96%
of reported CaHA adverse events were nodules (166 of 173), across 2,779 patients. Most resolved without treatment.
Kadouch, J Cosmet Dermatol 2017. Review of 21 articles.Chair-side protocol for PLLA and CaHA
Biostimulator Nodule Protocol
Inflammatory or non-inflammatory? Infection or product? A workup card, a decision algorithm, and a referenced evidence page that sort the nodule before you treat it. Built by a physician from the primary literature.
- 3 pages
- 2 products: PLLA and CaHA
- 12 PubMed references
A nodule is a description, not a diagnosis.
The first question is not which injection to reach for. It is whether this is product, immune reaction, or biofilm, because a steroid given to an unrecognized infection can make it worse.
This protocol sorts the nodule first, then gives the treatment ladder for each type, with every step traced to its source.
What the evidence shows
0.01 to 0.1%
estimated incidence of true PLLA granulomas, which are distinct from the more common early, technique-related papules.
Vleggaar et al., J Drugs Dermatol 2014. Expert review.40 studies
informed the most recent evidence-mapped pathway for PLLA nodules. None was a randomized trial of nodule treatment.
Flores Rodriguez et al., Cureus 2026. Scoping review.No antidote
reliably dissolves PLLA or CaHA. Hyaluronidase helps only if HA was co-injected; sodium thiosulfate data conflict.
Danysz et al., Clin Cosmet Investig Dermatol 2020. Preclinical study.Nodule treatment rests on reviews, guidelines, and case reports. The protocol labels the evidence level for every step.
What's inside
- Page 1
Workup card
A side-by-side comparison of non-inflammatory, inflammatory, and infectious nodules, the workup, size grading, product-specific facts, and treatment for each type.
- Page 2
Algorithm
A decision chart that asks the infection question first, then inflammation, then size and visibility, with refractory and follow-up steps.
- Page 3
References
Twelve sources with PubMed links, what each one supports, and a plain-language evidence level note.
Who it's for
- Injectors who use PLLA (Sculptra) or CaHA (Radiesse, including hyperdilute)
- Medical directors managing referred or delayed-onset nodules
- Practices building a consistent nodule follow-up schedule
What you get
- 3-page PDF, US Letter, prints cleanly in color or grayscale
- Inflammatory vs non-inflammatory vs infectious comparison table
- Treatment ladder with doses and reassessment intervals
- 12 references, each with a PubMed link and study type
Choose your license
Individual
$29
One practitioner. The full 3-page protocol PDF.
Buy nowFor practices
Practice license
$69
Up to 5 staff in one practice. Print it for every treatment room.
Buy nowSecure checkout by Stripe. Your download opens right after payment, and Stripe emails your receipt. NJ sales tax is added at checkout where applicable.
Checkout opens soon.
Questions
Is this a substitute for training?
No. It is a chair-side reference for trained practitioners. Biopsy, culture, and referral decisions remain clinical judgment.
Are the treatments on-label?
No. Triamcinolone, 5-FU, hydroxychloroquine, and sodium thiosulfate for nodules are off-label. The protocol notes this and cites the evidence for each.
Is the size grading validated?
No. It is a proposed pathway from a 2026 scoping review, labeled as such on the card.
Is this CME?
No. It is educational content for licensed practitioners and does not award CME credit.
Can my whole team use one copy?
The Individual license is for one practitioner. The Practice license covers up to 5 staff in one practice.