Description of Event or Problem · 1
SKIN NECROSIS. CASE DESCRIPTION: THIS SERIOUS DEVICE REPORT FROM (B)(6) WAS PUBLISHED IN THE JOURNAL OF CUTANEOUS MEDICINE AND SURGERY. THE PT, A (B)(6) MALE WITH OSTEOARTHRITIS, EXPERIENCED SKIN NECROSIS FROM INTRA-ARTICULAR INJECTION OF HYALURONIC ACID (PRODUCE NAME UNSPECIFIED, FORMULATION UNSPECIFIED AND DOSE UNSPECIFIED) INTO HIS RIGHT KNEE. TISSUE NECROSIS IS A RARE AND SERIOUS COMPLICATION OF HYALURONIC ACID (HA) INJECTIONS, OFTEN ADMINISTERED AS COSMETIC DERMAL FILLERS TO REDUCE WRINKLES AND FINE LINE AND REVITALIZE FACIAL APPEARANCE. A FEW CASES OF TISSUE NECROSIS IN THE GLABELLAR OR ALAR REGIONS DUE TO HA INJECTIONS FOR COSMETIC PURPOSES HAVE BEEN REPORTED. WE PRESENT A CASE OF LIVEDOID EPIDERMAL NECROSIS AS AN UNUSUAL COMPLICATION OF INTRA-ARTICULAR (IA) HA ADMINISTERED TO TREAT OSTEOARTHRITIS (OA). A (B)(6) MAN PRESENTED WITH A 1-MONTH HISTORY OF PAINFUL SKIN ERUPTION OVER THE RIGHT KNEE. THE ERUPTION DEVELOPED 48 HOURS AFTER A BILATERAL KNEE INJECTION WITH IA HA FOR TREATMENT OF KNEE OA. ON EXAMINATION, THERE WAS A WELL-DEMARCATED, LIVEDOID (NET-LIKE), VIOLACEOUS PATCH ON THE RIGHT KNEE WITH A DARK CENTER AND A LIGHTER BORDER. THE LEFT KNEE WAS NORMAL. A PUNCH BIOPSY OF THE SKIN WAS PERFORMED AND SHOWED ATROPHIC EPIDERMIS WITH PATCHY NECROSIS. THE VIABLE PORTIONS OF THE EPIDERMIS REVEALED REACTIVE KERATINOCYTES ADMIXED WITH SCATTERED NECROTIC KERATINOCYTES. IN THE DERMIS, THERE WAS AN AMORPHOUS BASOPHILIC FOREIGN MATERIAL CONSISTENT WITH HA PRESENT WITH BOTH THE DERMAL STROMA AND A MEDIUM SIZED VEIN WITH AN ASSOCIATED THROMBUS FORMING. HENCE, THE HISTOLOGIC FINDINGS WERE CONSISTENT WITH TISSUE NECROSIS DUE TO IA HA INJECTION ENTERING THE CUTANEOUS VASCULATURE. THE PT WAS TREATED CONSERVATIVELY WITH TOPICAL FUSIDIC ACID DRESSINGS. THE LESION RESOLVED IN 4 MONTHS' TIME. IN GENERAL, THE CONSENSUS IS THAT HA FOR KNEE OA SEEMS SAFE AND WELL TOLERATED; ADVERSE EVENTS ARE RARE, BENIGN, TEMPORARY, AND LIKELY ASSOCIATED WITH THE IA INJECTION. A RARE YET POTENTIALLY SERIOUS COMPLICATION OF IA HA IS TISSUE NECROSIS, AS DESCRIBED IN THIS CASE PRESENTATION. THERE HAS BEEN ONE CASE REPORT OF SKIN NECROSIS FOLLOWING IA HA INJECTION, BUT CASES OF TISSUE NECROSIS IN THE GLABELLAR OR ALAR REGION OF THE FACE FOLLOWING HA FILER INJECTION FOR COSMETIC PURPOSES ARE WELL DOCUMENTED. THE PATHOPHYSIOLOGY OF THIS ADVERSE EFFECT IS NOT FULLY UNDERSTOOD; HOWEVER, SIMILAR TO THE MECHANISM BY WHICH FACIAL FILLERS CAUSE CUTANEOUS NECROSIS, IT IS HYPOTHESIZED THAT THE TISSUE NECROSIS IS DUE TO DIRECT INJURY, COMPRESSION, OR OCCLUSION OF THE VASCULATURE IN THE INJECTION SITE BY THE FILLER MATERIAL (I.E., HA), WHICH IN TURN LIMITS VASCULAR SUPPLY, LEADING TO ISCHEMIA AND TISSUE NECROSIS. IN THE CASE OF OUR PT, IT IS POSSIBLE THAT EITHER THE INJECTION OF HA INTO THE INCORRECT ANATOMIC SITE OR THE ESCAPE OF HA FROM INSIDE THE JOINT DUE TO VESSEL RUPTURING BY DIRECT INJURY OR ENDOTHELIA ACTIVATION CAUSED THE OCCLUSION OF THE DEEP VEINS. ALTHOUGH MANY CASES OF CUTANEOUS NECROSIS ARE ASSOCIATED WITH INTRA-ARTERIAL INJECTIONS, THE PRESENCE OF HA IN THE VEIN CAUSING NECROSIS HAS ALSO BEEN REPORTED. THERE IS A PAUCITY OF LITERATURE ON THE TREATMENT MODALITIES FOR EPIDERMAL NECROSIS DUE TO HA INJECTIONS. SOME OF THE TREATMENT OPTIONS REPORTED FOR THE MANAGEMENT OF SKIN NECROSIS FOLLOWING HA INJECTION INCLUDE HYALURONIDASE INJECTION, 2% NITROGLYCERIN PASTE MASSAGE, WARM COMPRESSES, TOPICAL OXYGEN INFUSION CREAM, ASPIRIN, METHYLPREDNISOLONE, SILDENAFIL, AND, IN SEVERAL CASES, HYPERBARIC OXYGEN. TO PREVENT FURTHER ADVERSE COMPLICATIONS OF IA HA INJECTIONS, THE PHYSICIAN MUST BE WELL AWARE OF THE RELEVANT ANATOMY, AS WELL AS THE APPROPRIATE VOLUME AND DEPTH WITH WHICH TO ADMINISTER THE FILLER INJECTIONS. SENDER COMMENT: REPORTER CAUSALITY: LIKELY RELATED.