ER) on October 16, 2021, with a fever of 38C, itchy,
erythematous lesions on the face, tender to the touch, with increased
warmth and consistency. Past medical history included atopic derma-
titis, bronchial asthma, urticaria, and Hashimoto's disease.
Five days before admission to the ER, on October 11, she was
administered hyaluronic acid in the area of the nasolabial folds by a
beautician. The initial symptoms appeared 4 h post-procedure. At the
admission to the ER, laboratory tests revealed a decreased level of
lymphocytes (0.68 [10
9
/l]), an increased level of neutrophils (7.63
[10
9
]), a rise in C Reactive Protein (CRP levels 53 mg/dl), and anti-
streptolysin O (ASO) was 420 IU/ml. Performed pharyngeal swab
revealed Streptococcus group C. Based on the clinical picture and
additional tests, the diagnosis of erysipelas of the face was made.
Therefore, she was prescribed Penicillin 1000 mg twice daily. On
November 10, 2021, all symptoms have resolved.
Two months post-injection, in mid-December 2021, the second
episode occurred. The patient reported similar symptoms to those dur-
ing the first admission. (Figure 1) Since that was her second episode of
erysipelas, the patient was instructed to take Penicillin 1000 mg twice
daily for the following 6 months. In February 2022, ASO decreased to
197.4 IU/ml and the patient remains asymptomatic.
The second patient is a 42-year old female, without diagnosed
chronic diseases and with no history of allergic reactions. She
reported three transient swelling of the infraorbital area along with
the upper and lower lips. (Figure 1) Over the last 4 years, these places
were injected with hyaluronic acid several times—tear trough filler
(total volume =2.8 ml), lip augmentation (total volume =1.5 ml), as
well as nasolabial fold filler (total volume =1.0 ml).
Each episode occurred 3–6 months post HA injection starting in
August 2019, during infection of the throat and tonsils with accompa-
nying fever. Two to three days after the onset of the throat infection
symptoms, the patient would experience a feeling of distension
around the lips and infraorbital area. The physical examination
revealed no accompanying redness, increased warmth, or tenderness
on palpation. The swelling would resolve spontaneously after 3 days
each time, with only cool compresses applied to the infraorbital and
lip area.
Infectious complications such as cellulitis, abscess formation,
and other may occur when injecting dermal fillers due to a tempo-
rarily disrupted skin barrier. Erysipelas is an acute inflammation of
the skin that is prone to recur in the lower limbs, face, and other
areas. It is often caused by β-hemolytic streptococci group A (Strep-
tococcus pyogenes).
1
Erysipelas presents as an acute onset of local
inflammation and tender erythema with a sharp border to the unaf-
fected skin. Several studies discussed recurrent erysipelas,
2–4
none-
theless, to our knowledge our patient is the first case report of
recurrent erysipelas of the face as a complication after hyaluronic
acid injection.
Late-onset inflammatory reactions are uncommon complications
that may arise post injections with hyaluronic acid fillers. Their course
is rather unpredictable and can present weeks to months after treat-
ment. However, the exact mechanism is not fully understood and is
yet to be established. Nonetheless, the origin might be infectious,
immune-mediated, and related to filler properties, trauma, or injection
technique (filler volume, number of treatments). It may also be linked
to a flu-like illness or COVID-19 infections.
5–7
Delayed hypersensitivity reaction to HA post infection is rela-
tively scarce. Hypersensitivity type IV, initiated by T-lymphocytes
andmediatedbyCD4+cells, is proposed to be the underlying
cause of delayed swelling of hyaluronic acid fillers.
6
In our case
report, the most credible trigger seems to be a throat infection.
Furthermore, Homsy et al. presented two patients with an immune-
mediated delayed hypersensitivity after sore throat
8
;however,
unlike our patient, medical intervention was required to relieve
symptoms.
To conclude, complications after hyaluronic acid injections can
occur at any time after the procedure, however, the biggest risk of
infection arises during the procedure. Practitioners are responsible to
screen patients for potential risk factors by collecting a thorough medi-
cal history and performing a physical examination. Hypersensitivity
reaction is a potential risk for each patient undergoing hyaluronic acid
dermal filler injection since systemic infections are inevitable. No clini-
cal studies investigated this problem yet, hence management is often
challenging.
AUTHOR CONTRIBUTIONS
Conceptualization: Wioletta Bara
nska-Rybak and Zuzanna
´
Swierczewska. Patients' data: Natallia Romanowska and Wioletta
Received: 28 April 2022 Revised: 13 June 2022 Accepted: 31 July 2022
DOI: 10.1111/dth.15752
Dermatologic Therapy. 2022;35:e15752. wileyonlinelibrary.com/journal/dth © 2022 Wiley Periodicals LLC. 1of3
https://doi.org/10.1111/dth.15752
