Facial platelet rich plasma injections inducing cutaneous and lymph node sarcoidosis

Dear Editor,

Platelet-rich plasma (PRP) injection is a popular therapy in aesthetic and regenerative medicine. It involves the use of autologous blood products, making it a relatively safe and low-risk office procedure.¹ With expanding applications, newer adverse events are being increasingly recognised.¹

A 37-year-old woman presented with asymptomatic firm nodules on the face for one year and neck swelling for 2-months. She gave a history of undergoing ten PRP sessions 4-years back for acne scars and facial rejuvenation with no history of fever, cough, dyspnoea, vision disturbances, or systemic symptoms. Examination revealed multiple non-tender, uniformly spaced, firm nodules present in a linear fashion on the forehead [Figure 1a-b] and firm nodules present symmetrically over both cheeks on deep palpation. A single, non-tender lymph node was palpable, measuring 3×4 cm in the right supraclavicular region. A biopsy of the facial lesions revealed non-caseating epithelioid cell granulomas with Langhan’s giant cells and lymphocytes without necrosis/foamy macrophages [Figures 2a-2b]. Acid-fast bacilli and periodic acid-fast staining were negative. Fine needle aspiration cytology (FNAC) from the enlarged lymph node revealed multinucleated giant cells, epithelioid cells, and lymphocytes, suggesting chronic granulomatous lymphadenitis [Figure 2c]. Complete blood count, viral markers, inflammatory markers, Mantoux test, chest X-ray, serum angiotensin-converting enzyme levels, Antinuclear antibody (ANA) titres, and calcium levels were normal. Considering lesions appearing in the classical sites of PRP injections on the face and correlating with granulomatous changes on biopsy and FNAC, a diagnosis of cutaneous sarcoidosis triggered by PRP with lymph node involvement was confirmed. The patient was administered intralesional steroids (ILS) at 5 mg/mL in the facial lesions and started on oral prednisolone 30 mg daily. Within 2 weeks of the first ILS session, there was a dramatic improvement, further substantiating the diagnosis. Subsequently, there was almost complete resolution of facial lesions [Figure 3] and a slight decrease in lymph node. She remains under follow-up with no recurrence of lesions.

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Figure 1a and 1b:

Multiple symmetrical, uniformly spaced, firm, deep nodules (red arrow) present in a linear fashion on the forehead (red arrows).

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Figure 2a:

Histopathology showing non-caseating epithelioid cell granulomas with Langhans’ giant cells and lymphocytes in the dermis. (Haematoxylin & eosin,100x).

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Figure 2b:

Non-caseating epithelioid cell granuloma showing multiple Langhans’ giant cells and lymphocytes without necrosis/foamy macrophages. (Haematoxylin & eosin, 200x).

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Figure 2c:

Cervical lymph node FNAC revealing multiple Langhan’s giant cells with epithelioid cells forming non-caseating granuloma. (Haematoxylin & eosin, 400x).

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Figure 3:

Two weeks post-treatment showing significant resolution of forehead lesions after a single session of ILS along with oral steroids.

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Sarcoidosis is a multisystem granulomatous disease and a diagnosis of exclusion due to its varied manifestations. It has numerous known triggers; including botulinum toxin injections, hyaluronic acid injections, and tattoos.² Cutaneous sarcoidosis occurs in up to 30% cases due to aberrant immune response to certain triggers and may be the initial manifestation of systemic sarcoidosis; however, it remains under-reported as patients most commonly present with respiratory involvement.²

This case draws attention to PRP as a potential trigger for cutaneous sarcoidosis. To the author’s knowledge, only three cases of cutaneous sarcoidosis following PRP therapy have been documented. The first was from Japan in 2017, where a patient with a history of PRP injections developed cutaneous sarcoidosis, followed by ocular and pulmonary sarcoidosis.³ However, cutaneous sarcoidosis could not be completely attributed to PRP injections due to prior history of botulinum toxin and hyaluronic acid injections. In 2020, a Chilean woman developed cutaneous sarcoidosis at PRP injection sites with no prior history of injection of foreign materials, but had a history of uveitis prior to PRP therapy; therefore, undetected systemic sarcoidosis could not be completely ruled out.⁴ In 2023, a case was described in Lebanon where cutaneous sarcoidosis following PRP injections developed only after contracting COVID-19, despite the patient showing no similar side effects with previous PRP sessions.⁵ It is likely that COVID infection may have triggered sarcoidosis due to the common immune responses; including the Rat sarcoma (RAS) pathway, cell death pathways, and especially Interferon‐gamma (IFN‐γ), the production of which is triggered by COVID, crucial in sarcoidal granuloma formation.

To the best of our knowledge, the present case documents the first instance of PRP triggering sarcoidosis and presenting first with cutaneous sarcoidosis followed by lymph node sarcoidosis, showing excellent response to oral and ILS. The management strategies of three previously documented cases with favourable outcomes also included topical/ILS as first line for cutaneous sarcoidosis and incorporation of oral steroids/hydroxychloroquine, when associated with systemic involvement.

The causative link between PRP and cutaneous sarcoidosis is hypothesised to be due to growth factors in PRP causing chemotaxis and activating monocytes, thereby triggering granuloma formation.³ Additionally, skin trauma leading to koebnerization may further trigger cutaneous sarcoidosis in genetically predisposed patients. Data pertaining to PRP treatment and cutaneous sarcoidosis are limited to case reports, and more evidence is required to ascertain any causal associations. Physicians should vigilantly evaluate the need for PRP in patients with a history of systemic diseases associated with its complications. This case highlights the rare but significant adverse event of cutaneous sarcoidosis triggered by PRP. Absence of prior COVID infections or symptoms suggestive of systemic sarcoidosis, and no history of injections with foreign materials (fillers or botulinum toxin) unlike previous reported cases, substantiates the potential role of PRP in cutaneous sarcoidosis.