LETTER TO THE EDITOR Granuloma formation after oil-soluble vitamin D injection for lip augmentation – case report Editor Common minimally invasive cosmetic dermatologic procedures, including injectable fillers are safe when performed by experi- enced board-certified dermatologists. Adverse events occur in less than 1% of patients, and most of these are minor and tran- sient. 1 Improper product use as a filler such as oil-soluble vita- mins can lead to many side-effects. 2 We report a case of nodular fibrosis and granuloma for- mation in 30-year-old white female patient presented to us 2 years after performing a procedure for lip augmentation in a cosmetic centre. The procedure was performed by a beauti- cian. The injected substance had been aspirated with syringe from vitamin D yellow gel capsules made for oral supple- mentation, then injected into the upper and the lower lips of the patient from both sides. After 3 months two nodular lesions on both lips were noticed. Physical examination revealed two firm dermal nodules, a big one (5 9 5 mm), located on the left side of the upper lip and a smaller one (2 9 2 mm), localized on the left side of the lower lip (Fig. 1a). General physical examination and laboratory find- ings were unremarkable, and there were no systemic symptoms. A decision of surgical excision of the upper nodule was made. Histological analysis revealed acanthotic epidermis, fibrotic col- lagen and broad clefts splitting the whole papillary and reticular dermis, foreign body granuloma with multinucleated giant cells intermingled in the fibrotic collagen (Fig. 1b). Reported complications following soft-tissue augmentation are distinctive and consequence of poor injection technique, the filler material itself, or improper procedure sterilization. Each filler product has unique complications due to the composition of the product, injection techniques and dilutions. 3 In general complications of filler injections involve: local injection site reactions such as swelling, bruising, pain and pruri- tus; infections such as reactivation of herpes simplex virus, bac- terial infection with Mycobacterium abscesses, other soft-tissue infections of the face and development of a biofilm. 4 Other com- plications include: vascular occlusion which can lead to tissue necrosis and permanent scarring, ulceration, persistent erythe- matous nodules and granulomas. Rare cases of angioedema and other hypersensitivity reactions have been reported in the literature. 5 Improper product use such as oil-soluble vitamins can lead to the rise of lipogranulomas, 6 sclerodermoid lesions, subcutaneous nodules, oedema and/or hyperpigmentation at the site of injec- tion, deformation and ulceration. Soft-tissue infection and lymph adenopathy can also occur. 7 The treatment is difficult and needs immediate management to prevent disfiguring outcomes. Adequate surgical removal of the oil from the tissues is necessary to prevent serious late sequels; however, it is possible only by encapsulated and recalci- trant granulomas. Other options are intralesional or systemic glucocorticosteroids. The use of allopurinol and colchicine is ideal for treatment of larger and resistant to therapy lesions. 8 Other therapeutic alternatives include minocycline, cyclosporine and 5-fluorouracil. 9 Intralesional laser technology using 808-nm diode laser melt and liquefy the organic and synthetic compo- nents of the granulomas, facilitating subsequent evacuation. 10 In the presented case we performed surgical excision of the disfig- uring larger fibrotic nodule, trusting that other modalities of treatments will offer a little if any effect in this case. In conclusion this case represents the danger from the use of unsuitable products for lip augmentation. The performance of such procedure by beauticians and not by certified physicians can lead to serious and difficult for treatment side-effects which may cause permanent deformity. B. Kamouna, 1, * I. Litov, 2 E. Bardarov, 1 V. Broshtilova, 1 L. Miteva, 1 J. Kazandjieva 1 1 Department of Dermatology and Venereology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria, 2 Hospital Europe, Europe Aesthetic centre, Sofia, Bulgaria *Correspondence: B. Kamouna. E-mail: kamouna_ban@yahoo.com (a) (b) Figure 1 Clinical features and histological findings. Two firm nodular lesions on the left side of the upper and the lower lips (a). Histopathology examination of excised lesion (hematoxylin/eosine stain, magnification X40). Papillary dermis, foreign body granu- loma with multinucleated giant cells intermingled in the fibrotic collagen (b). © 2015 European Academy of Dermatology and Venereology JEADV 2015 JEADV