Periorbital Granuloma Annulare Following Mesotherapy

Received: 8 September 2020 Accepted: 18 September 2020
DOI: 10.1111/dth.14326
LETTER
Periorbital granuloma annulare following mesotherapy
Dear Editor, In physical examination, multiple nonpruritic subcutaneous pap-

Granuloma annulare (GA) is a noninfectious granulomatous skin ules with varying sizes between 0.5 and about 1 cm were observed on
disorder that can present with various clinical features. It is character- the lower eyelids (Figure 2). The patient stated that the growth of
ized by collagen degeneration, mucin deposition, and palisaded or these papules to be gradual during these 4 months. These papules
interstitial histiocytes. Although the pathogenesis of GA is not fully were surrounded by healthy skin and no erythema was seen in the
known, studies point to a cell-mediated hypersensitivity reaction to borders of lesions. The papules were firm and without tenderness.
1
an as-yet undetermined antigen. Mesotherapy is a nonsurgical proce- Her family history of dermatological disorders was unremarkable. All
dure that includes injection of different types of medications into the routine laboratory data were normal. We got suspected of foreign
middle layer of the skin, mostly for aesthetic uses. Various adverse body granuloma and sarcoidosis as differential diagnosis, so a skin
effects including granulomatous reactions have also been reported in biopsy was performed.
2,3
the case of nonapproved methods or unlicensed substances. Histopathologic examination revealed granuloma formation in
A 31-year-old woman was referred to the dermatology clinic of deep dermis, composed of eosinophilic degenerated necrobiotic colla-
our center due to the skin-colored papules in the preiorbital area that gen surrounded by palisaded histiocytes and scattered lymphocytes
appeared 4 months following mesotherapy for skin rejuvenation. The (Figure 3). Superficial dermis showed only mild perivascular inflamma-
patient had a severe diffuse facial edema following mesotherapy with tion. A few multinucleated giant cells were present. Alcian blue stain
hyaluronic acid for skin rejuvenation (Figure 1). She was not able to confirmed dermal mucin deposition. Ziehl-Neelsen and PAS staining
state the exact brand of the mesotherapy injection. Oral prednisolone were negative for the infectious causes. There was no cellular atypia,
has been prescribed and tapered for her by the nondermatologist increased mitosis or any evidence of malignancy. No polarizable for-
injector that performed the mesotherapy to control this severe eign particles were observed in the specimen. These histopathology
edema. She was also taking cetirizine and fexofenadine for facial findings was compatible with the diagnosis of granuloma annulare.
itching. The edema and pruritus got relatively improved, but some Granuloma annulare (GA) is typically localized to the dorsum of
papules appeared on the lower eyelids subsequently. the hands and/or feet. It can infrequently present on the face and
more rarely on periorbital structures including the eyelid and orbital
rim.4-6 Moreover, there is also very limited report of GA following the
F I G U R E 2 Multiple nonpruritic papules with varying sizes

between 0.5 and about 1 cm on the lower eyelids 4 months after
FIGURE 1 Facial edema 1 day after mesotherapy mesotherapy
Dermatologic Therapy. 2020;e14326. wileyonlinelibrary.com/journal/dth © 2020 Wiley Periodicals LLC. 1 of 2

https://doi.org/10.1111/dth.14326
2 of 2 LETTER
F I G U R E 3 Histopathological findings: A, Palisaded granuloma with necrobiotic center in deep dermis (H&E ×100). B, Necrobiotic collagen
surrounded by palisading histiocytes and scattered lymphocytes (H&E ×400)
2
mesotherapy. We found only a unique case of GA 7 months after Department of Dermatology, Loghman Hakim Hospital, Shahid Beheshti
abdominal mesotherapy in the literature. 7 University of Medical Sciences, Tehran, Iran
3
There are previous reports indicating the possibility of the GA for- Department of Pathology, Loghman Hakim Hospital, Shahid Beheshti
mation in response to a foreign body in skin.8 Researchers have University of Medical Sciences, Tehran, Iran
suggested that the immune response often starts with a foreign-body
and granulomas get formed in response. However, if the identified Correspondence
antigen be too small in size, the process of the immune reaction would Reza M. Robati, Skin Research Center, Shahid Beheshti University of
try to stop the production of granulomas. In case of GA, the defective Medical Sciences, Tehran, Iran.
regulation system tends to preserve the development of granuloma- Email: [email protected]
9
tous in a circular manner.
Herein, we report a distinctive and unique case of periorbital GA OR CID
on the lower eyelids following mesotherapy for facial and periorbital Reza M. Robati https://orcid.org/0000-0002-7947-8642
rejuvenation. It might be a reaction to the small particles in
mesotherapy injection especially in the case of nonapproved methods RE FE RE NCE S
or unlicensed substances. Therefore, we recommend to keep in mind 1. Keimig EL. Granuloma annulare. Dermatol Clin. 2015;33:315-329.
2. Mammucari M, Maggiori E, Russo D, et al. Mesotherapy: from histori-
GA as a differential diagnosis for any skin-colored papule in the peri-
cal notes to scientific evidence and future prospects. Scientific World
orbital area especially following injection procedures such as Journal. 2020;2020:3542848.
mesotherapy. 3. Gokdemir G, Küçükünal A, Sakiz D. Cutaneous granulomatous reaction
from mesotherapy. Dermatol Surg. 2009;35:291-293.
4. Barrett D, Petris C, Garrido Hermosilla AM, Oktavec K, Mansukhani M,
CONF LICT OF IN TE RE ST
Kazim M. Intraorbital granuloma annulare in an elderly patient. Orbit.
The authors declare no conflict of interest.
2016;35:170-172.
5. Chiang K, Bhalla R, Mesinkovska NA, Piliang MP, Tamburro JE. Peri-
DATA AVAI LAB ILITY S TATEMENT ocular granuloma annulare: a case report and review of literature.
The data that support the findings of this study are available from the Pediatr Dermatol. 2014;31:722-725.
6. McNeal S, Daw JL Jr. Subcutaneous granuloma annulare: an unusual
corresponding author upon reasonable request.
presentation in the eyelids and scalp. Ann Plast Surg. 2005;55:684-686.
7. Strahan JE, Cohen JL, Chorny JA. Granuloma annulare as a complica-
Reza M. Robati1,2 tion of mesotherapy: a case report. Dermatol Surg. 2008;34:836-838.
Ayda Bahmanjahromi1,2 8. Lo Schiavo A, Ruocco E, Gambardella A, O'Leary RE, Gee S. Granuloma-
Farahnaz Bidari-Zerehpoosh3 tous dysimmune reactions (sarcoidosis, granuloma annulare, and others)
on differently injured skin areas. Clin Dermatol. 2014;32:646-653.
9. Manestar-Blazic T, Brajac I, Dragojevic Malnar D, Kastelan M. Granu-
1
Skin Research Center, Shahid Beheshti University of Medical Sciences, loma annulare: a genetic disorder that sustain an incomplete foreign-
Tehran, Iran body granuloma reaction. Med Hypotheses. 2006;67:876-878.

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Received: 8 September 2020 Accepted: 18 September 2020

Periorbital granuloma annulare following mesotherapy

Dear Editor, In physical examination, multiple nonpruritic subcutaneous pap-

F I G U R E 2 Multiple nonpruritic papules with varying sizes

Dermatologic Therapy. 2020;e14326. wileyonlinelibrary.com/journal/dth © 2020 Wiley Periodicals LLC. 1 of 2

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