Periorbital granuloma annulare following mesotherapy

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