Journal of Clinical and Aesthetic Dermatology

APR 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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53 JCAD journal of clinical and aesthetic dermatology April 2017 • Volume 10 • Number 4 C A S E r E p o r T migrate along tissue planes and even work its way into lymphatics, the granulomas may be found distant from the original site of injection or implantation. 1–3 The first documented occurrence of a silicone granuloma was reported in 1964, and multiple cases since then have established a granulomatous response as a recognized complication of silicone injection. 8 The granulomas can occur years after injection, and typically present as soft, fixed nodules with associated swelling and occasional overlying redness. 7 They can also present with systemic signs and symptoms, such as fever and weight loss, mimicking infection or cancer and confounding the clinical picture. 2 This is especially true when the patient seeks silicone augmentation from illegal sources or is embarrassed about receiving cosmetic medical care and is reticent to disclose the procedure to the physician on history. 2,9 The pathophysiology underlying silicone granuloma formation is not completely understood, although it is a subtype of foreign body granulomas. 7 Various proposed triggers of the immune response include infections, trauma, impurities in the silicone, or host proteins that adsorb to the silicone. 2,5,10 These factors, alone or in combination, are presumed to activate T-cells and initiate granuloma formation. More research is needed to define the exact mechanism. Many treatment methods for silicone granulomas have been attempted, all showing varying success rates. When the disease is localized and well-circumscribed, surgical excision has been successful. 11 Intralesional steroids are also a well-recognized treatment of foreign body granulomas in general and silicone granulomas specifically. 2 ,7 However, in cases of widespread disease, such as in the authors' patient, systemic medical treatments are often required in addition to or in place of local therapies. These have included systemic steroid therapy, tetracycline antibiotics, and immunotherapies, such as tacrolimus, etanercept, and imiquimod. 2 ,3,10,12–15 The success of tetracycline-class antibiotics is attributed to their ability to both inhibit microbial growth and suppress fibrosis through host immune system modulation. 16 There have been no large clinical trials to compare the effectiveness of the above modalities, so treatment must be considered on a case-by-case basis utilizing clinical judgment and patient preferences and considering the patient's other medical comorbidities. This case represents the dual challenge of both silicone migration and host granulomatous immune response, making an already difficult condition more challenging to treat. Additionally, this patient shows an extensive contiguous tissue involvement previously unreported in the literature, with the additional unique challenge of unilateral vulvar enlargement producing undesirable symptoms and cosmetic appearance. Her history makes further surgical therapies unlikely to be beneficial. Given the relative safety of tetracycline antibiotics compared to other attempted systemic modalities for this condition (steroids, biologics), it seemed most prudent to attempt a trial of local steroid injection and oral minocycline before initiating more aggressive and potentially dangerous therapeutic options. ACKNOWLEDGMENT The authors would like to thank Dr. Travis W. Vandergriff, MD, of University of Texas Southwestern Medical Center for evaluating the pathology specimens and making the histologic diagnosis. REFERENCES 1. Narins RS, Beer K. Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006;118(3 Suppl):77S–84S. 2. Lopiccolo MC, Workman BJ, Chaffins ML, Kerr HA. Silicone granulomas after soft-tissue augmentation of the buttocks: a case report and review of management. Dermatol Surg. 2011;37(5):720– 725. 3. Paul S, Goyal A, Duncan LM, Smith GP. Granulomatous reaction to liquid injectable silicone for gluteal enhancement: review of management options and success of doxycycline. Dermatol Ther. 2015;28(2):98–101. 4. Altmeyer MD, Andersonn LL, Wang AR. Silicone migration and granuloma formation. J Cosmet Dermatol. 2009;8(2):92–97. 5. Schwartzfarb EM, Hametti JM, Romanelli P, Ricotti C. Foreign body granuloma formation

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