Reversible Alopecia with Localized Scalp Necrosis After Accidental Embolization of the Parietal Artery with Hyaluronic Acid

Abstract

Hyaluronic acid (HA) filler injection is widely used for soft-tissue augmentation. Complications associated with HA filling are not uncommon; however, HA-induced alopecia is a rarely reported complication that could result in severe secondary psychological trauma. The etiology, clinical traits, treatment strategies, outcomes, and possible reversibility of HA-induced alopecia have not been characterized. Here, we report a case in which bilateral temple injections of 6.5 mL of HA led to persistent pain over the left scalp for several days. Although the pain was relieved at day 9 after 600 U of hyaluronidase were injected in the left temple, the patient developed localized alopecia at the left temporoparietal region with central skin necrosis at day 15. After topical applications of recombinant bovine basic fibroblast growth factor gel and 2% minoxidil spay, the necrotic skin wound was healed at day 42. Hair regrowth and normal hair density were restored at day 74. Analyses of Doppler ultrasound examinations and histopathology of the skin biopsy suggested that mild ischemia of the left temporoparietal region led to reversible alopecia, while the permanent hair loss in the left parietal area was associated with severe skin ischemia. Therefore, the key to treatment would be to focus on the effective correction of severe ischemia-induced skin necrosis to prevent permanent hair loss. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Filler‐induced alopecia

“…4 It was suggested that the mutations on the N and C terminals of LSS may result in hypotrichosis and congenital cataract, respectively. 3 However, the patients in our family who harbored…”

“…Since the first report of FIA by Gan et al in 2013, 2 there have only been three cases to date. [2][3][4] All cases were of women. Two of these cases were ipsilateral on the temporal scalp after HA filler injection, and one case was on the forehead after calcium hydroxyapatite filler.…”

“…Lanosterol synthase (LSS; Entrez Gene ID, 4047), the responsible gene for hypotrichosis 14, congenital cataract and syndromic hypotrichosis, 1,2 encodes for lanosterol synthase (LSS; UniprotKB, P48449), which plays an important role in cholesterol biosynthesis. 3 In this paper, we describe a hypotrichosis 14 family in which patients were initially considered with atrichia with papular lesions. The study was approved by the ethics committee of Guangzhou Women and Children's Medical Center in accordance with the Declaration of Helsinki.…”

Cicatricial Alopecia

“…Examples of the clinical diseases that can be categorized in this form are known as "Late-stage nonscarring alopecias" including alopecia areata, patterned hair loss, and traction alopecia, etc. Recent report indicated that the occurrence of biphasic alopecia can also be iatrogenic [13].…”

“…Mechanistically, Figure 6. Hyaluronic acid filling in the left temple region results in the skin necrotic and ischemic lesion leading to an area of a permanent hair loss surrounded by regions with slow-restoration of hair regrowth [13]. (a) Complete hair loss was seen in the patient's left temple area after HA injection.…”