Making Sense of Late Tissue Nodules Associated With Hyaluronic Acid Injections.

BACKGROUND: The pathogenesis of delayed-onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain. OBJECTIVES: To formulate a rational theory for DTN development and their avoidance and treatment. METHODS: A multidisciplinary and multicountry DTN consensus panel was established, with 20 questions posed and consensus sought. Consensus was set at 75% agreement. RESULTS: Consensus was reached in 16 of 20 questions regarding the pathogenesis of DTNs, forming the basis for a classification and treatment guide. CONCLUSIONS: The group believes that filler, pathogens, and inflammation are all involved in DTNs and that DTNs most likely are infection initiated with a variable immune response. Injected filler may incorporate surface bacteria, either a commensal or a true pathogen, if the skin barrier is altered. The initially high molecular weight HA filler is degraded to low molecular weight HA (LMWHA) at the edge of the filler. Commensals positioned within the filler bolus may be well tolerated until the filler is degraded and the commensal becomes visible to the immune system. LMWHA is particularly inflammatory in the presence of any local bacteria. Commensals may still be tolerated unless the immune system is generally heightened by viremia or vaccination. Systemic pathogenic bacteremia may also interact with the filler peripheral LMWHA, activating Toll-like receptors that induce DTN formation. Given this scenario, attention to practitioner and patient hygiene and early systemic infection treatment deserve attention. Classification and treatment systems were devised by considering each of the 3 factors-filler, inflammation, and infection-separately.

Why we should be avoiding periorificial mimetic muscles when injecting tissue fillers.

BACKGROUND: Tissue fillers are generally safe and well tolerated by patients. However, complications do occur and may be very severe, such as intravascular injection (with occasional residual tissue loss, visual and neurological sequelae) and late nodularity and swelling. Methods to lessen the likelihood of complications have been the subject of much recent literature. Depth of injection has been identified as a key safety consideration. PATIENTS/METHODS: The role of injection of facial filler into the muscular layer of the face is explored in this article. Literature was explored using available search facilities to study the role of injections in or around this layer in the production of significant adverse reactions. RESULTS: A body of literature seems to suggest that injection into mimetic musculature of the face especially the musculature in the periorbital and perioral regions is prone to adverse reactions. CONCLUSIONS: Injection of agents into the perioral and periorbital mimetic muscular layer may produce, product clumping, displacement, and tendency to late nodularity and swelling. It also risks intravascular injection as compared to injection of other layers of the face. Injection into the mimetic muscles especially the sphincteric muscles should be avoided to minimize the risk of complications.

Lichen striatus following solarium exposure.

Two cases of lichen striatus occurring after solarium exposure are presented. Both patients were adult females who regularly attended a solarium prior to the development of their skin lesions. A 19-year-old woman attended the solarium twice weekly for 8 weeks prior to the appearance of lichen striatus on the chest and epigastrium. The condition resolved completely with the twice daily application of calcipotriol ointment for 6 months. The second patient, a 40-year-old woman, attended the solarium once weekly for 3 months before lichen striatus developed on the abdomen. She was treated with clobetasol propionate ointment, calcipotriol ointment and intralesional triamcinolone acetonide and the eruption cleared 7 months after onset. The histopathological picture in both patients supported a diagnosis of lichen striatus.

Warts are not merely blemishes on the skin: A study on the morbidity associated with having viral cutaneous warts.

Eighty-five people aged 2-76 years with 250 common and plantar warts were followed prospectively for 9 months. The majority (57; 67%) had one to two warts. Of the 54 subjects who had a past history of warts, 41 (75.9%) had sought treatment for them. Twenty-four (58.5%) said that treatment had been unsuccessful; 22 (53.7%) experienced pain during their treatment; 14 (34.1%) said that treatment had been inconvenient; nine (22%) required multiple treatments; and eight (19.5%) said the treatment resulted in the development of scars. The quality-of-life assessment related to their current warts revealed that 81.2% were moderately to extremely embarrassed by them; 70.5% were moderately to extremely concerned about negative appraisal by others for having them; 24.7% said that it was moderately to extremely difficult to play sport because of their warts. Moderate to severe discomfort from their warts occurred in 51.7% of people and 35.4% said they had moderate to severe pain. During the 9-month study period, 27 (31.8%) of the participants had at least one wart regress spontaneously with 49 (19.6%) of the 254 warts regressing during that time. These data confirm the impression that a wart is not merely a blemish on the skin. Warts have the potential to cause considerable morbidity at times; this should be taken into account when a patient asks for treatment.

Subacute cutaneous lupus erythematosus presenting in a child.

A 5-year-old girl presented in summer with an erythematous, scaly annular eruption in a malar distribution. She had no symptoms or signs of systemic lupus erythematosus. A diagnosis of subacute cutaneous lupus erythematosus was made on the basis of the clinical and histological features, positive anti-Ro antibody and a mildly elevated erythrocyte sedimentation rate. All other investigations, including complement studies, were normal. She has responded well to treatment with 0.5% alclometasone ointment and photoprotection.