Herpes Simplex Virus or Vascular Occlusion?

Dr Jessica Srivastava, BDS, MSc is a dentist who runs her own aesthetics practice and is a Harley Academy clinical trainer. Here she details her first experience of complications management and how she determined whether an “itchy blister” was herpes simplex virus or vascular occlusion.

Believe it or not, in the five years I have been injecting, I had not experienced any complications beyond massaging a few small lumps… until a few weeks ago! 

Dr Jess Srivastava - Complications Management - Harley Academy Aesthetic Medicine Training Courses - Injectables
Dr Jess Srivastava, BDS, MSc

A 29-year-old female patient re-attended my clinic having had previous filler and toxin treatments with myself. She had no relevant medical history, including no history of herpes simplex virus (HSV) and had experienced zero complications from her last treatments. She had been very happy with the results and decided to proceed with the lip augmentation she had been thinking about for a while. She had never had her lips injected before. 

After discussing and signing the consent forms, I disinfected the lips using Clinisept and applied LMX4 to topically numb the lips for 15 minutes. I injected 0.8ml of Juvederm Volift, which is my filler of preference for the lips, into the upper and lower lip body using a needle. I deposited the filler in retrograde linear threads combined with a fanning technique. 

Immediately after the procedure the patient had evident swelling, which is not unusual, but was slightly larger than most. I disinfected the lips one final time and checked the capillary refill, which was normal. All appeared well and the patient was pleased, whilst reporting no discomfort. Post procedure advice was given verbally and via email, and the patient went home.

Five days later I had a call from the patient at 10.30pm – and when a patient calls you at that time, it is often not just for a friendly chat! She also sent over some photos and explained that she was extremely worried about an itchy “bubble” forming on the upper lip. I remained calm and asked her some straightforward questions to try and rule out a delayed presentation of vascular occlusion (VO). I asked her: 

  • – Is there any change in colour to the area of concern or the surrounding areas? 
  • – Is there any change in sensation bar the itching? Is it cold to touch or painful?
  • – Was it there straight after the appointment or has it just appeared? 
  • – Has it changed in size at all since you have noticed it? 
  • – Is it firm or soft? 
  • – When you press it for 5 seconds and release, does it change colour or hurt at all?
  • – Are you sure you don’t suffer from cold sores or have you been in contact with anyone that has them? 

The answers to the above questions were that it has just appeared and there is no pain at all bar the itching sensation. It is not changing in size or colour and it feels soft to touch. When she pressed it for 5 seconds the colour of the lip returned immediately. She also reconfirmed that neither herself nor her partner suffers from HSV. From these answers and the pictures, I was pretty sure that it wasn’t a VO but I wanted to get her into the clinic first thing the next day and double check. 

Starting mentoring at Harley Academy last year meant that I went from being a sole practitioner to having a highly experienced and supportive team around me. I used this to my advantage for this case and called upon one of my most experienced team members, who regularly deals with complications management in our review clinics. 

This is where I can honestly say that if you have the ability to work as part of a team then it is invaluable. Two heads are always better than one, and when you’re in an unfamiliar scenario it is so useful to be able to talk to someone that has been in this situation before, be it in person or digitally via apps such as Comma.

We discussed some differential diagnoses and treatment protocols for the following possibilities: 

  • – HSV
  • – infection
  • – HSV with overlying infection 
  • – haematoma 
  • – VO
  • – and we ruled out inflammatory nodules as it was too early at this stage.
Dr Jess - Complications Management - Botox - Injectables - Harley Academy Aesthetics Training Courses

I saw the patient in clinic an hour later and did a recap of HSV history and a full examination. At this point I delved into her family history of HSV; this is when she mentioned that her mum and brother suffered from cold sores and, in addition, she had also been extremely stressed with work over the last week. This was a small lightbulb moment for me and I began to breathe a sigh of relief as I was almost sure it was HSV now. 

I still assessed for signs of haematoma, infection and VO, but HSV seemed to be the diagnosis. I followed Aesthetics Complications Expert Group (ACE) protocols for HSV +/- infection as it wasn’t clear if infection was present due to the swelling and now the blistering that had formed overnight. 

The patient was adamant that she did not want to take antibiotics but I still prescribed them with the antivirals and explained my reason for recommending them. She was fully informed of the risks if she didn’t take them and I had documented our conversations in her notes. Ultimately it was her choice as to whether she took them or not. 

I checked in with the patient daily to ensure that the area was not looking or feeling any worse and she reassured me that upon taking the antivirals it had started to improve. It went through a phase of blistering and scabbing over and she is now completely healed and happy with the result. 

At all times I follow ACE guidelines for HSV prophylaxis. For this patient presenting initially with no obvious history of HSV and no previous complications after aesthetic treatments, prophylaxis would never have crossed my mind. However, following ACE HSV prophylaxis protocol, she will now be someone that I will always cover with antivirals before further filler treatment.

At some point in our career we will all experience complications. The best advice I can give is to remain calm as the patient will mirror your reaction and look to you for reassurance. 

Complications can always be managed, but it is recognising the complication and managing it the right way that can be the challenging part. 

If you are beginning your aesthetic career and are working as a sole practitioner, then I would strongly recommend joining ACE for complication management protocols and network-building when you’re on courses, at conferences or on digital platforms for medical aesthetics such as Comma.

For a thorough grounding in preventing and managing complications from injectables, Harley Academy offers a comprehensive eLearning course. This can be followed in your own time, at your own pace and provides you with the latest protocols and reference resources which are yours to keep. Whether you’re just starting out in aesthetics or you just want to ensure your training is up-to-date, this is a fantastic option that will stand you in good stead throughout your career.

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