Derm Topics

Post-Hyaluronic Acid Filler Reaction Treated With Abrocitinib: A Case Report


Post-hyaluronic acid filler nodules are uncommon, unpredictable complications that present a challenge to clinical therapy. JDD authors Miyahra Haniko P. Lopez MD MBA, Sophie H. Guenin MSc, Jennifer Laborada BS, and Mark G. Lebwohl MD report a case of a female in her fifties who developed edema and nodules 6 weeks after hyaluronic acid (HA) filler injection. After minimal improvement with oral steroids and intralesional hyaluronidase, a trial of oral abrocitinib was initiated, which yielded significant clinical improvement. Thus, abrocitinib may be a novel therapeutic option for delayed-onset nodules following injection of hyaluronic acid.


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.



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 width of the patient’s face and swelling at both the zygomatic arches and in the submalar regions of her face (Figure 1).
Hyaluronic Acid Filler


Late-onset nodules post-filler injections are an uncommon and unpredictable complication. The pathophysiology for this phenomenon remains unclear — multiple mechanisms have been implicated including protein impurities left over from the bacterial fermentation process9 and biofilm formation.7,13 Recently, it has been proposed that the breakdown of the cross-linking components used to stabilize the filler may lead to an immunologic reaction and subsequent granuloma formation.8,10,11,14

Although nodules may resolve over time without intervention, the typical standard of care for persistent nodules includes oral and intralesional steroids, antibiotic therapy, and hyaluronidase injections. Other novel measures to manage nodules include the use of lasers15 as well as energy-based devices.16 Definitive management of recalcitrant nodules includes surgical removal or incision and drainage.2,7

Abrocitinib reversibly inhibits the Janus kinase 1 (JAK1) enzyme by blocking the adenosine triphosphate binding site.12 JAK inhibitors have been shown in recent reports to reduce inflammation and granuloma formation.17,18 In an open-label clinical trial (n=15), 10 patients with cutaneous sarcoidosis demonstrated marked improvement in their skin, and even complete response (n=6), after 6 months of tofacitinib 5 mg twice daily.19 Similarly, significant improvement was seen in 5 patients on tofacitinib for severe, recalcitrant granuloma annulare.20 Tofacinitib is also a therapeutic option for ulcerative colitis, gaining FDA approval in 2018. Other considerations included the patient’s desire for medical management as well as ease of oral intake. Abrocitinib has a low incidence of adverse effects, including hematologic toxicity and dose-dependent lipid abnormalities.


JAK inhibitors offer a promising targeted treatment for granulomatous disorders. However, to our knowledge, the use of JAK inhibitors for reactions to fillers has not been documented in the literature; thus, our case offers unique insight and the potential to expand our therapeutic armamentarium. Its oral route and short half-life make JAK-1 inhibitors an appealing novel therapeutic option. The study of its use in granulomatous diseases can progress our understanding of its therapeutic potential.



JDD authors thank the patient for providing permission for this case report.



    1. ISAPS-Global-Survey_2020.pdf. Accessed August 17, 2022. https://www. 
    2. Signorini M, Liew S, Sundaram H, et al. Global aesthetics consensus: avoidance and management of complications from hyaluronic acid fillers: evidence- and opinion-based review and consensus recommendations. Plast Reconstr Surg. 2016;137(6):961-971. doi:10.1097/PRS.0000000000002184 
    3. Humphrey et al. – 2020 – Retrospective review of delayed adverse events sec.pdf. Accessed August 17, 2022. ii=S0190-9622%2820%2930152-3 
    4. Ledon JA, Savas JA, Yang S, Franca K, Camacho I, Nouri K. Inflammatory nodules following soft tissue filler use: a review of causative agents, pathology and treatment options. Am J Clin Dermatol. 2013;14(5):401-411. doi:10.1007/s40257-013-0043-7 
    5. Andre P. Evaluation of the safety of a non-animal stabilized hyaluronic acid (NASHA – Q-Medical, Sweden) in European countries: a retrospective study from 1997 to 2001. J Eur Acad Dermatol Venereol. 2004;18(4):422-425. doi:10.1111/j.1468-3083.2004.00934.x 
    6. Modarressi A, Nizet C, Lombardi T. Granulomas and nongranulomatous nodules after filler injection: Different complications require different treatments. J Plast Reconstr Aesthet Surg. 2020;73(11):2010-2015. doi:10.1016/j.bjps.2020.08.012 
    7. Abduljabbar MH, Basendwh MA. Complications of hyaluronic acid fillers and their managements. J Dermatol Dermatol Surg. 2016;20(2):100-106. doi:10.1016/j.jdds.2016.01.001 
    8. Sadeghpour M, Quatrano NA, Bonati LM, Arndt KA, Dover JS, Kaminer MS. Delayed-onset nodules to differentially crosslinked hyaluronic acids: comparative incidence and risk assessment. Dermatol Surg. 2019;45(8):1085-1094. doi:10.1097/DSS.0000000000001814 
    9. Artzi O, Loizides C, Verner I, Landau M. Resistant and recurrent late reaction to hyaluronic acid-based gel. Dermatol Surg. 2016;42(1):31-37. doi:10.1097/ DSS.0000000000000562 
    10. Beleznay K, Carruthers JDA, Carruthers A, Mummert ME, Humphrey S. Delayed-onset nodules secondary to a smooth cohesive 20 mg/mL hyaluronic acid filler: cause and management. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2015;41(8):929-939. doi:10.1097/DSS.0000000000000418 
    11. Humphrey S, Jones DH, Carruthers JD, et al. Retrospective review of delayed adverse events secondary to treatment with a smooth, cohesive 20-mg/mL hyaluronic acid filler in 4500 patients. J Am Acad Dermatol. 2020;83(1):86-95. doi:10.1016/j.jaad.2020.01.066 
    12. Cibinqo (abrocitinib) [prescribing information]. New York, NY: Pfizer Labs; January 2022. Published online January 2022. Accessed September 9, 2022. 
    13. Alhede M, Er O, Eickhardt S, et al. Bacterial biofilm formation and treatment in soft tissue fillers. Pathog Dis. 2014;70(3):339-346. doi:10.1111/2049- 632X.12139 
    14. Rivers JK. Incidence and treatment of delayed-onset nodules after VYC filler injections to 2139 patients at a single Canadian clinic. J Cosmet Dermatol. 2022;21(6):2379-2386. doi:10.1111/jocd.15013 
    15. Zaccaria G, Cassuto D, Baccarani A, Lusetti IL, Santis GD. Filler-induced complications of the lips: 10 years experience with intralesional laser treatment and refinements. J Plast Reconstr Aesthet Surg. 2022;75(3):1215- 1223. doi:10.1016/j.bjps.2021.11.042 
    16. Ostezan L, Peck J. Radial Sound (Shockwave) Therapy resolves delayed-onset nodules following injection of hyaluronic acid dermal filler: a case study. J Clin Aesthetic Dermatol. 2021;14(12 Suppl 1):S15-S17. 
    17. Talty R, Damsky W, King B. Treatment of cutaneous sarcoidosis with tofacitinib: A case report and review of evidence for Janus kinase inhibition in sarcoidosis. JAAD Case Rep. 2021;16:62-64. doi:10.1016/j.jdcr.2021.08.012 
    18. Damsky W, Thakral D, McGeary MK, Leventhal J, Galan A, King B. Janus kinase inhibition induces disease remission in cutaneous sarcoidosis and granuloma annulare. J Am Acad Dermatol. 2020;82(3):612-621. doi:10.1016/j. jaad.2019.05.098 
    19. Damsky W, Wang A, Kim DJ, et al. Inhibition of type 1 immunity with tofacitinib is associated with marked improvement in longstanding sarcoidosis. Nat Commun. 2022 Jun 6;13(1):3140. doi: 10.1038/s41467-022- 30615-x 
    20. Wang A, Rahman NT, McGeary MK, et al. Treatment of granuloma annulare and suppression of proinflammatory cytokine activity with tofacitinib. J Allergy Clin Immunol. 2021 May;147(5):1795-1809. doi: 10.1016/j. jaci.2020.10.012


Lopez, Miyahra Haniko P., et al. “Post-Hyaluronic Acid Filler Reaction Treated With Abrocitinib: A Case Report.” Journal of Drugs in Dermatology: JDD 23.1 (2024): 1355-1356.

Content and images published with permission from the Journal of Drugs in Dermatology.

Adapted from original article for length and style.

Did you enjoy this JDD Case Report? You can find more here.



Enjoy this blog? Please spread the word :)