title: Delayed-onset nodules secondary to a smooth cohesive 20 mg/mL hyaluronic acid filler: cause and management.
abstract: BACKGROUND
  The shift from 2- to 3-dimensional soft tissue augmentation has allowed the development of hyaluronic acid (HA) fillers, which are long lasting and also reversible. Delayed-onset inflammatory nodules have recently been reported with the use of HA fillers.
  
  
  OBJECTIVE
  The authors document their experience with delayed-onset nodules after 3-dimensional facial injection of Juvéderm Voluma (HA-V) over 68 months.
  
  
  METHODS
  The authors conducted a retrospective chart review of patients who were treated with HA-V between February 1, 2009, and September 30, 2014, to evaluate for delayed-onset nodules.
  
  
  RESULTS
  Over 68 months, 4,702 treatments were performed using 11,460 mL of HA-V. Twenty-three patients (0.5%) experienced delayed-onset nodules. The median time from injection to reaction was 4 months, and median time to resolution was 6 weeks. Nine of the 23 (39%) had an identifiable immunologic trigger such as flu-like illness before the nodule onset. In the authors' experience, prednisone, intralesional corticosteroids, and hyaluronidase were effective treatments.
  
  
  CONCLUSIONS
  Although delayed nodules are uncommon from HA-V (0.5%), it is important to be aware of this adverse effect and have a management protocol in place. It is the authors' opinion from the patients' responses and from the literature that these nodules are immune mediated in nature.
authors.affiliation: Departments of *Dermatology and Skin Science, and †Ophthalmology and Visual Science, University of British Columbia, Vancouver, British Columbia, Canada; ‡Department of Psychiatry and Behavioral Health, University of North Texas Health Science Center, Fort Worth, Texas; §Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas.
authors.forename: Katie
authors.initials: K
authors.lastname: Beleznay
authors.forename: Jean D A
authors.initials: JD
authors.lastname: Carruthers
authors.forename: Alastair
authors.initials: A
authors.lastname: Carruthers
authors.forename: Mark E
authors.initials: ME
authors.lastname: Mummert
authors.forename: Shannon
authors.initials: S
authors.lastname: Humphrey
mesh_terms: D000328:Adult; D000368:Aged; D003357:Cosmetic Techniques / Q000009:adverse effects*; D003879:Dermatologic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D003875:Drug Eruptions / Q000188:drug therapy / Q000209:etiology* / Q000276:immunology; D005148:Facial Dermatoses / Q000139:chemically induced* / Q000188:drug therapy / Q000276:immunology; D006801:Humans; D006820:Hyaluronic Acid / Q000008:administration & dosage / Q000009:adverse effects*; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors; D055815:Young Adult
chemical_list: D003879:Dermatologic Agents; C000596435:Juvederm VOLUMA; D006820:Hyaluronic Acid