Case and Research Letters
Foreign-Body Reaction to Dermal Filler: Good Response to Treatment With Allopurinol
Respuesta favorable al tratamiento con alopurinol de reacción granulomatosa a relleno
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González-Delgado, P. Cordero-Romero, L. Terrádez-Mas, J.M. Martín" "autores" => array:4 [ 0 => array:4 [ "nombre" => "V.A." "apellidos" => "González-Delgado" "email" => array:1 [ 0 => "victorgd1989@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Cordero-Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Terrádez-Mas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J.M." "apellidos" => "Martín" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario de Valencia, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Clínico Universitario de Valencia, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Medicina, Universidad de Valencia, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta favorable al tratamiento con alopurinol de reacción granulomatosa a relleno" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 942 "Ancho" => 1255 "Tamanyo" => 424735 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin. A, Intense foreign-body granulomatous reaction (original magnification, ×20). B, Eosinophilic material (original magnification, ×40). C, Basophilic material (original magnification, ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Procedures involving dermal filler for cosmetic purposes are carried out every day. However, this practice is not risk-free. One reported complication is that of foreign-body granulomatous reaction to a component of the filler.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> One of the initial treatment options is infiltration with corticosteroids, although the condition can also be managed with oral allopurinol.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">An 83-year-old woman was referred for a lesion on her left cheek that had been treated for 3 weeks with oral antibiotic therapy (amoxicillin clavulanate, 875/125<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h), surgical drainage, and a 2-week tapering course of oral corticosteroids (starting with prednisone 30<span class="elsevierStyleHsp" style=""></span>mg/d), albeit with minimal improvement. The patient's history was remarkable only for the fact that she reported undergoing surgery in this area some years previously. Similarly, she denied having received infiltrations or fillers. Physical examination revealed a fistulous tract with purulent discharge, depressed areas of scarring, and, adjacent to these areas, a reddish exudative papular lesion. The lesions were surrounded by an edematous area with a doughy consistency, occupying almost the whole cheek (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Ultrasound revealed several nodular hypoechoic lesions that differed in size, the largest being 1<span class="elsevierStyleHsp" style=""></span>cm in diameter. These were mainly superficial, with vascularization in the interior and slightly increased echogenicity of the underlying subcutaneous tissue. A histopathology study was recommended. Biopsy revealed a foreign-body granulomatous reaction in the dermis and subcutaneous tissue, with the presence of 2 different materials in the histology sections: a superficial eosinophilic material with no associated granulomatous reaction and a deeper basophilic amorphous material accompanied by a moderate inflammatory infiltrate composed of macrophages with granular cytoplasm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Given the diagnosis of a foreign-body granulomatous reaction and the uselessness of previous treatments, we offered the patient the possibility of treatment with allopurinol under a compassionate use regimen (300<span class="elsevierStyleHsp" style=""></span>mg/d, po) combined with mometasone furoate in blocks of 15 days every month. This treatment led to a slow but gradual improvement with fluctuations until the lesions were totally controlled 8 months later (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), with resolution of the initial soft tissue edema and atrophic scarring. Treatment was well tolerated, and no adverse effects were reported during follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Comment</span><p id="par0015" class="elsevierStylePara elsevierViewall">While relatively harmless, infiltration of dermal filler is not free of complications, which can be classed as short-term, such as hematomas and infections, and long-term, such as migration of material or foreign-body granulomatous reactions, as in the present case. Granulomatous reactions are more frequent with longer-term fillers, especially those that are permanent or semipermanent, such as silicone, polyacrylamide, and polymethyl methacrylate polymers. Once infection has been ruled out, the most common maintenance treatment reported in the literature is application of topical corticosteroids followed by infiltration of corticosteroids alone or combined with 5-fluorouracil.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> If the product used is suspected of being hyaluronic acid, the infiltration can be with hyaluronidase.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> In more refractory cases, oral corticosteroid regimens can be used. Nevertheless, in the long term, these treatments can lead to unaesthetic adverse effects, such as skin atrophy.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Given the similarity between foreign-body granulomas and sarcoid granuloma,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Reisberger et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> prescribed allopurinol (200<span class="elsevierStyleHsp" style=""></span>mg/d, increasing gradually to 600<span class="elsevierStyleHsp" style=""></span>mg/d). Subsequent studies revealed improvements in granulomatous reactions to silicone<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> and tattoo materials.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7,8</span></a> In these cases, daily doses range from 300 mg<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,7</span></a> to 600<span class="elsevierStyleHsp" style=""></span>mg.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> Oral allopurinol can be combined with infiltrations of 5-fluorouracil and triamcinolone acetonide.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Allopurinol has been associated with downregulation of intracellular adhesion molecule 1 and P2X<span class="elsevierStyleInf">7</span>, which are receptors of the monocyte and macrophage lineages. The reduction in intracellular adhesion molecule interferes with cellular adhesion, and P2X<span class="elsevierStyleInf">7</span> receptors have been associated with the cell fusion process leading to multinucleated giant cells during granulomatous inflammation.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A review of the literature shows that the more superficial material (eosinophilic, with no associated reaction) could correspond to substances such as silicone, paraffin, or polymethyl methacrylate microspheres. Polymethyl methacrylate seems to be the most likely option, since the remaining products usually produce cystic/lanceolate areas in histopathology, with a very characteristic pattern. In morphological terms, the deeper material (basophilic with an associated inflammatory reaction) could correspond to polyacrylamide hydrogel, polyalkylimide gel, polyvinyl hydroxide microspheres in polyacrylamide gel, alginate reticulation, or hyaluronic acid. Given that the patient had undergone surgery several years previously, we can rule out hyaluronic acid, with a permanent filler seeming more likely. Polyacrylamide gel is more multivacuolated in appearance, whereas polyalkylimide is more granular; therefore, the substance involved in the present case could be polyalkylamide.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, we present a case of foreign-body granulomatous reaction with a good response to daily allopurinol 300<span class="elsevierStyleHsp" style=""></span>mg. This treatment could be a useful alternative in patients who do not respond to conventional therapy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Comment" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of Interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: González-Delgado VA, Cordero Romero P, Terrádez-Mas L, Martín JM. Respuesta favorable al tratamiento con alopurinol de reacción granulomatosa a relleno. Actas Dermosifiliogr. 2020;111:439–441.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 517 "Ancho" => 1305 "Tamanyo" => 104410 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Edematous area with loss of expression wrinkles and external orifices of fistulous tracts. B, Reduced edema and scarring of the tracts.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 942 "Ancho" => 1255 "Tamanyo" => 424735 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin. A, Intense foreign-body granulomatous reaction (original magnification, ×20). B, Eosinophilic material (original magnification, ×40). C, Basophilic material (original magnification, ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Facial filler complications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Woodward" 1 => "T. Khan" 2 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 11 | 22 |
| 2024 October | 120 | 54 | 174 |
| 2024 September | 122 | 32 | 154 |
| 2024 August | 139 | 80 | 219 |
| 2024 July | 144 | 44 | 188 |
| 2024 June | 119 | 32 | 151 |
| 2024 May | 109 | 46 | 155 |
| 2024 April | 101 | 30 | 131 |
| 2024 March | 143 | 38 | 181 |
| 2024 February | 126 | 33 | 159 |
| 2024 January | 124 | 29 | 153 |
| 2023 December | 112 | 22 | 134 |
| 2023 November | 145 | 49 | 194 |
| 2023 October | 143 | 39 | 182 |
| 2023 September | 97 | 41 | 138 |
| 2023 August | 101 | 28 | 129 |
| 2023 July | 118 | 41 | 159 |
| 2023 June | 96 | 26 | 122 |
| 2023 May | 134 | 41 | 175 |
| 2023 April | 112 | 20 | 132 |
| 2023 March | 127 | 38 | 165 |
| 2023 February | 129 | 32 | 161 |
| 2023 January | 95 | 24 | 119 |
| 2022 December | 129 | 50 | 179 |
| 2022 November | 91 | 37 | 128 |
| 2022 October | 59 | 37 | 96 |
| 2022 September | 103 | 47 | 150 |
| 2022 August | 51 | 42 | 93 |
| 2022 July | 55 | 68 | 123 |
| 2022 June | 50 | 51 | 101 |
| 2022 May | 169 | 49 | 218 |
| 2022 April | 232 | 41 | 273 |
| 2022 March | 223 | 63 | 286 |
| 2022 February | 186 | 32 | 218 |
| 2022 January | 188 | 40 | 228 |
| 2021 December | 136 | 50 | 186 |
| 2021 November | 163 | 47 | 210 |
| 2021 October | 213 | 72 | 285 |
| 2021 September | 108 | 63 | 171 |
| 2021 August | 142 | 52 | 194 |
| 2021 July | 99 | 38 | 137 |
| 2021 June | 78 | 38 | 116 |
| 2021 May | 81 | 51 | 132 |
| 2021 April | 161 | 105 | 266 |
| 2021 March | 139 | 37 | 176 |
| 2021 February | 83 | 37 | 120 |
| 2021 January | 72 | 17 | 89 |
| 2020 December | 47 | 21 | 68 |
| 2020 November | 25 | 16 | 41 |
| 2020 October | 37 | 7 | 44 |
| 2020 September | 39 | 23 | 62 |
| 2020 August | 48 | 25 | 73 |
| 2020 July | 62 | 30 | 92 |
| 2020 June | 25 | 17 | 42 |
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