We have received several calls from the industry regarding the issue of vaccination and how much time should be allowed before an injectable procedure, such as fillers or a skin penetration procedure should be performed. We are putting this to the Ministry of Health and seeking their advice, as at this stage there are no studies that can confirm a specific timeframe. However, we have been encouraged that all skin penetration procedures such as cosmetic tattooing and dermal needling that create an immune response should follow the same advice as services such as dermal fillers. In the autumn issue of APJ Journal, our editor Dr. Giulia D’Anna presented an excellent article on the issue of delayed hypersensitivity reaction. Here is an excerpt as it addresses key issues for consideration. Giulia starts by explaining the issue of delayed hypersensitivity, something that we may start to experience more of.
Delayed hypersensitivity is a reaction that can appear like an allergy, a delayed reaction occurs a week to months after the injection of filler. The dermal filler is usually completely without any concerns or complications at the time of placement, so when the hypersensitivity reaction occurs weeks to months later, it is completely spontaneous and unexpected. The reaction appears to be mediated by T-lymphocytes. There usually appears to be influenza-like symptoms that precede the reaction. It is suggested that the HA molecules in all fillers act as a foreign implant. Since HA molecules are a polysaccharide that is naturally found in the skin, the HA is not thought to be the focus of the delayed hypersensitivity. Instead, all the filler manufacturers need to modify the HA so that it is resistant to breakdown by our body. This provides longevity, structure, and predictability to the filler. The manufacturing process of the HA is where the filler differs from our innate HA, and it is hypothesized that this processing of the filler creates the seed for delayed hypersensitivity as the T-lymphocytes see these structural chains as foreign when the immune system is triggered by influenza.
A delayed hypersensitivity reaction is characterised by induration (localised hardening), erythema (redness), and oedema (swelling). It is also very important to remember that more than 2 million of these procedures are performed in the US alone every single year, and many millions more worldwide, but these reactions only occur in an extremely small group of people that develop influenza-like symptoms, and not every time they are sick.
All case reports of delayed hypersensitivity reactions contain a very small cohort of patients, and there is variation in the filler brand, position of the filler, treatment undertaken. Ideally, there would be a histological study done, but most patients are understandably resistant to this as they prefer quick and non-invasive resolution. The delayed hypersensitivity rate is believed to be around 0.42% (https://www.sciencedirect.com/science/article/pii/S2352647521000083_) of all patients treated.
Treatment varied in each study, which also makes it difficult to evaluate. Some practitioners will use the Hyaluronidase enzyme to dissolve the filler, thereby removing the allergen potential. Others use steroids to reduce the reaction. Others that have patients with milder symptoms simply wait for the immune system to settle down, and the hypersensitivity reaction appears to resolve spontaneously without treatment.
HOW DO VACCINES WORK?
Now, let’s look at how vaccines work and their potential implications for individuals who have had fillers. A pathogen is a bacterium, virus, parasite, or fungus that can cause disease within the body. Each pathogen is made up of several smaller parts, usually unique to that specific pathogen and the disease it causes. These subparts of a pathogen cause our body to produce antibodies in response. This is how we fight disease. Each new pathogen produces a new antibody.
The reason COVID-19 has been so deadly is that our bodies have never been exposed to anything like it. No one had. All of a sudden, our bodies are exposed to pathogens with no antibodies to fight them. Vaccines contain weakened or inactive parts of a particular pathogen, and this will trigger an immune response within the body. So, before you are ever exposed to the actual pathogen, your body has prepared antibodies that are on standby for the real assault. Some vaccines, such as the Pfizer vaccine, require multiple doses so that the antibodies develop and are long-lived. Occasionally, some vaccines have a more widespread effect on susceptible people. Those people react as though they are ill. I am sure that we have all heard people complain that they got the flu after a flu vaccine, and maybe they did. This is their immune system putting up a strong fight against being inoculated with a foreign antigen.
It makes sense that any challenge to the immune system, will raise the level of activity in our immune system, this is an expected and desired sequela to vaccination. This can lead to “chills”, feeling generally unwell, and so on. What has been reported after COVID-19 vaccines have been delivered is that a very small cohort of patients that have previously had dermal filler may have experienced a delayed hypersensitivity reaction in the treated areas.
Why do I say, may have experienced a reaction? Because the data at this stage is poor. There are no statistics behind how many people that have had the vaccine have had fillers, and those with delayed hypersensitivity type reactions did not have a biopsy. At present, the presentation of the delayed hypersensitivity reactions following the COVID-19 vaccine appears to be consistent with the presentation of other virus-initiated hypersensitivity reactions. Those that have had influenza-like symptoms in the past and those with post-COVID-19 vaccination hypersensitivity appear the same. This is not a new phenomenon.
THE AUSTRALIAN SITUATION
In Australia, we are in the position of being able to see both the Pfizer and Moderna vaccines being delivered to overseas populations before it is rolled out here. Again, the data that we are seeing in terms of the rollout delayed hypersensitivity, and dermal filler injections are very sporadic and limited. None of the patients that have been inoculated were asked on the medical history forms whether they had dermal filler. These questions were asked once the hypersensitivity reaction occurred. I am sure that there will be more data that will be disclosed as more of the population overseas and eventually in Australia are treated. There is some suggestion to wait 4-8 weeks between filler treatment and vaccination so that as the immune system reacts to the vaccine, there is no further challenge from dermal filler being injected, and vice versa. Additionally, in the extremely small cohort of patients that have had the COVID-19 vaccine and experienced dermal filler delayed hypersensitivity reactions, the vaccine appears to be effective at the same level as in those that have had no reaction.
WHAT ABOUT OTHER SKIN-PENETRATION PROCEDURES?
At this stage, the advice we have been given is to wait 4-8 weeks if someone has been vaccinated before performing a skin-penetration procedure. This will allow for any potential reactions or delayed hypersensitivity reaction to run it’s course without possible association to the procedure you have given them. If we gain further updates, we will keep you informed.