Oleoma following vitamin K1 injection treated with laser‐assisted drug delivery

Abstract

A 4-month male infant was referred to our department for evaluation of a skin lesion on the right thigh. At birth, the infant received an intramuscular injection of vitamin K1 (phytonadione) on the right thigh. A few days later he developed a nodule at the injection site that was initially diagnosed as an abscess and treated by surgical incision. The lesion worsened and grew to form an infiltrated sclerotic plaque surmounted by a few nodules. On physical examination, there was a 4-cm erythematous infiltrated nodule surmounted by multiple painless erythematous papules and crusted erosions of up to 0.5 cm diameter on the lateral aspect of the right thigh (Figure 1A). Physical examination was unremarkable. A skin biopsy was performed (Figure 2A,B). Histopathologic examination showed a dense inflammatory infiltrate of the dermis composed of giant cells phagocytizing lipid vacuoles, thus concluding in an oleoma. Topical corticosteroids, used once a day for a month, were ineffective. An ablative fractional CO2 laser (10 600 limmer laser, output power freely adjustable between 0.4 and 30 Watts) was used to treat the plaque followed by immediate application of topical corticosteroids. The plaque was treated using a continuous setting with a single pass. The device consists of a fractionated handheld, using a 125 mm handpiece, 10 mm spot, 25% density, and 10 Watts of energy. The session was carried out under local anesthesia. Four sessions were performed at a 1-month interval with a significant improvement (Figure 1B). Vitamin K1 is a fat-soluble vitamin. Intramuscular vitamin K1 may rarely cause localized drug-induced injection site reactions such as hematoma, pain, soreness, and swelling. Less commonly, a pseudo-sclerodermatous reaction, a localized eczematous reaction, and a rare diffuse maculopapular eruption may occur.1 Oleoma is a chronic granulomatous foreign body reaction resulting from oil injections. It is frequently described after self-injection of anabolic steroids or other lipophilic substances such as sesame seed oil in bodybuilders.2 There are also some cases described after injections of subcutaneous vitamin B12 combined with mineral oil to give a slower resorption release and after mesotherapy with unknown substances.3, 4 Oleomas have been linked to subcutaneous injection rather than intramuscular injection.2 A defective injection technique could have played a potential pathogenic role in the occurrence of oleoma in our case. To our knowledge, there are no case reports of oleomas induced by vitamin K1 injection. The clinical presentation of oleoma ranges from inflammatory nodules in the injected site to the formation of hardened, panniculitis-like plaques to severe fibrosis. Oleoma can also present as scars, dyspigmentation, or ulceration. The presentation can be atypical leading to diagnostic delay and inadequate treatment. Differential diagnoses include local abscess formation, hypertrophic scar, vitamin K1-induced morphea or pseudo-sclerodermatous reaction, aluminum granulomas, and cutaneous xanthoma. Diagnosis is facilitated when there is a report of an oily substance injection. The final diagnosis relies upon histopathology which shows a dense inflammatory infiltrate of the dermis composed of giant cells phagocytizing empty material (Figure 2). Complications may occur, such as abscess formation, draining sinuses, lymphangitic spreads, and sometimes ulcerations.5 As in our patient, in the acute phase, surgical procedures may induce the progression of the disease. Treatment is complex and challenging for practitioners. Complete surgical excision has been reported as the first-line treatment for localized lesions. Topical and oral steroids have been tried in multiple lesions with favorable outcomes in some cases. In some other cases, colchicine and tetracycline appeared to help selected patients.6, 7 To our knowledge, the CO2 laser has not been previously used for the treatment of oleomas. Interestingly, in our patient, the lesion was successfully improved with fractional ablative CO2 laser followed by immediate application of topical corticosteroids. The effectiveness of fractional ablative CO2 laser has been proven in the treatment of other granulomatous diseases such as cutaneous leishmaniasis, necrobiosis lipoidica, and sarcoidosis.8-10 Indeed, the CO2 laser creates channels, allowing deeper penetration of topical medication as well as creating microscopic columns of tissue destruction inducing the remodeling of dermal granuloma without any fibrosis.8 In summary, this case serves as a reminder for clinicians to consider oleoma as an unusual side effect of intramuscular vitamin K1 injection in infants. Besides, our case suggests the effectiveness of laser-assisted drug delivery for the treatment of oleomas in infants. Further studies are necessary to confirm our results. R.F., A.C. and A.Z. wrote the manuscript with support from H.H., I.H., F.K. and A.D. analyzed the histopathological images. H.H. and S.F. supervised the project. All authors have read and approved the final manuscript. None. No external funding. The authors declare that there are no conflicts of interest in this work. The authors confirm that the ethical policies of the journal, as noted on the journal's author guidelines page, have been adhered to. No ethical approval was required as this is a review article with no original research data. The examination of the patient was conducted according to the principles of the Declaration of Helsinki. The authors certify that they have obtained all appropriate patient consent forms, in which the patient gave his consent for images and other clinical information to be included in the journal. The patient understands that his name and initial will not be published and due effort will be made to conceal his identity, but that anonymity cannot be guaranteed. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.