Effective Treatment Is Available
The same treatments that physicians have used for years to manage DIRs are effective in managing COVID-19 vaccine/dermal filler reactions. Some physicians are also using lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, to treat DTRs related to COVID-19 or the COVID-19 vaccine, as the SARS-CoV-2 spike protein uses angiotensin-converting enzyme 2 (ACE2) to enter cells.
Explore This IssueAugust 2021
Treatment, however, isn’t always necessary. “‘Skillful neglect,’ as the English call it, is a real part of this treatment process,” Dr. Nayak said, noting that many reactions will resolve in a few days without intervention. If the reaction is causing the patient discomfort or distress, you may want to consider a tiered approach to treatment:
Over-the-counter medication. OTC antihistamines and anti-inflammatory pain medications such as ibuprofen are often sufficient to relieve patient discomfort, particularly when coupled with home remedies such as cold compresses, head-of-the-bed elevation, salt restriction, and alcohol avoidance, said Dr. Kourosh and Dr. Nayak. Dr. Nayak also sometimes recommends the use of arnica montana and bromelain, two dietary supplements that studies show may decrease edema and pain (Am J Ther. 2016;23:e184-197).
Because some journal articles suggest that nonsteroidal anti-inflammatory drugs (NSAIDs) might negatively affect vaccine efficacy, Dr. Munavalli said he doesn’t recommend NSAIDs as first-line treatment, while noting that typical doses of OTC NSAIDs “wouldn’t hurt, necessarily.” Indeed, a 2016 literature review found that the only studies that noted a “significant negative impact on immune response” were those in which NSAIDs were administered preventively at the time of vaccination, not when they were administered later to treat uncomfortable side effects (Hum Vaccin Immunother. 2016;12:2391-2402). A 2021 study found that NSAID treatment impaired the immune response of mice to SARS-CoV-2 infection (J Virol. 2021;95:e00014-21).
Steroids. The American Society for Dermatologic Surgery (ASDS) Guidance Regarding SARS-CoV-2 mRNA Vaccine Side Effects in Dermal Filler Patients, released in January 2021, states that “Delayed noninflammatory nodules without suspicion of infection may be treated initially with oral corticosteroids for 1 to 2 weeks, rather than dissolving with hyaluronidase, should the retention of the filler effect be desired. Addition of antibiotics (doxycycline or minocycline) should be considered for anti-inflammatory and antimicrobial properties.”
Dr. Kontis used a prednisone taper to successfully treat a woman who experienced facial swelling after her second dose of the Pfizer-BioNTech COVID-19 vaccine, which the patient received approximately eight months after receiving hyaluronic acid filler. Dr. Munavalli said that, in his experience, “Quite a few of these cases are not steroid-responsive anyway. … I’m not really sure why except that it may be that this reaction isn’t as sensitive to inhibition with steroids based on the mechanism of action.”
Antibiotics. The ASDS also recommends consideration of either doxycycline or minocycline. Dr. Nayak said he likes to use doxycycline treatment when it isn’t entirely clear whether a patient’s symptoms—redness, discomfort, and edema—are due to infection or inflammation. “Doxycycline is a nice choice because it’s anti-inflammatory as well as anti-infectant,” he said.
Lisinopril. Dr. Munavalli has published two articles about his experience using the ACE inhibitor lisinopril to proactively manage COVID-19 vaccine/dermal filler reactions (Arch Dermatol Res [published online ahead of print February 9, 2021]; JAAD Case Rep. 2021;10:63-68).
“Since high levels of the COVID-19 spike protein get into the skin and inactivate one of the checks and balances that keep angiotensin 2 under control, causing an inflammatory cascade, I postulated that treatment with an ACE inhibitor might interrupt that cascade and ease inflammation,” Dr. Munavalli said.
The first patient he treated with lisinopril was a 43-year-old woman who experienced significant intraorbital and perioral edema after receiving her second dose of the Pfizer-BioNTech COVID-19 vaccine. The swelling persisted despite treatment with cetirizine, and the patient refused corticosteroid treatment because she was concerned the steroids might blunt her immune response to the vaccine, so Dr. Munavalli prescribed 5 mg oral lisinopril. Within five hours, facial swelling had decreased, with a return to baseline in 24 hours.
An increased dose may be needed to treat resistant cases. “If a patient isn’t responding after a couple of days of treatment or their initial presentation is severe or uncomfortable, I have no problem starting at 10 milligrams, with the understanding that if we don’t see much of a response in a few days, we may need to try an even higher dose or consider other options,” Dr. Munavalli said.
In at least one documented instance, Dr. Munavalli used oral lisinopril as a prophylactic treatment before dose two of a mRNA COVID-19 vaccine. Lisinopril relieved the facial edema the patient experienced after her first dose of the Moderna vaccine, so Dr. Munavalli advised the patient to begin taking lisinopril (10 mg qd) two days prior to her second dose. The patient did and experienced only mild edema that resolved completely within 72 hours following her second shot (JAAD Case Rep. 2021;10:63-68).
Such low doses of lisinopril are unlikely to dramatically affect a patient’s blood pressure, but Dr. Munavalli advises patients to stand up slowly and watch for dizziness. If a patient is already on blood pressure medication, he consults with the patient’s internist before prescribing lisinopril.
Filler dissolution. If discomfort and edema persist despite home remedies, OTC, and prescription drug treatment, dissolution of the filler with hyaluronidase will resolve the problem. “The filler is the nidus of the problem,” Dr. Nayak said. “If all else fails, you can dissolve the filler. It’s a process, but it should help almost every time.”