Delayed-onset granulomatous reaction presenting as chronic facial edema: a review of the diagnostic and therapeutic challenges

Injection of soft tissue fillers for esthetic purposes is considered a relatively simple, minimally invasive procedure. Although rare, significant complications exist and may occur in the setting of both non-medical grade and medical-grade silicone fillers, administered by untrained or trained providers. We report a case of a 61 y/o male with an unusual case of foreign body granulomas arising on his forehead and periorbital region for the past 3 years. He had no drug allergies or history of trauma. He only recalled administration of "Botox" near the affected area 20 years ago, although he acknowledged being unsure of the nature of the substance. Examination showed bilateral, periorbital, edematous plaques, with subcutaneous nodules on the forehead. Punch biopsy showed multiple vacuoles surrounded by collagen bundles in the dermis, a histiocytic infiltrate, and multinucleated giant cells. Based on clinicopathological correlation, a diagnosis of foreign body granuloma related to silicone filler injections was made. He was treated with intralesional steroids and doxycycline 100 mg twice daily with complete resolution. Physicians should acknowledge this potential complication of silicone fillers and should inquire about their use with close-ended questions. We also review the diagnostic and therapeutic challenges faced by physicians when encountering this diagnosis.

Mohs Micrographic Surgery Versus Wide Local Excision in the Treatment of Merkel Cell Carcinoma: A Systematic Review

BACKGROUND

Merkel cell carcinoma (MCC) is an aggressive neoplasm with high rates of recurrences. Current guidelines recommend wide local excision (WLE) with 1 to 2 cm margins. However, Mohs micrographic surgery (MMS) offers a potential advantage over WLE because of its ability of sparing healthy tissue and assessing 100% of margins.

OBJECTIVE

To systematically evaluate the surgical modalities for the treatment of MCC.

MATERIALS AND METHODS

Eligible articles were identified using MEDLINE, Scopus, EMBASE, and Cochrane Library. All available studies investigating surgical treatment of MCC with WLE or MMS were considered.

RESULTS

Forty studies met the inclusion criteria. Thirty-one studies described patients treated with WLE, 3 with MMS, and 6 with either WLE or MMS. Subgroup analysis of Stage I MCC showed recurrence rates similar in both surgical modalities with local recurrence rate of 6.8% for WLE versus 8.5% for MMS (p = .64) and a regional recurrence rate of 15.2% for WLE versus 15.3% for MMS (p = .99).

CONCLUSION

Overall WLE cases were at a higher stage at presentation. Subgroup analysis showed that MMS is not inferior to WLE excision for the treatment of Stage I MCC and is a reasonable option for anatomic locations where tissue sparing is important.

Folliculocystic and Collagen Hamartoma: A Distinct Hamartoma Associated With Tuberous Sclerosis Complex

ABSTRACT

Tuberous sclerosis complex (TSC) is a neurocutaneous disease characterized by cutaneous and extracutaneous hamartomas. Dermatologic evaluation is critical for early diagnosis because mucocutaneous manifestations account for 4 of 11 major and 3 of 6 minor diagnostic criteria. Folliculocystic and collagen hamartoma (FCCH) is a recently described entity associated with TSC. We herein describe the case of a 28-year-old woman with a history of TSC who presented with a scalp lesion present since childhood. Physical examination revealed a solitary, well-circumscribed exophytic tumor over the occipital scalp measuring 9 × 8 cm and covered with comedones and cyst-like structures. Biopsy of the lesion demonstrated thickening of the collagen bundles throughout the dermis, concentric perifollicular and perivascular fibrosis, an increased number of dilated vessels, and keratin-filled cysts lined by the infundibular epithelium. Clinicopathologic correlation was diagnostic for FCCH. The patient was referred for surgical excision. In addition, we review 11 other cases of FCCH previously reported in the literature.