Case for diagnosis. Noninfectious suppurative panniculitis induced by mesotherapy with deoxycholate,

AnBrasDermatol.2019;94(6):754---756

Anais

Brasileiros

de

Dermatologia

WHAT

IS

YOUR

DIAGNOSIS?

Case

for

diagnosis.

Noninfectious

suppurative

panniculitis

induced

by

mesotherapy

with

deoxycholate

夽,夽夽

Luana

Moraes

Campos

_,

_Luciane

_Donida

_Bartoli

_Miot

_,

Mariângela

Esther

Alencar

Marques

_,

_Hélio

_Amante

_Miot

a_{DepartmentofDermatologyandRadiotherapy,FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista,Botucatu,}

SP,Brazil

b_{ServiceofPathology,DepartamentodePatologia,FaculdadedeMedicina,UniversidadeEstadualPaulista,Botucatu,SP,Brazil}

Received23September2018;accepted1February2019 Availableonline24October2019

KEYWORDS

Dermatology; Mesotherapy; Therapeutics

Abstract A 28-year-old white female patient presented with multiple erythematous-to-violaceous,painful,suppurativenodulesonthebuttocksandthighsthatappearedaftertwo weeksofmesotherapywithdeoxycholate,caffeine,sunflowerliposomes,andsinetrolfor local-izedfat.Shewastreatedforatypicalmycobacteriosis,butwithnosatisfactoryresponseafter antibiotictherapy.Bacterial,mycobacterial,andfungalculturewereallnegative. Histopatho-logicexaminationofthebiopsyshowednoninfectioussuppurativepanniculitis.Itresolvedafter treatmentwithmethotrexate,prednisone,andhydroxychloroquine.Thisreporthighlightsthe rarityofthiscomplication,theimportanceofitsearlyrecognition,anddifferentiationwith atypicalfastgrowingmycobacterioses.

©2019SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

夽 _{Howtocitethisarticle:CamposLM,MiotLDB,MarquesMEA,Miot}

HA.Noninfectioussuppurativepanniculitisinducedbymesotherapy withdeoxycholate.AnBrasDermatol.2019;94:754---6.

夽夽_{StudyconductedattheDepartmentofDermatologyand}

Radio-therapy,FaculdadedeMedicinadeBotucatu,UniversidadeEstadual Paulista,Botucatu,SP,Brazil.

∗_{Correspondingauthor.}

E-mail:[email protected](H.A.Miot).

Case

report

Female, 28 years of age, white, previously healthy, pre-senting multiple reddish-violaceous, painful, suppurative nodules on the buttocks and lateral side of the thighs (Fig.1).Shepresentedaftertwoweeksofmesotherapywith sodiumdeoxycholate 6%,sunflower liposomes 5%,sinetrol 5%,and50mgofcaffeine(fromacompoundingpharmacy); usedtotreatlocalizedfatdeposits,administeredbya phar-macistatthepatient’soffice.

https://doi.org/10.1016/j.abd.2019.02.003

0365-0596/©2019SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

Noninfectioussuppurativepanniculitisinducedbymesotherapywithdeoxycholate 755

Figure1 Multiplereddish-violaceousnodules,with suppura-tion anddrainage inareas ofmesotherapyapplication.Thigh andrightgluteus.

Clarithromycin, ciprofloxacin, doxycycline, and sulfamethoxazole---trimethoprim were used, with no response. Bacterial, mycobacterial, and fungal culture were all negative. Histopathologic examination showed a diffuse lymphohistiocytic inflammatory process with neutrophilic microabscesses affecting the superficial and deepdermis,andsubcutaneouscellulartissue(Fig.2).

In this case, dapsone 100mg was initiated; how-ever, the patient developed DRESS (drug reaction with eosinophilia andsystemic symptoms)after 15 days,being replaced by methotrexate 17.5mg/week, hydroxychloro-quine 400mg/day, and prednisone 10mg/day. After two months of treatment, there wassubstantial improvement oftheinflammatoryprocessandevolutiontoresidual cica-tricialareas(Fig.3).

Discussion

Mesotherapy was described in the 1950s;however, it has beenreintroducedasamethodofskinrejuvenationand dis-solutionof adiposetissue, aimingat weightloss, reduced measurements,andreductionofcellulite.Inthesecases,it induceslipolysisbymultipleinjectionstothesubcutaneous adiposetissueoflipolyticsubstancesordetergentssuchas deoxycholate,phosphatidylcholine,andcaffeine.1---3

Excludinglocalimmediateeffects,infectionisthemost commonly reported complication. There are more than 200infections reportsassociated withmesotherapyin the

Figure 3 Residual scarring and discreet reddish aspect of nodularlesionsaftertreatmentwithmethotrexate,prednisone, andhydroxychloroquine.Thighandrightgluteus.

medicalliterature, allcaused by rapidlygrowing atypical mycobacteria.4---6

Theincreaseduseofthistechnique,conductedby medi-caland non-medical professionals, makes it necessary to know possible complications and treatment options. The authors report a case of suppurative noninfectious pan-niculitisafter mesotherapy, a rare event that may result from injection pressure, local trauma, or injected sub-stancetypes,especiallyhigh dosesof phosphatidylcholine ordeoxycholate.7,8

Deoxycholateisthesubstancemostinvolved,especially inconcentrationshigherthan5%,asinthiscase.However, itisnotpossibletoestimatetheeffectofothersubstances usedortheimportanceoftheirassociation.7---10

The clinical similarity with fast growing mycobacte-ria infections (M. fortuitum, M. abscessus, M. chelonae,

M.frederiksbergense, M.cosmeticum,M. peregrinum,M.

simiae, M. immunogenum, M. bolleti, M. massiliense)

---whichcanalsobeinoculatedbymesotherapy---requiresthe searchforacid-fastbacilliinthesecretionortissue,which usuallyshowsalargenumberofbacilli,andwhosetreatment differsfromnoninfectiouspanniculitis.4---6

Therehave been onlyfew reports onthetreatment of thiscomplication.Untilnow,nofirst-choicedrughasbeen established.Someauthorshave reportedtheuse of corti-costeroidsandespeciallydapsone,withgoodresultsafter twotofourmonthsoftreatment.7---9

The present case report aimed to highlight the need to suspect the diagnosis of noninfectious suppurative

Figure2 (A)Dermismicrographshowingsuperficialanddeepinvolvementofthedermisandsubcutaneouscellulartissue (Hema-toxylin&eosin,x200).(B)Mid-dermismicrographshowingdenselymphohistiocyticinfiltratewithneutrophils(Hematoxylin&eosin, x400).

756 CamposLMetal. panniculitis after mesotherapy and the importance of

knowing the components and concentrations of injected substances,aswell asthevalue of initiating early appro-priatetherapy.10

Financial

support

Nonedeclared.

Author’s

contributions

Luana Moraes Campos: Conception and planning of the study; intellectual participation in propaedeutic and/or therapeuticconductofthecasesstudied;criticalreviewof theliterature;criticalreviewofthemanuscript.

Luciane Donida Bartoli Miot: Approvalof the final ver-sion of the manuscript; elaboration and writing of the manuscript;effectiveparticipationinresearchorientation; intellectualparticipationinpropaedeuticand/or therapeu-tic conduct of the cases studied; critical review of the literature;criticalreviewofthemanuscript.

MariângelaEstherAlencarMarques:Obtaining,analyzing andinterpretingthedata.

Hélio Amante Miot: Approval of the final version of themanuscript;elaborationandwritingofthemanuscript; obtaining,analyzingandinterpretingthedata;intellectual participationinpropaedeuticand/ortherapeuticconductof thecasesstudied;criticalreviewoftheliterature;critical reviewofthemanuscript.

Conflicts

of

interest

Nonedeclared.

References

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