透明质酸(HA)真皮填充剂,通常被认为是低风险的,可导致罕见的迟发性反应(LORs),表现在注射后3至4个月之间,偶尔甚至早在注射后24小时。成立了并发症评估和风险评估(CARE)委员会来审查这些反应。在本出版物中,作者旨在探索LORs背后的病因假设,相关危险因素,预防,和CARE董事会建议的管理方法。护理委员会确定了三个有助于LOR的病因假设。首先,填料的物理化学结构,特别是低分子量HA,这可能会引发免疫反应。其次,感染,可能在注射过程中或通过休眠生物膜激活引入。最后,宿主免疫系统的不平衡,由自身免疫性疾病或病毒感染等因素引起的,可能会导致长期的异物反应,迟发型IV型超敏反应,或基于佐剂的反应。基于这些假设,委员会将各种风险因素归类为与患者相关的(例如,最近的牙科治疗,医疗现状,活动性自身免疫性疾病),产品相关(例如,分子量),和程序相关(例如,无菌技术和创伤)。为了降低LOR的风险,护理委员会建议认真选择病人,包括全面的病史评估和知情同意。从业人员应保持有效的无菌技术,并为解剖位置选择合适的产品和注射深度。手术后,患者应接受适当填充护理的教育。LOR的管理取决于可疑的病因,CARE董事会提出了一种算法来确定最合适的治疗方法。透明质酸酶被推荐用于无活动性感染的非炎症反应,而观察等待和/或类固醇治疗可能是炎症反应的首选。透明质酸酶不推荐作为感染的一线治疗,需要排水,细菌培养,和抗生素治疗。然而,董事会强调在所有情况下都需要进行个性化评估和治疗。
Hyaluronic acid (HA) dermal fillers, generally considered low-risk, can lead to rare late-onset reactions (LORs) manifesting between 3 and 4 months postinjection, occasionally even as early as 24 h postinjection. The Complication Assessment and Risk Evaluation (CARE) board was established to review these reactions. In this publication, the authors aims to explore the etiological hypotheses underlying LORs, associated risk factors, prevention, and management approaches suggested by the CARE board. The CARE board identified three etiological hypotheses contributing to LORs. Firstly, the physicochemical structure of the filler, particularly low molecular weight HA, which may trigger an immune response. Secondly, infection, potentially introduced during injection or by dormant biofilm activation. Lastly, an imbalance in the host immune system, caused by factors like autoimmune diseases or viral infections, may lead to extended foreign body reactions, delayed type IV hypersensitivity, or adjuvant-based reactions. Based on these hypotheses, the board categorized various risk factors as patient-related (e.g., recent dental treatment, current medical status, active autoimmune disease), product-related (e.g., molecular weight), and procedure-related (e.g., aseptic technique and trauma). To reduce the risk of LORs, the CARE board recommends diligent patient selection, including comprehensive medical history assessment and informed consent. Practitioners should maintain an effective aseptic technique, and choose an appropriate product and injection depth for the anatomical location. Post-procedure, patients should receive education on proper filler care. Management of LORs depends on the suspected etiology, and the CARE board has proposed an algorithm to determine the most appropriate treatment. Hyaluronidase is recommended for noninflammatory reactions in the absence of active infection, while watchful waiting and/or steroid treatment may be preferred for inflammatory reactions. Hyaluronidase is not recommended as a first-line treatment for infections, which require drainage, bacterial culture, and antibiotic treatment. However, the board emphasizes the need for individualized evaluation and treatment in all cases.