Platelet-Rich Plasma Injection and Cutaneous Sarcoidal Granulomas

Abstract

Dear Editor: Sarcoidosis is a systemic granulomatous disease that affects multiple organs including the lung, eyes and skin1. Platelet-rich plasma (PRP) is an autologous concentration of human platelets and has been used for treatment of skin wrinkles2. Here, we report the first case of sarcoidosis diagnosed by lesions of the lung, eyes and skin which was manifested as multiple sarcoid granulomas on the face where PRP had been injected for the treatment of skin wrinkles. A 68-year-old Japanese woman who was suspected of ocular sarcoidosis was referred to us in January 2014 for evaluation of her skin lesions that had developed 5 months earlier. Physical examination showed multiple slightly reddish nodules up to 1 cm in diameter on the cheeks and forehead, around the eyes and mouth (Fig. 1). Her skin wrinkles on the nasolabial folds and outside the eyes had been treated by the injection of hyaluronic acid (12 times) and botulinum toxin (7 times) during 4 years from 2006. Thereafter skin wrinkles on her face had been treated by PRP injection (12 times) during 2 years beginning in 2010. In August 2013, multiple skin nodules had appeared on her face where PRP had been injected. Two months later, she had seen an ophthalmologist complaining of dim eyesight. She had been suspected of ocular sarcoidosis because of her uveitis with granulomatous keratic precipitates and vitreous opacity. She had no other symptoms such as cough. Laboratory finding disclosed an elevated level of angiotensin converting enzyme (37.1 U/ml, normal 7.0~25.0 U/ml) and chest computed tomography showed bilateral hilar adenopathy. Skin biopsy specimen revealed non-caseating granulomas in the mid to deep dermis and subcutis (Fig. 2A). Granulomas contained numerous epithelioid cells and giant cells including Langhans' type with a small number of lymphocytes, indicating the naked granuloma (Fig. 2B). From these findings, the diagnosis of sarcoidosis was made and her skin lesions were effectively treated by topical corticosteroid injection without other systemic treatments. PRP has been used for the treatment of skin wrinkles as it contains various growth factors such as platelet-derived growth factor and vascular endothelial growth factor (VEGF)3. The appearance of cutaneous sarcoid granulomas is well known to be related to the presence of foreign bodies such as silica, silicone and hyaluronic acid4. However, there has been no report of sarcoid granuloma appearing in the skin where PRP has been injected. We could not rule out completely the possibility that hyaluronic acid and botulinum toxin induced the formation of sarcoid granulomas. We speculate that PRP might be a trigger of cutaneous sarcoidal granulomas in an active sarcoidosis patient rather than that systemic sarcoidosis developed related with PRP injection. Although PRP does not contain foreign bodies, it contains various growth factors including VEGF, which is known to be an activating and chemotactic factor for monocytes and might be a triggering factor for cutaneous granuloma formation5. In addition, the possibility remains that cutaneous sarcoidosis developed incidentally at the PRP injection sites by the unknown factors other than PRP itself under the active sarcoidosis patient.