Papanicolaou Cytology as a Suitable Technique for a Diagnostic Approach to an Adverse Reaction to Polyalkylamide Gel Filler

Abstract

To the Editor: Mr. Editor: the use of fillers in cosmetic dermatology has increased in recent decades.1 However, there is not yet a perfect material because all of them can induce adverse reactions, although some fillers are known to be riskier than others. Sometimes these reactions can be serious and require early treatment.2 We present a clinical case of a severe inflammatory reaction by polyalkylamide gel (Bio Alcamid), where Papanicolaou cytology allowed us to perform an early diagnosis. We present a 59-year-old woman referred to our service by her primary care physician because of a left facial cellulitis that did not improve with antibiotic treatment. The examination revealed a warm erythematous plaque with ill-defined borders located in the left periorbital area and cheek (Fig. 1, up). There were palpable but not fluctuating subcutaneous nodules, not attached to deep tissues of the face. An ultrasound was performed showing multiple round hypoechogenic lesions with posterior reinforcement and without visible vascularization in Doppler mode. A punch biopsy was performed, and yellowish gelatinous material drained from the incision (Fig. 1, down). A sample was taken to perform a Papanicolaou stain, where we observed a basophilic amorphous material surrounded by an intense inflammatory infiltrate constituted mainly by neutrophils and erythrocytes (Fig. 2). The patient was treated with 30 mg of oral prednisone and systemic antibiotic therapy. In addition, a new suborbital incision was made to drain the material that still persisted after the biopsy. The lesions resolved completely within 10 days of treatment. The skin biopsy finally confirmed the diagnosis of late adverse reaction to polyalkylamide gel (Fig. 3). The filling material was visible as an intensely basophilic, nonvacuolated amorphous material that occupied the whole deep dermis and was surrounded by red blood cells and an intense inflammatory reaction.FIGURE 1.: Erythematous plaque with ill-defined borders located in the left periorbital area and cheek. A yellowish gelatinous material drained from the incision after of punch-biopsy.FIGURE 2.: Papanicolaou stain shows a basophilic amorphous material surrounded by an intense inflammatory infiltrate constituted by neutrophils and erythrocytes.FIGURE 3.: Skin biopsy shows a basophilic, nonvacuolated amorphous material that occupied the whole deep dermis and was surrounded by red blood cells and an intense inflammatory reaction.Each filler presents specific histopathological features, so it is important to know these features and be able to recognize them.3 Cytology can be a useful technique to guide the diagnosis faster than conventional skin biopsy and offer an optimal early treatment. To the best of our knowledge, there is only 1 article analyzing the cytological characteristics of the polyalkylamide gel by Papanicolaou staining.4 The view of an amorphous basophilic material surrounded by inflammatory cells and erythrocytes in the cytology is similar to the findings in the histopathological analysis. As a conclusion, we propose Papanicolaou cytology as a technique able to offer an adequate diagnostic approach to adverse reactions to polyalkylamide gel. Further studies are needed to confirm our findings and to analyze the cytopathological correlation of this technique on other filler materials.