Cushing’s Likely Result of Glucocorticoid Use After Facial Fillers

Cushing's Likely Result of Glucocorticoid Use After Facial Fillers

Prolonged use of glucocorticoids to reduce inflammation triggered by facial dermal filler procedures likely caused Cushing’s syndrome in a 45-year-old woman, a case report describes.

Long-term use of glucocorticoids should be avoided in such cases in favor of alternative treatments, its author noted.

The report, “Case report of possible iatrogenic Cushing’s disease with low-dose prednisone to treat dermal filler hypersensitivity,” was published in the Journal of Cosmetic Dermatology.

Dermal fillers are a popular nonsurgical procedure to improve the appearance of wrinkles and fine lines. Hyaluronic acid — currently the most commonly used filler — is injected below the skin.

The procedure is considered safe, yet rare complications may occur, such as facial swelling. This results from a delayed inflammatory reaction, but it may occur immediately or within months after a procedure.

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Although the exact causes of facial swelling are poorly understood, treatment generally includes using topical or systemic (acting in the whole body) glucocorticoids to suppress the inflammatory reaction. These medications can safely be used in controlled doses, but overusing them can lead to complications.

A researcher from Brazil described a case of Cushing’s syndrome associated with a delayed inflammatory response due to a facial dermal filler procedure. The patient, a 45-year-old woman with no known diseases and taking no medications underwent two dermal filler procedures.

In the first, she received a hyaluronic acid-based lip filler. The injection, containing 2 mL of filler, was performed by a physician.

The woman was pleased with the results and a month later opted for a full-face filler procedure by a dentist. In it, 10 mL of filler targeting the nose, cheekbone, the area immediately under the eyes, and chin were treated. Her lips were treated with an additional one mL. The woman was again satisfied with the results.

Reaction to injections, then to glucocorticoid

Twenty days after the second procedure, she showed signs of facial swelling. A delayed inflammatory reaction to hyaluronic acid was suspected and she was prescribed the glucocorticoid prednisolone (5 mg, once a day).

Within three days of treatment, the swelling diminished significantly. The woman was told that if facial swelling persisted, removing the injected fillers might be required.

Ten days after stopping prednisolone, her facial swelling returned. Despite medical advice to have the procedure reversed, the woman refused and continued prednisolone treatment. For more than two months and despite using prednisolone, she had multiple swelling episodes.

After two months of prednisolone, she developed two masses in the neck, one on each side, and started complaining of muscle weakness and fatigue. She consulted a maxillofacial surgeon who considered the symptoms to be consistent with a potential case of iatrogenic Cushing’s syndrome — a form of Cushing’s triggered by certain medications — in this case, overusing prednisolone.

A reversal procedure was performed wherein hyaluronidase, an enzyme that breaks down hyaluronic acid, was injected in her face, resulting in a clear reduction in swelling. Three days after the procedure, the woman developed numbness in her cheeks, but this was resolved within a week after the treatment.

A CT scan showed cervical lymph node enlargement, corresponding to the neck masses, but no signs of tumor masses.

Around 40 days after the reversal procedure and with no glucocorticoid use, both neck masses disappeared and her fatigue resolved. No additional treatments were necessary.

Despite the generally safe profile of dermal fillers, reports of complications are increasing and the causes for these reactions, such as delayed inflammation, should be explored, the researcher wrote, noting professionals don’t recommend using different filler brands in the same region and during the same session as it can trigger complications.

“Combination of different brands of dermal fillers must be extremely avoided, notably in the same session,” the researcher wrote, adding that treating delayed inflammation with long-term glucocorticoids is not appropriate. “In case of persistence, intralesional hyaluronidase is the safer alternative. Written consent is mandatory for dermal filler procedures to alert the risks.”

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