Safety and Efficacy of Dermal Fillers in Patients With Connective Tissue Disease: A Review

Abstract

BACKGROUND Dermal fillers such as hyaluronic acid, poly-l-lactic acid, and polymethyl-methacrylate are often used to treat cutaneous defects such as lipoatrophy. However, concern exists regarding their use in patients with a connective tissue disease (CTD) because of a theoretical risk of disease reactivation or exacerbation. Evidence regarding their use in patients with CTD also remains limited. OBJECTIVE This review intends to summarize and evaluate the available literature regarding the use of dermal fillers in patients with CTD. MATERIALS AND METHODS A literature search until May 2020 was conducted through PubMed, Ovid MEDLINE, and Ovid Embase to identify articles discussing the treatment of cutaneous defects secondary to CTD. Articles discussing the use of autologous fat transfer alone were excluded. RESULTS Twenty-three articles were reviewed. The amount of available evidence varies between the type of CTD and type of filler with morphea having the most published evidence out of the CTDs discussed and hyaluronic acid having the most published evidence out of the fillers discussed. Most studies demonstrated positive results with no report of disease reactivation or exacerbation. CONCLUSION Despite limited available evidence, dermal fillers seem to be safe as an adjunctive treatment for cutaneous defects in patients with CTD.

Novel use of poly‐L‐lactic acid filler for the treatment of facial cutaneous atrophy in patients with connective tissue disease

“…Of note, the previously mentioned articles discussing the use of HA fillers in scleroderma and the use of PLLA fillers in other CTDs showed no serious adverse effects to any patients aside from one patient with rheumatoid arthritis who developed severe ulcerations and multiple inflamed nodules on 12 months after receiving PLLA injections 1,4‐8,10 8,10 . Similar to previous reports, our patients whose disease states were stable, although not necessarily inactive, did not experience worsening or progression of their disease after PLLA injections even after months to years of follow‐up.…”

“…1,[4][5][6][7][8]10 While this may sound concerning, no disease reactivation was noted, and 12 non-CTD patients in the same trial developed similar complications as a side effect of PLLA filler with the study also finding that these effects can be more easily avoided with safer dilution practices. 8,10 Similar to previous reports, our patients whose disease states were stable, although not necessarily inactive, did not experience worsening or progression of their disease after PLLA injections even after months to years of follow-up. While Patient #3 did report nodularity, this soon resolved even without significant treatment with this patient also exhibiting the most significant improvement.…”

“…1 While a recent review summarizes how several types of fillers, including hyaluronic acid (HA), calcium hydroxyapatite, and PLLA, have all successfully been used in the treatment of a variety of CTDs with minimal side effects, it also highlights the dearth in available literature and the huge need for further research into safe treatments for facial cutaneous defects in this cohort. 8 For example, the only articles determining the efficacy of fillers F I G U R E 2 Patient 2 frontal October 2018 (top left), frontal after (top right), lateral October 2018 (bottom left), lateral after (bottom right); injections made to the mid-and lower face resulting in no significant improvement for scleroderma are two small studies that employed the use of HA filler. 1,9 With regard to PLLA filler, again only a few small studies have incorporated their use for CTDs, specifically in patients with morphea, LEP, Parry-Romberg syndrome, and rheumatoid arthritis (RA), and no published articles exist regarding their use in patients with scleroderma or CREST syndrome.…”

“…1,5,11 However, there is a growing body of evidence that these risks are largely theoretical in patients whose disease is well controlled at the time of treatment. 4,5,7,8 It is also unknown whether immunosuppressive medications may diminish response to PLLA as the mechanism of action is via an inflammatory reaction that promotes the endogenous production of collagen. 3 Of note, the previously mentioned articles discussing the use of HA fillers in scleroderma and the use of PLLA fillers in other CTDs showed no serious adverse effects to any patients aside from one patient with rheumatoid arthritis who developed severe ulcerations and multiple inflamed nodules on 12 months after receiving PLLA injections.…”

“…The most notable barrier toward more widespread use of fillers for treatment of CTD is theoretical concern for disease exacerbation or reactivation 1,5,11 . However, there is a growing body of evidence that these risks are largely theoretical in patients whose disease is well controlled at the time of treatment 4,5,7,8 . It is also unknown whether immunosuppressive medications may diminish response to PLLA as the mechanism of action is via an inflammatory reaction that promotes the endogenous production of collagen 3 .…”