BC07: Self-injected fillers: a case of severe pustular reaction with a review of the scale of the problem

M. Wynne,¹ A. Shajahan,² M. de Brito,¹ B. Kaur,¹ K. McAlister² and T. Griffiths³

¹Department of Dermatology, East Lancashire Teaching Hospitals and ²Department of Maxillo-Facial Surgery, East Lancashire Teaching Hospitals, Lancashire, UK; and ³Department of Dermatology, Salford Royal Hospital NHS Foundation Trust, Manchester, UK

A 45-year-old woman with no past medical history presented with pain and swelling the day after using an internet-bought 0·5 mL ‘hyaluron pen’. She self-treated her cheeks, lips, glabella and nasolabial fold, having performed a test patch on her left hand. Examination revealed oedema, erythema and pustules draining from all treated sites, coalescing to form an ulcer on the right cheek. She was admitted under the maxillofacial surgical team, who initiated intravenous (IV) co-amoxiclav, 40 mg oral prednisolone and analgesia. On the second day of admission, she received 3000 units (U) of Hyalase to all sites, with a further 2000 U 2 days later. Twenty-four hours after the second treatment, her pustules had resolved and her oedema had improved but erythema persisted. She remained systemically and biochemically well, and no pathogenic organisms were cultured from multiple swabs. She received 7 days of IV co-amoxiclav followed by a further 5 days of oral co-amoxiclav. Her prednisolone was continued at 40 mg for 7 days, weaning by 5 mg per week. She was discharged with follow-up after 8 days. Initially designed for insulin administration, jet-injection devices emerged in the cosmetic industry in 2018. Hyaluronic acid pens, also known as ‘Hyaluron pens’, are marketed as needleless devices, using pressure to self-deliver dermal fillers without pain. While they are classified as medical devices by the Medicines and Healthcare products Regulatory Agency (MHRA), they are not prescription-only medications as recommended by the British Association of Dermatologists (https://www.bad.org.uk/shared/get-file.ashx?id=1258&itemtype=document). This means they can legally be used by nonmedically trained personnel in the UK and are not required to detail their constituents except on the packaging. Complications of clinician-delivered injectable fillers are well documented in the medical literature. However, a literature review of complications after self-injection of facial dermal fillers revealed only three cases and none of the severity seen in this case (Rauso R, Nicoletti GF, Zerbinati N et al. Complications following self-administration of hyaluronic acid fillers: literature review. Clin Cosmet Investig Dermatol 2020; 13: 767–71). A lack of expertise of anatomy, procedural planning and aseptic technique increases the risk of complications, which are likely under-reported. We believe this case further highlights fundamental flaws in cosmetic regulations in the UK, which inevitably put patients at risk.