35423 ASIA syndrome following deoxycholic acid injection

Abstract

A 50-year-old woman with a history of hypertension presented for progressive and debilitating cutaneous fibrosis. Onset occurred after injection of an Argentinian deoxycholic acid product (46% “Desoxicolato”) meant to induce cosmetic lipolysis. The examination revealed sharply demarcated, indurated, depressed plaques with an inflammatory border on the left arm, hips and buttocks. Laboratory values were notable for thrombocytosis, but otherwise unremarkable complete blood cell count and comprehensive metabolic panel. ANA, anti-scleroderma, anti-centromere, SM, and SM/RNP antibodies were negative. Histopathology had features suggestive of scleroderma or scleredema. MRI revealed diffuse subcutaneous edema in the left arm and pelvis. Given acute worsening, she was hospitalized for intravenous methylprednisolone and sirolimus, before being discharged on an oral prednisone taper and sirolimus. She continues to follow longitudinally and was recently initiated on mycophenolate mofetil. Gas spectrometry analysis was considered but the there was no additional product available. ASIA syndrome (autoimmune/inflammatory syndrome induced by adjuvants) is an umbrella term encompassing syndromes united by the underlying hypothesis that genetically susceptible individuals exposed to an adjuvant may develop granulomatous or systemic autoimmune disorders. There remains controversy over the diagnosis, as the criteria regarding adjuvant dose or temporal association evolve. Historically management of ASIA syndrome was guided by explantation of extraneous substances from the body; however, recent data suggest a role for immunomodulatory and immunosuppressive therapy, including corticosteroids and calcineurin inhibitors. In light of the epidemic of illicit cosmetic procedures, sometimes using counterfeit or contaminated products, dermatologists should educate patients about how to identify appropriate product, technique, and practitioners.