Multifocal scalp abscess with subcutaneous fat necrosis and scarring alopecia as a complication of scalp mesotherapy

Journal of Drugs in Dermatology, Jan, 2008 by Razan Kadry, Issam Hamadah, Abdullah Al-Issa, Lawrence Field, Fahad Alrabiah

Abstract

Over the past several years, there has been a growing interest in the treatment method termed mesotherapy. Marketed for nonsurgical fat melting, skin rejuvenation, and hair regrowth, this technique has become increasingly popular and, in the public's view, it is considered to be a relatively benign intervention method. Mesotherapy was introduced over 50 years ago by M. Pistor, a French physician who utilized this technique initially as a novel analgesic therapeutic method for a variety of rheumatologic disorders. Since its introduction, the basic principal of locally injecting subcutaneous doses of varying chemicals has been expanded and is now utilized for the aforementioned cosmetic concerns. With its increased popularity, there has been an increase in the number of reported side effects resulting from mesotherapeutic intervention. We report multifocal scalp abscesses with subcutaneous fat necrosis as a direct result of mesotherapy; therefore, requiring extensive surgical repair.

Case Report

A 26-year-old Saudi female presented to the hospital with a 10-day history of painful, burning sensation throughout the scalp associated with diffuse draining abscesses. Two weeks prior, the patient had gone to an outpatient clinic where a physician advised her of mesotherapy as a therapeutic option for postpartum hair loss. She reported receiving multiple injections into the scalp containing a mixture of "vitamins." Immediately following the injection, the patient experienced painful, burning sensations which progressively increased in intensity. Simultaneously erythema occurred, and multiple swellings appeared throughout her scalp. Based on this history and clinical presentation, the treating physician from the private clinic suspected herpes zoster and instituted a course of oral prednisone and acyclovir. Despite this treatment regimen, her clinical picture worsened and the patient was admitted emergently to a private hospital and started on meropenam empirically. The abscesses continued to worsen by progressing to draining sinuses, which spread centrifugally to the forehead and glabellar area.

The patient requested a transfer to the King Faisal Specialist Hospital, a tertiary care government-sponsored facility. In the emergency room, she complained of continuing pain, yet she remained afebrile. A vial of the chemicals used in their mesotherapy treatment sessions was obtained from the private clinic. The vial contents, identified by chemical analysis, included a mixture of ingredients with: flavonoside, vitamins (B1, B3, B5, B6, B8, and C), procaine, and saline.

A review of systems was otherwise negative. A CT scan (with and without contrast) was performed and showed 2 sites of fluid collection on the scalp, the loculation on the right extending from vertex-to-glabella. A second loculation on the left extended from the superior parietal area inferiorly to the left temporal fossa. Both areas revealed peripheral enhancement on contrast images. The brain parenchyma and cerebrospinal fluid spaces appeared to be within normal limits. There were no comments, either in the radiology or surgery reports, to rule in the possibility of intravascular occlusive phenomenon.

[FIGURE 1 OMITTED]

The patient underwent incision and drainage with 2 Jackson-Pratt drains inserted. Bacterial cultures of the drained material grew pseudomonas aeruginosa and acinobacter. Piperacillin/tazobactam (Tazocin[R] and ciprofloxacin were promptly delivered intravenously based on drug sensitivity studies. The attending surgeon reported a 7xl0-cm abscess over the left parieto-temporal area and another 4x15-cm abscess oriented longitudinally from the right supraorbital area extending posteriorly to the vertex. There were additional extensive areas of fat necrosis and erosions reaching the outer table of the cortical bone. As these lesions healed, large areas of alopecia amidst pockets of scarring were left as sequelae to the process (Figure 1).

Discussion

Mesotherapy has recently become an increasingly popular procedure. (1,2) Dr. Pistor from France was the first to introduce the concept of mesotherapy in the early 1950s as analgesic therapy in rheumatologic diseases. (3) In the recent past, mesotherapy has become popularized for its claims in the alleviation of a variety of cosmetic concerns, including fat and cellulite reduction, skin rejuvenation, and reducing hair loss. (4,5,6) In facial rejuvenation, a recent series of cases by Amin et al showed no difference between placebo and mesotherapy. (1) Although there are some publications that suggest oral vitamins may show some benefit in treating nonscarring hair loss disorders, there are no studies to date which substantiate the use of mesotherapy (ie, subcutaneous injections of antioxidants and minerals) as part of a therapeutic ladder for alopecia. (7,8)

At present, no pharmaceutical drug of any type is approved by the US Food and Drug Administration (FDA) for use in mesotherapy. (9) Use of medications and substances for non-approved indications may place a practitioner at medicolegal risk. As described by Pistor, the principal of mesotherapy is to apply an adequate amount of medication directly to the area in question rather than parenterally. Furthermore, many topical therapies do not penetrate transcutaneously to a sufficient degree to have a therapeutic affect on the area involved. Compounded mixtures used to date have all been in anecdotal reports and vary from physician to physician. No standardization for the mixtures exists to date.