Conflict of interest
None.
Dear Editor,
Dermatologists have questioned the possibility of continuing hyaluronic acid (HA) injections during the COVID‐19 pandemic period, fearing especially an increase in immune complications. Therefore, the Group for Aesthetic and Corrective Dermatology of the French Society of Dermatology (gDEC) decided to set up a prospective, clinical study over the period May to July 2020 to follow a large patient cohort being injected with HA during the COVID‐19 pandemic.
Overall, 14 dermatologists working in France, Belgium and Switzerland participated in the study. Each physician included all patients during the observation period that received facial HA injections. Participating physicians were encouraged to treat all patients according to their usual practice. Due to the COVID‐19 pandemic, the hygiene measures were reinforced by the use of hydroalcoholic gel of physician and patient and the practitioners wearing a FFP2 masks at all times during the patient encounters. All products injected were commercially available within Europe and were purchased by the physicians.
Two types of side‐effects were recorded: (i) patient self‐reported side‐effects at any time of the study, (ii) side‐effects discovered during the systematic follow‐up by the treating physician at 1 and 3 months after the treatment.
A total of 1093 patients were included. Overall, 1927 syringes of HA were used, i.e. an average of 1.8 syringes per patient. 921 and 873 patients were reached, respectively, for the 1‐ and 3‐month systematic follow‐up. Ten patients with COVID‐19 infection were injected later than 2 months after their infection. Five patients were diagnosed with an active COVID‐19 infection within 3 months after their HA injection. 19 (1.7%) side‐effects were reported, three self‐reported and 16 (84% of side effect) observed at systematic follow‐up. The recorded side‐effects were those frequently associated with HA filler injections like erythema, oedema and temporary discomfort. They were all self‐resolving within a few days and occurred in the absence of symptoms suggestive of COVID‐19 infection. No further serious or unexpected side‐effects were reported. A summary of the results can be found in Table 1.
Table 1.
Tolerance of hyaluronic acid injections during the COVID‐19 pandemic period
| Number of patients injected | 1093 |
| Number of syringes injected | 1927 |
| Number of patients reached at 1 months | 921 |
| Number of patients reached at 3 months | 873 |
| Number of patients injected with previous COVID‐19 | 10 |
| Number of patients injected by COVID‐19 between first and third month after injection | 5 |
| Physician or patient COVID‐19 infection just after injection | 0 |
| Immediate self‐reported side effect | 3 |
| Discomfort + erythema + oedema | 1 |
| Oedema only | 2 |
| Immediate side effects on patients reached | 16 |
| Discomfort + erythema + oedema | 10 |
| Oedema only | 2 |
| Ecchymosis | 4 |
| Delayed self‐reported side effects at 1 or 3 months | 0 |
| Delayed side effects on patients reached at 1 or 3 months | 0 |
This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.
Our study shows an excellent tolerance of HA injections during the COVID‐19 pandemic. No immune complications, that usually are triggered by viral or bacterial infections 1 , 2 were reported. Most studies show that immediate and delayed immune HA complications are relatively quick to appear and are rare 2 months after the injection. 3 A few case reports document granuloma formation in patients injected with HA after receiving therapeutic cytokine (interferon) injections. 4 In this context, it is feared that COVID‐19 infections, known to cause sometimes a ‘cytokine storm’, lead to an increase in immune complications during the current COVID‐19 pandemic. Data collected by André, Beleznay and Humphrey 1 , 2 , 5 before the current sanitary crisis found a frequency of immune complications of 0.8%, 0.5% and 0.93%, respectively. Other smaller studies 3 reported comparable rates of immune complications. Based on these data, the expected number of patients with immune complications can be expected to be within five to 10 patients in our cohort; however, we did not find any immune complications. It is possible that due to the additional hygiene measures that physicians implemented in this study and the generally increased hygiene measures in the population at large, we may observe a reduction in viral and bacterial infectious disease and with this also a reduction in immune complications.
Our prospective study with a systematic follow‐up at 1 and 3 months of over 1000 patients did not reveal any unexpected side‐effects in the context of facial hyaluronic acid injections during the COVID‐19 pandemic. Particularly, immune response‐related complications were not observed in our entire study population.
Acknowledgements
None.
References
- 1. Andre P. Evaluation of the safety of a non‐animal stabilized hyaluronic acid (NASHA ‐ Q‐Medical, Sweden) in European countries: a retrospective study from 1997 to 2001. J Eur Acad Dermatol Venereol. 2004; 18: 422–425. 10.1111/j.1468-3083.2004.00934.x. [DOI] [PubMed] [Google Scholar]
- 2. Beleznay K, Carruthers JD, Carruthers A, Mummert ME, Humphrey S. Delayed‐onset nodules secondary to a smooth cohesive 20 mg/mL hyaluronic acid filler: cause and management. Dermatol Surg 2015; 41: 929–939. [DOI] [PubMed] [Google Scholar]
- 3. Alijotas‐Reig J, Garcia‐Gimenez V. Delayed immune‐mediated adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers: clinical findings, long‐term follow‐up and review of the literature. J Eur Acad Dermatol Venereol 2008; 22: 150–161. [DOI] [PubMed] [Google Scholar]
- 4. Descamps V, Landry J, Francès C, Marinho E, Ratziu V, Chosidow O. Facial cosmetic filler injections as possible target for systemic sarcoidosis in patients treated with interferon for chronic hepatitis C: two cases. Dermatology 2008; 217: 81–84. [DOI] [PubMed] [Google Scholar]
- 5. Humphrey S, Jones DH, Carruthers JD et al. Retrospective review of delayed adverse events secondary to treatment with a smooth, cohesive 20‐mg/mL hyaluronic acid filler in 4500 patients. J Am Acad Dermatol 2020; 83: 86–95. [DOI] [PubMed] [Google Scholar]