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Agnieszka Owczarczyk-Saczonek, Natalia Zdanowska, Ewa Wygonowska, Waldemar Placek Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, Warmia and Mazury Universities in Olsztyn, Poland Newsletter: Agnieszka Owczarczyk-Saczonek, Dermatology, Sex Department of Transmitted Diseases and Clinical Immunology, Warmia and Mazury University, Olsztyn, Poland. Wojska Polskiego 30, Olsztyn, 10-229, PolishTel +48 89 6786670 Fax +48 89 6786641 Email [email protected] Abstract: Hyaluronic acid (HA) is a glycosaminoglycan, a natural component of the extracellular matrix. The same structure of molecules in all organisms is its main advantage, because it has the least chance of being transformed into immunogenicity. Therefore, due to its biocompatibility and stability at the implantation site, it is the closest ideal formulation to be used as a filler. This article includes a discussion of the underlying mechanism of HA’s adverse immune response, as well as the response mechanism after vaccination against SARS-CoV-2. According to the literature, we tried to systematize the adverse immune response with systemic manifestations into HA. The occurrence of unpredictable reactions to hyaluronic acid suggests that they may not be considered neutral or non-allergenic. Changes in the HA chemical structure, additives, and individual tendency in patients may be the cause of unpredictable reactions, leading to serious health consequences. Preparations of unknown origin, poor purification or containing bacterial DNA are particularly dangerous. Therefore, long-term follow-up of patients and selection of FDA or EMA approved preparations are very important. Patients often do not know the consequences of cheaper operations performed by people without proper knowledge using unregistered products, so the public should be educated and laws and regulations should be introduced. Keywords: Hyaluronic acid, fillers, delayed inflammation, autoimmune/auto-inflammatory adjuvant-induced syndrome, SARS-CoV-2
Hyaluronic acid (HA) is a glycosaminoglycan, a natural component of the extracellular matrix. It is produced by dermal fibroblasts, synovial cells, endothelial cells, smooth muscle cells, adventitia cells and oocytes and released into the surrounding extracellular space. 1,2 The same structure of molecules in all organisms is its main advantage, which is associated with the smallest risk of immunogenicity. The biocompatibility and stability of the implantation site make it an almost ideal choice for the entire filler series. Due to the mechanical expansion of the tissue after injection and subsequent activation of skin fibroblasts, it has the significant advantage of being able to stimulate the production of new collagen. 2-4 Hyaluronic acid is highly hydrophilic, has the special characteristics of binding water molecules (more than 1000 times its own weight), and forms an extended conformation with a huge volume compared to the weight. It can also form condensation even at very low concentrations. glue. It causes the tissues to quickly hydrate and increase the volume of the skin. 3,5,6 In addition, skin moisturizing and the antioxidant potential of hyaluronic acid can promote skin cell regeneration and stimulate collagen production. 5
Over the years, it has been observed that the popularity of cosmetic procedures using substances such as HA has continued to increase. According to data from the International Society of Aesthetic Plastic Surgery (ISAPS), more than 4.3 million cosmetic procedures were performed using HA in 2019, an increase of 15.7% compared to 2018. The American Society of Dermatology (ASDS) reports that dermatologists performed 2.7 million dermal filler injections in 2019. 8 The implementation of such procedures is becoming a very profitable form of paid activity. Therefore, due to the lack of laws and regulations in many countries/regions, more and more people provide such services, but usually do not have sufficient training or qualifications. In addition, there are competitive formulations on the market. They may be cheaper, of lower quality, and have not been approved by the FDA or EMA, which is a risk factor for the development of new types of adverse reactions. According to research conducted in Belgium, most of the 14 suspected illegal samples contained much less product than specified on the packaging. 9 Many countries have gray areas of illegal cosmetic procedures. In addition, these procedures are not registered and no taxes payable are paid.
Therefore, there are many reports of adverse events in the literature. These adverse events usually lead to considerable diagnosis and treatment problems and unpredictable consequences for patients. 7,8 Hypersensitivity to hyaluronic acid is particularly important. The pathogenesis of some reactions has not been fully elucidated, so the terminology in the literature is not uniform, and many consensuses on the management of complications have not yet included such reactions. 10,11
This article includes data from the literature review. Identify the articles evaluated by searching PubMed using the following phrases: hyaluronic acid, fillers, and side effects. The search continues until March 30, 2021. Found 105 articles and analyzed 42 of them.
Hyaluronic acid is not organ or species specific, so it can be assumed that it does not cause allergic reactions. 12 However, it is important to remember that the injected product also includes additives, and hyaluronic acid is obtained through bacterial biosynthesis.
It has also been demonstrated that individual propensities can cause patients with HLA-B*08 and DR1*03 haplotypes to have the risk of delayed, immune-mediated adverse reactions related to dermal fillers. This combination of HLA subtypes is associated with an almost four-fold increase in the likelihood of adverse reactions (OR 3.79). 13
Hyaluronic acid exists in the form of multiparticulates, its design is simple, but it is a multifunctional biomolecule. The size of HA affects the opposite effect: it may have pro-inflammatory or anti-inflammatory properties, promote or inhibit cell migration, and activate or stop cell division and differentiation. 14-16 Regrettably, there is no consensus on the split of HA. The term for molecular size. 14,16,17
When using HMW-HA products, it is worth remembering that natural hyaluronidase triggers its degradation and promotes the formation of LMW-HA. HYAL2 (anchored on the cell membrane) cleaves high molecular weight HA (>1 MDa) into 20 kDa fragments. In addition, if HA hypersensitivity starts, inflammation will promote its further degradation (Figure 1).
In the case of HA products, there may be some differences in the definition of molecular size. For example, for a group of Juvederm products (Allergan), molecules >500 kDa are considered LMW-HA, and >5000 kDa – HMW-HA. It will affect the improvement of product safety. 18
In some cases, low molecular weight (LMW) HA may cause hypersensitivity 14 (Figure 2). It is considered a pro-inflammatory molecule. It is abundantly present in active tissue catabolism sites, for example, after injury, it triggers inflammation by affecting Toll-like receptors (TLR2, TLR4). 14-16,19 In this way, LMW-HA promotes the activation and maturation of dendritic cells (DC) and stimulates various types of cells to produce pro-inflammatory cytokines, such as IL-1β, IL-6, IL-12, TNF-α and TGF-β, controls the expression of chemokines and cell migration. 14,17,20 LMW-HA may act as a danger-related molecular model (DAMP) to initiate innate immune mechanisms, similar to bacterial proteins or heat shock proteins. 14,21 CD44 serves as a form of receptor pattern recognition for LMW-HA. It exists on the surface of all human cells and may interact with other ligands such as osteopontin, collagen, and matrix metalloproteinases (MMP). 14,16,17.
After the inflammation subsides and the remnants of the damaged tissue are eliminated by macrophages, the LMW-HA molecule is removed by CD44-dependent endocytosis. In contrast, chronic inflammation is associated with an increase in the amount of LMW-HA, so they can be regarded as natural biosensors of tissue integrity status. 14,20,22,23 The role of the CD44 receptor of HA has been demonstrated in studies on the regulation of inflammation under in vivo conditions. In mouse models of atopic dermatitis, anti-CD44 treatment inhibits the development of conditions such as collagen-induced arthritis or skin damage. twenty four
High molecular weight (HMW) HA is common in intact tissues. It inhibits the production of pro-inflammatory mediators (IL-1β, IL-8, IL-17, TNF-α, metalloproteinases), reduces TLR expression and regulates angiogenesis. 14,19 HMW-HA also affects the function of macrophages responsible for regulation by stimulating their anti-inflammatory activity to improve local inflammation. 15,24,25
The total amount of hyaluronic acid in a person weighing 70 kg is about 15 grams, and its average turnover rate is 5 grams per day. About 50% of the hyaluronic acid in the human body is concentrated in the skin. Its half-life is 24-48 hours. 22,26 Therefore, the half-life of unmodified natural HA before it is rapidly cleaved by hyaluronidase, natural tissue enzymes and reactive oxygen species is only about 12 hours. 27,28 The HA chain was developed to extend its stability and produce larger and more stable molecules, with a longer residence time in the tissue (about several months), and with similar biocompatibility and viscoelastic filling properties. 28 Crosslinking involves a higher proportion of combined HA with low molecular weight molecules and a lower proportion of high molecular weight HA. This modification changes the natural conformation of the HA molecule and may affect its immunogenicity. 18
Cross-linking mainly involves the cross-linking of polymers to form covalent bonds, mainly including (-COOH) and/or hydroxyl (-OH) skeletons. Certain compounds can promote crosslinking, such as 1,4-butanediol diglycidyl ether (BDDE) (Juvederm, Restylane, Princess), divinyl sulfone (Captique, Hylaform, Prevelle) or diepoxy octane (Puragen ). 29 However, the epoxy groups of BDDE are neutralized after reacting with HA, so only trace amounts of unreacted BDDE (<2 parts per million) can be found in the product. 26 Cross-linked ha hydrogel is a highly adaptable material that can lead to the formation of 3D structures with unique properties (rheology, degradation, applicability). These features promote the easy distribution of the product and at the same time stimulate the production of molecular components of the extracellular matrix. 30,31<>
In order to increase the hydrophilicity of the product, some manufacturers add other compounds, such as dextran or mannitol. Each of these additives may become an antigen that stimulates the immune response.
Currently, HA preparations are produced from specific strains of Streptococcus through bacterial fermentation. (Streptococcus equi or Streptococcus zooepidemicus). Compared with previously used animal-derived preparations, it reduces the risk of immunogenicity, but it cannot eliminate the contamination of protein molecules, bacterial nucleic acids and stabilizers. They may become antigens and stimulate the host’s immune response, such as hypersensitivity to HA products. Therefore, filler production technologies (such as Restylane) focus on reducing product contamination. 32
According to another hypothesis, the immune response to HA is caused by inflammation caused by bacterial biofilm components, which are transferred to the tissues when the product is injected. 33,34 Biofilm is composed of bacteria, their nutrients and metabolites. It mainly includes the main non-pathogenic bacteria that colonize healthy skin or mucous membranes (for example, Dermatobacterium acnes, Streptococcus oralis, Staphylococcus epidermidis). These The strain has been confirmed by the polymerase chain reaction test. 33-35
Due to their unique slow-growing characteristics and their variants called small colonies, it is often difficult to identify pathogens in culture. In addition, their metabolism in the biofilm may be slowed down, which helps to avoid the effects of antibiotics. 35,36 In addition, the ability to form the extracellular matrix of extracellular polysaccharides (including HA) is a preventive factor for phagocytosis. These bacteria may stay dormant for many years, then be activated by external factors and trigger a reaction. 35-37 Macrophages and giant cells are usually found in the vicinity of these microorganisms. They may be rapidly activated and induce an inflammatory response. 38 Certain factors, such as bacterial infections with bacterial strains that are similar in composition to biofilms, may activate dormant microorganisms through mimicry mechanisms. Activation may be due to damage caused by another dermal filler procedure. 38
It is difficult to distinguish between inflammation and delayed hypersensitivity caused by bacterial biofilms. If a red sclerotic lesion appears at any time after surgery, regardless of the duration, the biofilm should be suspected immediately. 38 It may be asymmetrical and symmetrical, and it may sometimes affect all locations where HA is administered during surgery. Even if the culture result is negative, a broad-spectrum antibiotic with good penetration into the skin should be used. If there are fibrous nodules with increasing resistance, it is likely to be a foreign body granuloma.
HA may also stimulate inflammation through the mechanism of superantigens. This response does not require the initial stages of inflammation. 12,39 Superantigens trigger 40% of initial T cells and possibly NKT clonal activation. The activation of these lymphocytes leads to a cytokine storm, which is characterized by the release of large amounts of pro-inflammatory cytokines, such as IL-1β, IL-2, IL-6 and TNF-α40.
Severe pneumonia, often accompanied by severe respiratory failure, is an example of a pathological response to bacterial superantigen (staphylococcal enterotoxin B), which increases LMW-HA produced by fibroblasts in lung tissue. HA stimulates the production of IL-8 and IP-10 chemokines, which play an important role in recruiting inflammatory cells to the lungs. 40,41 Similar mechanisms have been observed in the course of asthma, chronic obstructive pulmonary disease and pneumonia. The increase in COVID-19.41 LMW-HA production leads to overstimulation of CD44 and the release of pro-inflammatory cytokines and chemokines. 40 This mechanism can also be observed in inflammation caused by biofilm components.
When the filler production technology was not so precise in 1999, the risk of delayed reaction after HA injection was determined to be 0.7%. After the introduction of high-purity products, the incidence of such adverse events dropped to 0.02%. 3,42,43 However, the introduction of HA fillers that combine high and low HA chains resulted in higher AE percentages. 44
The first data on such reactions appeared in a report on the use of NASHA. This is an erythema and edema reaction, with infiltration and edema in the surrounding area lasting up to 15 days. This reaction was observed in 1 of 1400 patients. 3 Other authors have reported longer lasting inflammatory nodules, occurring in 0.8% of patients. 45 They emphasized the etiology related to protein contamination caused by bacterial fermentation. According to the literature, the frequency of adverse reactions is 0.15–0.42%. 3,6,43
In the case of applying the time standard, there are many attempts to classify the adverse effects of HA. 46
Bitterman-Deutsch et al. classified the causes of adverse reactions and complications after surgery with hyaluronic acid-based preparations. They include
The expert group tried to define the response to hyaluronic acid based on the time of appearance after surgery: “early” (<14 days), “late” (>14 days to 1 year) or “delayed” (>1 year). 47-49 Other authors divided the response into early (up to one week), intermediate (duration: one week to one month), and late (more than one month). 50 Currently, late and delayed responses are considered as one entity, called delayed inflammatory response (DIR), because their causes are usually not clearly defined and treatments are not related to the cause. 42 The classification of these reactions can be proposed based on the literature (Figure 3).
Transient edema at the injection site immediately after surgery may be due to the histamine release mechanism in patients prone to type 1 allergic reactions, especially those with a history of skin diseases. 51 It is only a few minutes after administration that the mast cells are mechanically damaged and release pro-inflammatory mediators to cause tissue edema and wind mass formation. If a response involving mast cells occurs, a course of antihistamine therapy is usually sufficient. 51
The greater the skin damage caused by cosmetic surgery, the greater the edema, which may even progress to 10-50%. 52 According to randomized double-blind multicenter patient diaries, the frequency of edema after Restylane injection is estimated to be 87% of the study 52,53
The areas on the face that seem to be particularly prone to edema are the lips, periorbital and cheek areas. 52 In order to reduce the risk, it is recommended to avoid the use of large amounts of fillers, infiltration anesthesia, active massage and highly hygroscopic preparations. Additives (mannitol, dextran). 52
Edema at the injection site lasting several minutes to 2-3 days may be caused by the hygroscopicity of HA. This reaction is usually observed in the perilip and periorbital area. 49,54 should not be mistaken for edema caused by a very rare mechanism of immediate allergic reaction (angioedema). 49
After the injection of Restylane (NASHA) in the upper lip, a case of hypersensitivity to angioedema was described. However, the patient also took 2% lidocaine, which may also trigger type I hypersensitivity reactions. Systemic administration of corticosteroids caused the edema to subside within 4 days. 32
The rapidly evolving reaction may be due to hypersensitivity to the protein residue contamination of HA synthesizing bacteria. The interaction between the injected HA and the remaining mast cells in the tissue is another mechanism to clarify the immediate response phenomenon. The CD44 receptor on the surface of mast cells is the receptor for HA, and this interaction may be important for their migration. 32,55
Treatment includes immediate use of antihistamines, systemic GCS, or epinephrine. 46
The first report, published by Turkmani et al., described women aged 22-65 who had undergone HA surgery produced by different companies. 39 The skin lesions are manifested by erythema and painful edema at the filler injection site on the face. In all cases, the response begins 3-5 days after flu-like illness (fever, headache, sore throat, cough, and fatigue). In addition, all patients had received HA administration (2 to 6 times) in the 4 years before symptoms appeared on different parts of the face. 39
The clinical presentation of the described reaction (erythema and edema or urticaria-like rash with systemic manifestations) is similar to type III reaction-a pseudoserum sickness reaction. Unfortunately, there are no reports in the literature that confirm this hypothesis. A case report describes a patient with a rash-like lesion during Sweet syndrome, which is a pathological sign that appears 24-48 hours after the HA administration site. 56
Some authors believe that the mechanism of the reaction is due to type IV hypersensitivity. The previous HA injection stimulated the formation of memory lymphocytes, and the subsequent administration of the preparation quickly triggered a response of CD4+ cells and macrophages. 39
The patient received oral prednisolone 20-30 mg or methylprednisolone 16-24 mg daily for 5 days. Then the dose was reduced for another 5 days. After 2 weeks, the symptoms of the 10 patients who received oral steroids completely disappeared. The remaining four patients continued to have mild edema. Hyaluronidase is used for one month after the onset of symptoms. 39
According to the literature, many delayed complications may occur after injection of hyaluronic acid. However, each author classified them based on clinical experience. A unified term or classification has not been developed to describe such adverse reactions. The term continuous intermittent delayed swelling (PIDS) was defined by Brazilian dermatologists in 2017. 57 Beleznay et al. introduced another term to describe this pathology in 2015: delayed onset nodule 15,58 and Snozzi et al: advanced inflammatory response syndrome (LI). 58 Another term was proposed in 2020: delayed inflammation Reaction (DIR). 48
Chung et al. emphasized that DIR includes four types of reactions: 1) DTH reaction (correctly called: delayed type IV hypersensitivity reaction); 2) foreign body granuloma reaction; 3) biofilm; 4) atypical infection. DTH reaction is a delayed cellular immune inflammation, which is a response to allergens. 59
According to different sources, it can be said that the frequency of this reaction is variable. Recently published a paper written by Israeli researchers. They assessed the number of adverse events in the form of DIR based on the questionnaire. The questionnaire was completed by 334 doctors who gave HA injections. The results showed that almost half of the people were not diagnosed with DIR, and 11.4% responded that they had observed this reaction more than 5 times. 48 In the registration test to assess safety, the reactions triggered by the products produced by Allergan have been well documented. Approximately 1% of 103 patients monitored 24 months after taking Juvederm Voluma® reported similar reactions. 60 During the 68-month retrospective review of 4702 surgeries, 0.5% of patients observed similar response patterns in 2342 patients using Juvederm Voluma®. 15 A higher percentage was observed when Juvederm Volbella® products were used in the tear groove and lip area. After an average of 8 weeks, 4.25% (n=17) had recurrences that lasted up to 11 months (average 3.17 episodes). 42 The latest analysis of more than one thousand patients undergoing Vycross treatment for a 2-year follow-up with fillers showed that the incidence of delayed nodules was 1%. 57 Chung et al.’s response frequency to the report is very critical. According to calculations in prospective studies, the incidence of delayed inflammatory reactions was 1.1% per year, while in retrospective studies, it was less than 1% during the period from 1 to 5.5 years. Not all reported cases are actually DIR because there is no precise definition. 59
Delayed inflammatory response (DIR) secondary to the administration of tissue filler occurs at least 2-4 weeks or later after the injection of HA. 42 The clinical manifestations are in the form of recurrent episodes of local solid edema, accompanied by erythema and tenderness, or subcutaneous nodules at the HA injection site. 42,48 The nodules may be warm to the touch, and the surrounding skin may be purple or brown. Most patients have reactions in all parts at the same time. In the case of having used HA before, regardless of the type of filler or the number of injections, it is an important factor that reflects the clinical manifestations. 15,39 Skin lesions are more common in people who have previously injected large amounts of HA. 43 In addition, the accompanying edema is most obvious after waking up, and it improves slightly throughout the day. 42,44,57 Some patients (~40%) have concomitant systemic flu-like manifestations. 15
These reactions may be related to the contamination of DNA, protein, and bacterial endotoxin, even if the concentration is much lower than that of HA. 15 However, LMW-HA may also be present in genetically susceptible individuals directly or through related infectious molecules (biofilms). 15,44 However, the appearance of inflammatory nodules at a certain distance from the injection site, the resistance of the disease to long-term antibiotic treatment and the exclusion of infectious pathogens (cultivation and PCR testing)) question the role of biofilms. In addition, the effectiveness of hyaluronidase treatment and the dependence on HA dose indicate the mechanism of delayed hypersensitivity. 42,44
The response due to infection or injury leads to an increase in serum interferon, which may exacerbate pre-existing inflammation. 15,57,61 In addition, LMW-HA stimulates CD44 or TLR4 receptors on the surface of macrophages, dendritic cells. It activates them and delivers costimulatory signals to T cells. 15,19,24 Inflammatory nodules associated with DIR occur within 3 to 5 months after injection of HMW-HA filler (with anti-inflammatory properties), which then decompose and transform into LMW- with pro-inflammatory properties HA. 15
The onset of the reaction is most often triggered by another infection process (sinusitis, urinary tract infection, respiratory infection, tooth infection), facial injury, and dental surgery. 57 This reaction was also caused by vaccination and recurred due to menstrual bleeding. 15, 57 Each episode may be caused by infectious triggers.
Some authors have also described the genetic predisposition of individuals with the following subtypes to respond: HLA B * 08 or DRB1 * 03.4 (four-fold increase in risk). 13,62
DIR-related lesions are characterized by inflammatory nodules. They should be distinguished from nodules, abscesses (softening, fluctuations), and granulomatous reactions (hard inflammatory nodules) caused by biofilms. 58
Chung et al. propose to use HA products for skin testing before the planned procedure, although the time required to interpret the test results may even be 3-4 weeks. 59 They specifically recommend such tests in people who have had adverse events. I’ve noticed before. If the test is positive, the patient should not be treated again with the same HA filler. However, it may not eliminate all reactions because they are usually caused by triggers, such as concomitant infections that may occur at any time. 59
Post time: Jul-27-2021