Injection of thin face is a nerve regulator that can reduce facial wrinkles by temporarily relaxing the facial muscles that cause skin wrinkles. Skin filler is the second common non surgical injection product used to treat age-related soft tissue loss, sunken scars, facial shaping and contour.
Case report
A 28 year old female has swelling of the jaw. Three months before the swelling, she received hyaluronic acid (HA) chin injection in the clinic. She went to another local clinic and received oral antibiotics for two weeks, but her symptoms did not improve.
Physical examination revealed swelling, induration, pain and tenderness in the jaw. As far as the medical history is concerned, she has no history of skin disease or local contact. Foreign body reaction (a kind of cross-linked collagen tissue between tissues, mixed with hyaluronic acid) was shown in biopsy samples extracted from the lesions. Based on these findings, she was diagnosed as allergic to hyaluronic acid and received injections of hyaluronidase, systemic corticosteroids, antihistamines and clindamycin. Symptoms improved within 7 days. Outpatient follow-up is conducted every four weeks, and there is no recurrence so far.
Figure: The patient's chin is swollen
Materials and methods
The database of PubMed will not be searched in detail until September 2019. The following search terms are used to obtain all relevant English literature: allergy, beauty injection, hyaluronic acid, face slimming injection, microneedle injection, allergic reaction, immune reaction and non inflammatory reaction. Further evaluate articles with full text access. The inclusion and exclusion criteria are shown in the following figure. Results Fourteen articles were selected for data extraction.
Table: Search Criteria and Exclusion Criteria
Table: Data extracted from 14 articles
Patient characteristics
There were 57 patients, including 2 men and 55 women, aged between 27 and 70 years. Past medical history: 2 cases of allergic rhinitis, 1 case of breast cancer and lymphocytic colitis, 1 case of hypothyroidism, 1 case of endometriosis, 1 case of arthritis and 1 case of hypertension.
Figure: Age of 57 allergic patients
Among 57 patients, 3 cases were sensitized by injection of thin face, 3 cases were hypersensitive by microneedle, and 46 cases were hypersensitive by hyaluronic acid. In addition, 5 patients were allergic to collagen, polyacrylamide, paraffin, hyaluronidase and alkylimide (see the table below).
Table 2: Number of allergic cases caused by facial injection
Clinical analysis of injection of face slimming
The injection site of face thinning: eyebrow, orbicularis oculi and frontal muscle in 1 case; Forehead and eyebrow 1 case; Masseter muscle 1 case. Allergies occurred 5 times~36 hours after injection, and the main symptoms were redness and itching at the injection site. All three patients had local anesthesia test, which was negative. The main treatment is antihistamines and cortisol. The prognosis is quite satisfactory.
Table: Data of patients with injection allergy
Clinical analysis Microacupuncture treatment
All cases were injected into the whole face with microneedles. Vitamin C was injected in 2 cases and skin gel in 1 case. Allergic symptoms are facial erythema, rash and swelling, which occur several days to weeks after surgery. Two patients received vitamin C patch test, 96 cases were positive at h, and three patients underwent skin biopsy, and the results were foreign body granuloma. The main treatment is antihistamine and tetracycline. There were 2 cases of residual erythema.
Table: Data of patients treated with micro acupuncture
Clinical analysis of patients injected with hyaluronic acid filler
46 patients received hyaluronic acid filling injection. Medical history: hypothyroidism in 1 case, endometriosis in 1 case. 10 patients received multi site injection. There were 14 cases of lacrimal groove injection, 11 cases of chin injection, 8 cases of lip injection, 8 cases of puppet pattern injection, 6 cases of nasolabial groove injection, 5 cases of eyebrow injection, 3 cases of nasal injection, 3 cases of cheek injection, 2 cases of mandibular injection, and 1 case of forehead injection.
Table: Injection site for patients with hyaluronic acid allergy
Hypersensitivity symptoms were swelling (37 cases), induration (31 cases) and pain (5 cases) in the injection area. Time of occurrence of allergic symptoms: 83% of patients had symptoms within 1 to 12 months after injection, 2% of patients had symptoms within 1 month after injection, 9% of patients had symptoms more than 1 year after injection, and 6% of patients did not know.
Table: Main allergy symptoms
Table: Time of hypersensitivity reaction
Twenty three patients received skin biopsy, and the results showed foreign body reaction (cross-linked collagen tissue or amorphous non inflammatory mass between tissues, mixed hyaluronic acid). 7 cases were treated with antihistamine, and no 6 cases. Hyaluronidase injection was performed in 11 cases, glucocorticoid therapy in 12 cases, antibiotic or antiviral therapy in 9 cases, and surgical resection in 1 case. In patients receiving hyaluronidase injection or surgical removal of filler, the improvement was 91.7%. However, in patients without filler removal, the improvement was 58.3% (as shown in the figure). The prognosis of 11 cases was unknown, 34 cases improved after treatment (4~20 months), and 1 case had no treatment.
Table: HA Hypersensitivity Treatment Results
Analysis of patients with other fillers
Collagen, polyacrylamide, paraffin, alkylimide and hyaluronidase were used in 5 patients without special medical history. Nasolabial groove injection was performed in 3 cases, nasal tip injection in 1 case, and cheek and temple injection in 1 case. One patient received a positive skin test and histopathological biopsy (see the table below), which showed cell edema and lymphocyte infiltration. One patient received antibiotics, and one patient received cortisol and antihistamines. The prognosis was increased in 2 cases, and unknown in 3 cases.
Table: Data of patients injected with other fillers
Analyze the cause of allergic reaction
There are two possible ingredients that can cause allergic reactions: injection of protein and gelatin contained in the face slimming preparation. The more complex the protein contained in the preparation, the higher the possibility of allergy. Secondly, gelatin is the commonly used pharmaceutical solvent in the injection of face slimming preparations. According to the research report, gelatin can cause degranulation of mast cells due to mast cells in some people.
According to a few reports, the allergic reaction caused by microneedle belongs to type IV hypersensitivity reaction. The application of local products in microneedle therapy can introduce immunogen particles into high-quality sources, and enhance local or systemic allergic reactions.
The nodules caused by injection of hyaluronic acid filler have acute and delayed reactions.
The acute reaction usually occurs within 48 hours after injection, and usually shows local swelling and skin changes. Delayed reaction occurs more than two weeks after injection, and local induration usually occurs at the injection site, which can be further divided into non inflammatory or inflammatory induration.
Acute reaction is considered as a non allergic chronic inflammatory reaction, which is mainly caused by immune reaction. Erythema, edema, sclerotic papules, nodules and/or itching are the clinical features of delayed allergy. The causes of allergies seem complicated. In addition, like many diseases, infection itself is one of the causes of delayed hypersensitivity (such as tuberculin), and foreign body granuloma is one of its clinical manifestations.
Therefore, the relationship between infection, foreign body granuloma and immune mediated delayed hypersensitivity is complex. They may not only be different diseases coexisting with other types of delayed response. Infection and foreign body granuloma reaction may also be part of the pathophysiological process of delayed allergy, and its specific mechanism needs further study.
It is recommended to diagnose allergic reaction
Detailed consultation and physical examination are necessary for the diagnosis of allergy. Symptoms and signs are helpful to make a clear diagnosis and have special significance in guiding the selection of treatment plans. The use of ultrasound imaging helps to determine the properties of these materials, and to show their exact location, and whether they violate the basic structure, but it is not as accurate as MRI.
Biopsy will help determine the diagnosis. Delayed hypersensitivity in histology is manifested as foreign body granuloma or reaction. What needs to be determined is the pathological manifestations of long-term fillings. The pathological manifestations of paraffin tissue are cystic spaces of different sizes and shapes, which extend to subcutaneous fat and cause lobular vasculitis. Silica granuloma and paraffin granuloma can sometimes appear as non birefringent translucent particles.
