INTRODUCTION
The use of soft tissue fillers is an increasingly popular means of rejuvenation; it was the second most common minimally invasive cosmetic procedure worldwide in 2020.1 Although fillers have a favorable safety profile,2 adverse events may still occur. One such event is the occurrence of delayed onset nodules. Although more common with permanent fillers such as polymethylmethacrylate or silicone, nodules have also been reported with non-permanent hyaluronic acid fillers.3,4
Historically, the risk of delayed onset nodules in the hands of a well-trained injector is low2,4-6 with the incidence for granulomatous reactions ranging from 0.02%-0.4%.7 However, there is a reported increase in nodule formation with the use of newer fillers with proprietary cross-linking technology.8-11
Recent publications suggest that targeting the Janus kinase (JAK) and signal transducer and activator of transcription (STAT) pathway decreases inflammation, leading to disease improvement in granulomatous diseases. One such medication is abrocitinib, a JAK inhibitor approved in the US for the treatment of refractory, moderate to severe atopic dermatitis in adults.12 In this case report, we document clinical improvement of delayed-onset nodules from filler with the use of oral abrocitinib.
CASE REPORT
A 55-year-old woman presented with a chief complaint of swelling over her cheeks and jawline 6 weeks after hyaluronic acid filler injections (Juvederm Voluma) to her zygomatic arches. The patient reported previous hyaluronic acid filler injections without complications. Past medical history included atopic dermatitis particularly affecting her face, as well as Hashimoto's thyroiditis. Prior to consulting dermatology, the patient underwent three courses of oral antibiotics (cephalexin, amoxicillin clavulanate, and clarithromycin) as well as two separate week-long courses of a methylprednisolone taper. She reported rapid improvement during steroid therapy but with rebound swelling upon completion of each taper. Concomitantly, five courses of hyaluronidase injections were also attempted, which softened and decreased the size of some but not all of the nodules. Oral antihistamines were of no benefit.
On physical examination, the patient had erythematous patches on bilateral eyelids and malar cheeks, mild swelling of the zygomatic arches and lower cheeks, and multiple firm, palpable nodules of varying sizes over the upper, mid, and lower cheeks. The patient also had dermographism at the time of her visit, and eyelid swelling.
After baseline examinations to rule out active infection, the patient was started on abrocitinib 100 mg/tab daily, fexofenadine (Allegra) 180 mg/tab twice daily, and fluticasone 0.0005% ointment for pruritus. The patient reported marked improvement in itch and reduction in swelling within 14 days of starting the abrocitinib. At the 2-month follow-up, the edema had resolved with further improvement in some of the nodules as well as pruritus (Figure 1). There was visible reduction in the
