Indurated pruritic papules at HA filler injection entry sites

Описание пациента

42 yo female, history of breast cancer, treatment completed. Not immunocompromised. Allergic to doxycycline.

Derm history: Mild acne treated with tretinoin and topical clinda prn. She had Fraxel treatment by me in September without complications.

Описание кейса

She received Restylane-L injections using sterile pilot needle and 25 1.5 inch cannula to the bilateral tear troughs, medial cheeks and chin. (For the record I usually inject Restylane Define and Refine or even higher G products like Radiesse in the chin, but this was her first ever injection and she wanted very subtle correction and I ended up splitting and using the same HA in the triangle under the lateral lips.) 

Injection went without complications. She has never received any fillers in the past. Face was cleansed with chlorhexidine before inejection, alcohol wipes was used at entry site in case I had to go back with my cannula (I routinely do this). I used vaseline that is pressed out of a tube to steril surface first, to massage face after injection was completed. Exactly 24 hours later she developed pruritic non-painful red indurated papules exactly at the cannula entry sites. By day 2 the  papules appeared spongiotic and on the left cheek she developed scattered micropustules. She also received dysport and she had no reaction at those sites. No systemic symptoms including fever, malaise, only itch.

Upon questioning she admitted that after the injection she went home, washed off the vaseline (she thought it caused acne) used hypochlorous acid to cleanse (she is a nurse BTW...of course) and used a niacinamide cream. I asked it is not expired and has no odor.

I started her on cefadroxil 500 mg twice daily on day 1 along with topical ruxolitinib alternating with triamcinolone 0.1% ointment and added flucomazole 100 mg daily on day 2. She started cetirizine on her own for itching and I left her on it. I haven't resolved HA yet because she has no reaction where the HA was actually placed.

I have been following her daily and she has improved some but not as much as  I was hoping for. Last picture is day 4 after injection. 

I have been injecting for 18 years and I have never seen this.

The same day I injected 3 more people with various fillers using the same technique and same  vaseline.

My differencial diagnosis is infection (although only strep can act this fast and  I didn't send culture because she had no discharge) or some localized allergic reaction. 

Have you seen this? I really appreciate any input. She agreed to post her pictures. (Sorry I am doing this from my IPhone traveling...)