Infectious complications in esthetic dermatology procedures: A narrative review

INTRODUCTION

Minimally invasive esthetic dermatology procedures have gained immense popularity worldwide and have expanded dramatically owing to the ever-growing demand of the population to stay young.¹ It encompasses a wide range of treatments, such as chemical peels, lasers, botulinum injections, soft-tissue fillers, dermabrasion, microneedling, mesotherapy, and facial thread lifts (FTL).² Over 14 million non-surgical procedures and 10 million surgical procedures have been reported by the International Society of Plastic Surgery in 2020.² Although generally safe, these procedures are not without risk.

A significant concern is the growing number of infectious complications from these procedures, fueled by medical tourism (the practice of patients seeking medical services abroad) and procedures performed in non-medical settings.^3,4 However, the incidence of this complication is frequently under-reported.² This can affect the results of the procedure, increasing healthcare costs, and even be life-threatening in extreme cases. The absence of robust clinical regulation, alongside heightened accessibility and subject exposure, has led to an increase in complications in cosmetic procedures.⁵ A systematic review of complications arising from cosmetic tourism revealed that infection was the most prevalent complication. Others include wound dehiscence, seroma, tissue necrosis, and thromboembolic events.⁶ Most of the infectious organisms were bacterial, which include Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa, and Escherichia coli.^4,7 It may present as superficial skin infections such as abscess, cellulitis or non-healing ulcers to more severe conditions such as necrotizing fasciitis or sepsis, particularly after surgeries involving deeper tissues.^3,4 One of the most alarming trends is the prevalence of non-tuberculous mycobacterial (NTM) infections. It usually presents as recalcitrant ulcerations, subcutaneous abscess formation, draining sinuses, or firm and fluctuant subcutaneous nodules, all of which are resistant to empiric antibiotic regimens.^8,9 These infections are often difficult to diagnose, resulting in major diagnostic and treatment delays. Viral infections, such as herpes simplex virus (HSV) and varicella zoster virus (VZV) reactivation, are less common, particularly affecting immunocompromised and elderly patients.^10,11 Human papillomavirus, as wart-like growths following injections or skin treatments, has been reported.¹² Fungal infections are relatively uncommon but can occur, particularly in immunocompromised patients, usually as candidal infections.

The scant literature on this topic necessitates a discussion of infectious complications associated with diverse esthetic dermatology procedures. This review aims to provide a comprehensive analysis of infectious complications associated with minimally invasive esthetic procedures, exploring the risk factors, pathogens involved, clinical manifestations, preventive strategies, and management approaches.

CHEMICAL PEELING

Chemical peeling, a common procedure, involves the controlled destruction of the epidermis, with or without the dermis, through the application of a chemical agent, resulting in skin exfoliation and rejuvenation. Since the 18^th century, chemical peels have been the most common and popular non-invasive cosmetic procedure. Although rare, complications may occur, including delayed wound healing, ulceration, and tissue necrosis, especially with medium-to-deep peels [Figure 1]. Due to the epidermal damage, there is also a risk of bacterial, herpetic, and candidal infections.¹³ It clinically presents as folliculitis [Figure 2], impetigo, grouped vesicopustules, delayed wound healing, ulceration, superficial erosions, crusting, and discharge. BarańskaRybak and Merholtz report a case of simultaneous HSV and impetigo after a 20% trichloracetic acid peel done on the face for fine superficial wrinkles and photoaging.¹⁴

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Figure 1:

Eschar following a medium depth chemical peel. Image courtesy of Dr. Madhuri Agarwal, Yavana Skin and Hair Clinic, Mumbai.

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Figure 2:

Folliculitis post- peel. Image courtesy of Dr. Sonali Langer, Apollo Hospitals, New Delhi.

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LASERS AND LIGHT DEVICES

Non-ablative lasers with CO₂ and erbium: Yttrium– aluminum–garnet (Er: YAG) devices are widely used for skin rejuvenation and treating conditions such as acne scars, hyperpigmentation. It is based on the principle of fractional photothermolysis that generates microthermal treatment zones in the dermis. They offer less downtime with more favorable side effects as compared to ablative lasers. Although rare, infections post-laser resurfacing have been well documented. HSV infection is common after fractional laser skin resurfacing, reported in 0.3–2% of cases.¹⁵ It presents as vesicopustules [Figure 3] or as superficial erosions. In a case report by Winn et al., the development of verruca plana 6 weeks after fractionated CO₂ laser for surgical scars and diffuse actinic damage was observed.¹² Although uncommon, secondary bacterial infections, such as impetigo, folliculitis [Figure 4] may occur. In a report by Culton et al., two patients developed papulopustules in the treatment area within a fortnight of fractional CO₂ laser resurfacing. Histologic analysis and culture revealed an NTM infection caused by Mycobacteroides abscessus and Mycobacteroides chelonae.¹⁶ While infrequent, cutaneous candidiasis by Candida albicans can develop (usually within 7–14 days of treatment).

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Figure 3:

Herpes simplex virus reactivation after CO₂ laser for perioral hyperpigmentation.

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Figure 4:

Secondary bacterial infection following a burn after CO2 ablative laser for an epidermal naevus.

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MICRODERMABRASION AND MICRONEEDLING

Both microdermabrasion and microneedling are techniques used to treat skin conditions such as uneven texture and tone, photoaging, striae, melasma, and scars. The former employs mechanical abrasion to exfoliate the stratum corneum, while the latter utilizes microneedles to induce collagen and elastin production. Although considered minimally invasive, this treatment modality may induce sufficient trauma to create a nidus for infection. The organisms implicated in early infection are bacterial and HSV reactivation, whereas late infection may be seen with NTM.^8,17 In recent times, the affordability and accessibility of home-based equipment have significantly risen. Leathem et al.¹⁸ reported a case of extensive, unintended facial varicella autoinoculation following the patient’s use of a commercial micro needling device to treat presumed acne and wrinkles. This resulted in grouped, eroded papulovesicles within the right T4 dermatome and corresponding areas treated with the device. The VZV polymerase chain reaction (PCR) test was positive.¹⁸ A case report by Grubb and Bowen reports a patient who developed a tender lump on her cheek after using an at-home microdermabrasion device; the culture was positive for M. abscessus. The infection likely stemmed from tap water used to clean the device, highlighting poor sterile technique.⁸

BOTULINUM TOXIN (BTX) AND DERMAL FILLERS

Globally, non-surgical procedures utilizing Botulinum toxin type A (BoNTA) and hyaluronic acid (HA) fillers are the most prevalent, ranking first and second in frequency, respectively.^19,20 It was reported that in 2021, more than 7.3 million BTX injections and more than 5.2 million HA filler injections were performed worldwide, with a dramatic increase in trend over the past decade.²¹ Infection rates with soft-tissue fillers are low and are estimated at 0.04–0.2%.⁹ It can occur either by direct inoculation or hematologic spread from elsewhere.

The most common organisms involved in filler infections arise from common skin commensals such as Staphylococci, Streptococci, or skin commensals such as Staphylococcus epidermidis, Cutibacterium acnes, due to a breach in the skin surface.⁹ HSV reactivation after dermal filler injection is uncommon, affecting <1.45% of cases, and Herpes Zoster is even rarer.²² Infections by M. abscessus and M. chelonae have resulted from using unapproved and contaminated fillers.^3,23

Complications linked to BTX injections are relatively rare. If lesions presenting as nodules persist for more than 2 weeks, atypical infections are suspected, and mycobacteria are a frequent culprit.⁷ A report by Ou et al. describes a patient who developed multiple painful nodules on both cheeks 4 months after injection of BTX (product name unknown) for masseter hypertrophy, with culture positive for M. abscessus.²¹ This study also summarized 24 cases from 18 studies of subcutaneous infections caused by NTM following cosmetic injections, of which the primary clinically significant species were M. abscessus, M. chelonae, and Mycobacterium fortuitum. In a report by Chen et al., two patients developed multiple painful nodules and abscesses on the face after BoNTA injection performed by non-medical staff in a non-hospital institution.²⁴ The culture was positive for M. abscessus. He found that cosmetic procedures undertaken in non-clinical environments by non-clinicians pose a substantial infection risk resulting from inadequate sterilization processes.²⁴

FTL

FTL is a minimally invasive cosmetic intervention involving the use of absorbable sutures through the superficial musculoaponeurotic system to achieve skin lifting and tightening. Infection rates following FTL are highly variable and are a common reason for thread removal.²⁵ It is often caused by improper technique, inappropriate disinfection, and unsterile operation. Bacterial complications, including NTM infection, seem to be a well-known complication following the use of polydioxanone (PDO) threads [Figure 5].²⁶ We report a case where a patient developed multiple tender nodules after PDO threads. On histopathological examination of hematoxylin and eosin stain, epidermis showing keratinizing stratified squamous epithelium with irregular elongation of the rete ridges with histiocytic collections surrounding mononuclear inflammatory infiltrate in the dermis [Figure 6] ZN staining was negative for acid-fast bacilli. Online probe assay, Mycobacterium intracellulare was detected. Shin et al. reported a case of a 47-year-old woman who presented with multiple erythematous nodular lesions 6 weeks after a PDO thread-lift procedure at a cosmetic beauty salon, culture showing growth for M. massiliense^.27

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Figure 5:

Atypical mycobacterial infection after polydioxanone threads. Image courtesy of Dr. Indu Ballani, Ballani Skin Aesthetics, New Delhi.

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Figure 6:

Hematoxylin and eosin stain shows the presence of histiocytic collections surrounded by mononuclear inflammatory infiltrate. (X200) (red arrow) Ziehl-Neelsen (ZN) staining for acid fast bacilli (AFB) was negative.

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MESOTHERAPY

It is a minimally invasive method of direct drug delivery that involves intradermal/subcutaneous injections of a mixture of compounds in the area of interest. The low cost and minimal training needed have made this procedure very popular among unlicensed providers over the past few years. The absence of substantial regulation raises concerns regarding unstandardized compounds.^28,29

Infections are the most commonly cited complication and are mainly related to rapidly growing mycobacteria.^1,30 Orjuela et al.³¹ present a case series of six patients who developed cutaneous tuberculosis with M tuberculosis after the injection of unknown mesotherapy cocktails for cellulite treatment.²⁹ 15 cases of NTM infection presenting with multiple skin nodules and draining abscesses following mesotherapy done for esthetic purposes were identified, who developed the lesions within 6 months. Culture showed growth of M. fortuitum, M. abscessus, and M. chelonae.³¹ A variety of other organisms have been isolated, including S. aureus, P. aeruginosa, Sporothrix schenckii, and Nocardia brasiliensis.^1,30 A common trend throughout the reported cases was that non-medical or otherwise unorthodox treatments were often implicated, leading to the deduction that these settings are subjected to more contamination and subsequent complications.

RISK FACTORS FOR INFECTION

Recognition and management of infectious complications

Flowchart 1 illustrates the diagnostic and management approach to infectious complications following aesthetic procedures.

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Flowchart 1:

Approach to infectious complications in esthetic procedures. HSV: Herpes simplex virus, VZV: Varicella zoster virus, NTM: Non-tuberculous mycobacteria.

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Early identification and diagnostic approach

1. Timely intervention is critical to prevent the spread of infection and reduce the risk of complications. Clinicians should identify the source and cause of infection through a systematic approach, including:

2. Tissue or aspirate culture for microbial analysis and antibiotic sensitivity testing.¹⁷

3. PCR for precise microbial identification.

4. Diagnostic tools such as Tzanck smear for identifying HSV and VZV, while the gold standard for viral diagnosis remains viral culture.

5. Histological evaluation of biopsy specimens to ensure diagnostic accuracy.

6. Imaging studies are essential as pre-operative planning tools to assess the depth and extent of infection, aiding in diagnosing to detect threads, abscesses, or filler material.³² It is also used to employ cellulitis as it can appear as stranding and enhancement of the subcutaneous tissues surrounding the filler or as ring-enhancing collections if an abscess develops.⁹

Empiric and targeted pharmacotherapy

Initiate empiric therapy promptly with either broad-spectrum antibiotics targeting both Gram-positive and Gram-negative organisms or antivirals (acyclovir, valacyclovir, famciclovir) if viral etiology (e.g., HSV, VZV) is suspected and when culture results become available, the initial therapy may be modified.¹⁷ If the infection is resistant to treatment, or if cultures are negative, suspicion should be raised for resistant microorganisms, mycobacteria, or biofilm involvement.³³

For suspected MRSA infections, coverage with clindamycin or vancomycin may be necessary. Although there is no standard treatment for cutaneous NTM infections, combination drug therapy (defined as ≥2 agents) is usually necessary to minimize the development of drug resistance, with macrolides and aminoglycosides being the most frequently employed antimicrobials.^21,29 Other agents include aminoglycosides, fluoroquinolones, tetracyclines, rifampin, ethambutol, trimethoprim-sulfamethoxazole, cephalosporins, and diarylquinolines. The duration of therapy can vary from 2 to 6 months, depending on the immunocompetence status of the patient and the disease location and severity of the infection.^1,28

If infection is resistant to treatment, or in the event of infection in immunocompromised patients, the possibility of Candida species infection should be considered for those not responding to treatment with antiviral agents and antibiotics alone.^5,33

Drainage of abscesses and wound debridement

Surgical intervention, including incision and drainage or debridement, may be required in refractory cases to prevent systemic spread and deformity. To effectively manage persistent infections, comprehensive debridement and the removal of all foreign materials, such as threads and fillers, may be necessary.^9,32 Niu et al., in their systematic meta-analysis, describe cases of abscess, ulceration post-FTL, which alleviated after drainage and thread removal.²⁵ Infection secondary to HA fillers can be managed with hyaluronidase diluted with either local anesthetic or normal saline into the affected site following incision and drainage, for initiation of hydrolysis of the HA.⁹

CONCLUSION

With an ever-increasing prevalence of esthetic dermatology treatments, there have also been increasing rates of skin and soft-tissue infections. It is worth noting that these infections are increasingly caused by procedures generally considered to be minimally invasive. This can result in significant morbidity and impact the outcome of esthetic treatments. The risk of infection varies by type of procedure, patient health status, and the environment in which the procedure is performed. NTMs are environmental organisms that are increasingly associated with systemic and cutaneous disease in humans. Cutaneous infections, as previously discussed, may arise secondary to injections (e.g., BTX, fillers, mesotherapy) or minor surgical procedures that compromise the cutaneous barrier. These infections are challenging to treat, often necessitating the use of multiple antimicrobial agents and a prolonged treatment period of several months, frequently resulting in persistent cutaneous sequelae rather than improved cosmetic outcomes.

Surgeons and healthcare providers must remain vigilant in identifying early signs of infection and managing them promptly or referring to dermatologists to avoid severe outcomes. As the popularity of esthetic procedures continues to rise, ongoing education, research, and adherence to best practices are essential to ensure patient safety and optimal cosmetic results. The need for further studies is indicated to develop evidence-based best practices for the management of this progressively prevalent complication and establish a consensus.