Hyaluronic acid delayed inflammatory reaction after third dose of SARS-CoV-2 vaccine.

BACKGROUND: Treatments based on hyaluronic acid represent one of the most largely used practice of esthetic medicine. In the literature, it has already been described delayed reaction after vaccine like flu vaccine mediated by T-lymphocytes. AIM: We report three cases of dermal filler reactions following mRNA vaccination against SARS-CoV-2; all the patients had received the filler months or even years before the vaccine. PATIENTS: Patient one: A 60-year-old female patient that was treated one year ago in the lip developed swelling days after getting mRNA Pfizer Biotech vaccine. She received her booster of Pfizer vaccination one week before. Patient two: A 45-year-old female patient treated in the lip two years before developed angioedema days after getting her booster of Pfizer Biotech vaccine. In this case, it was necessary to prescribe cortisone per os. Patient three: A 40-year-old female patient treated for the nasolabial fold five months before developed erythema and edema after receiving the booster of Moderna Vaccine.
RESULTS: As demonstrated in our three case reports, even the booster of vaccine can cause delayed inflammatory reactions in patients that have previously received fillers.
CONCLUSION: Delayed inflammatory reactions in patients that have received filler in the past are uncommon and usually self-limited. Those are the first example reported in the literature of reaction after the booster dose without any previous symptoms.

INTRODUCTION

The use of hyaluronic acid filler is becoming prevalent worldwide. Most people start with this kind of procedure in a very early age, especially in the lip area.

Recently, the FDA reported adverse events in patients with dermal fillers after receiving the SARS‐CoV‐2 mRNA vaccine. For this reason, some authors suggest a window (before and after) between the SARS‐CoV‐2 vaccine and HA filler injections for the general population. This window should be longer for people who have autoimmune risk factors or immunologic disorders.

Despite that, some cases of delayed inflammatory reaction have been reported.

CASE REPORT

Patient one

A 60‐year‐old female patient who have received one years before Allergan Juvederm Ultra 3 in the lips. She developed swelling in the upper lip after five days of her third dose of Comirnaty—BioNTech/Pfizer. Her first two doses were with Oxford—AstraZeneca. She did not have any reaction with the first two doses. The patient denied any past history of allergy. The swelling gradually resolved spontaneously after three days (Figures 1 and 2).

FIGURE 1

Patient one before

FIGURE 2

Patient one after

Patient two

A 45‐year‐old female patient treated in the lips two years before with Juvederm Volift. She developed, after her Comirnaty—BioNTech/Pfizer booster, angioedema in the upper lip. The other two doses of vaccine were with Pfizer too without any dermatological symptoms. In this case, a cortisone therapy was necessary with prednisolone 25 mg for three days (Figures 3 and 4).

FIGURE 3

Patient two before

FIGURE 4

Patient two after

Patient three

A 40‐year‐old female patient treated for the nasolabial fold five months before with Juvederm Volift. She developed, after the booster with Moderna Vaccine, erythema and edema at the site of injections. The first two doses were with Comirnaty—BioNTech/Pfizer, without any reaction. We examined her for seven days with a complete resolution of the symptoms (Figures 5 and 6).

FIGURE 5

Patient three before

FIGURE 6

Patient three after

DISCUSSION

The use of dermal fillers has an increasing demand and popularity in the last few years in esthetic medicine. Usually, the procedure is quite safe and secure, although in the literature, hypersensitivity reactions have been described.

Hypersensitivity reactions can be easily classified into acute and delayed.

Acute or type I hypersensitivity reactions have an onset within minutes to hours from injection time and they are immunoglobulin‐E‐mediated.

Delayed or type IV hypersensitivity reactions can take place from 24 h to months after allergen contact. Delayed‐type hypersensitivity reaction to dermal fillers is a very rare complication that usually presents as a tender, erythematous swelling. It is a cell‐mediated hypersensitivity reaction caused by T‐lymphocytes.

In our case reports, we have delayed hypersensitivity reactions because they occur days after the vaccine.

When a reaction occurs, all the authors in the literature suggest a waiting approach, as we did in our cases except one, the second where it was necessary to take oral prednisolone for three days.

Some other authors have reported similar reaction to SARS‐CoV‐2 vaccine, but none with the booster dose without previous symptoms with the others , , , , ,

Probably, in these cases, the first two doses have activated the immune system with a reaction between the hyaluronic acid filler and the SARS‐CoV‐2 vaccine.

CONCLUSION

We have presented three cases of a COVID‐19 spike protein triggered inflammatory reaction to dermal HA filler. Prevention of delayed or type IV hypersensitivity reactions should include a thorough history and patient education and a window waiting between the vaccine and the dermal filler.

These kind of reactions are very rare, and previous fillers are not a contraindication for the SARS‐CoV‐2 vaccine.

CONFLICT OF INTEREST

The authors declared no potential conflict of interest to this article.

ETHICAL APPROVAL

The participants provide their written informed consent to participate in this study. The Declaration of Helsinki was adequately addressed.