CASE REPORT

Mesotherapy-Induced Panniculitis Treated with Dapsone:

Case Report and Review of Reported Adverse Effects
of Mesotherapy
Jennifer Tan and Babar Rao

Background: Mesotherapy is a procedure involving the injection of substances into the dermis and subcutaneous tissue. Used in
Europe for decades in the treatment of various medical conditions and cosmetic fat dissolution, the technique only recently became
widely available in the United States. Mesotherapy has been surrounded by controversy pertaining to efficacy and has been
associated with localized complications, including allergic reactions, necrosis, and infections. Panniculitis is a rare adverse reaction
to mesotherapy that may result from injection pressure, local trauma, or the type of injected substances.
Objective: Treatment options for complications are limited. We report a case of mesotherapy-induced panniculitis successfully
treated with dapsone.
Conclusion: This case illustrates one of the potential adverse effects of mesotherapy and suggests that dapsone may be effective
in the treatment of panniculitis resulting from such injections. Reported adverse effects associated with mesotherapy are also
reviewed.

Antécédents: La mésothérapie est une procédure impliquant l’injection de substances dans le derme et le tissu sous-cutané.
Utilisée en Europe pendant des décennies dans le traitement de diverses conditions médicales et le traitement esthétique de la
cellulite, cette technique n’est devenue offerte à grande échelle aux États-Unis que récemment. L’efficacité de la mésothérapie est
controversée et cette technique est associée à des complications locales dont les réactions allergiques, les nécroses, et les infections.
La panniculite est une réaction néfaste rare à la mésothérapie, qui pourrait résulter de la pression de l’injection, d’un traumatisme
local, ou du type de substance injectée.
Objectif: Les options de traitement en cas de complications sont limitées. Nous rapportons le cas d’une panniculite provenant
d’une mésothérapie qui a été traitée avec succès à la dapsone.
Conclusion: Ce cas illustre l’un des effets secondaires néfastes de la mésothérapie et suggère que la dapsone peut être
un traitement efficace de la panniculite résultant d’une telle injection. D’autres effets néfastes associés à la mésothérapie sont
également rapportés.

Case Report
Approximately 3 weeks after receiving mesotherapy injec-
tions to the thighs for fat reduction, a 47-year-old white
female presented with a slightly painful, reddish dis-
coloration on treatment areas. Small areas were initially af-
From the Division of Dermatology, University of Medicine and Dentistry
of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ.
Address reprint requests to: Jennifer Tan, BA, Division of Derma-
tology, Clinical Academic Building, Suite 5100B, University of Medicine
and Dentistry of New Jersey, Robert Wood Johnson Medical School, New
Brunswick, NJ 08901-1977; E-mail: tanje@umdnj.edu.
DOI 10.2310/7750.2006.00013
fected, which over a few weeks progressed in size to involve
the entire medial thighs. The patient denied any associated
symptoms, including notable lesional discharge, limb swell-
ing, fevers, or chills. She had no significant medical prob-
lems and received mesotherapy only once. The nature and
chemical composition of injected substances could not be
confirmed; however, the patient believed that phospha-
tidylcholine was used. Physical examination revealed diffuse,
slightly tender, livedoid, erythematous patches and sub-
cutaneous nodules appearing bilaterally on the posterior,
medial, and lateral thighs in the distribution of mesotherapy
injections (Figure 1). There was no regional lymphadeno-
pathy. Laboratory workup for systemic disease, including
connective tissue diseases, was negative. The patient was
initially treated with potent topical steroids, and a biopsy was

92 Journal of Cutaneous Medicine and Surgery, Vol 10, No 2 (March/April), 2006: pp 92–95
 Mesotherapy-Induced Panniculitis Treated with Dapsone
Figure 1. Photograph of the patient’s medial thigh prior to treatment.
Numerous erythematous, livedoid patches and subcutaneous nodules
were appreciated on the posterior, lateral, and medial surfaces of
the thighs. The lesions developed on areas subject to previous meso-
therapy injections.
performed. Dermatopathologic examination of the biopsy
showed septal panniculitis with mixed inflammatory cells,
including neutrophils, involving the deep dermis, fat, and
subcutaneous tissue. Fungal, bacterial, and acid-fast bacilli
stains and cultures were all negative.
Unfortunately, the panniculitis subsequently worsened,
and the patient was treated with oral prednisone for
4 weeks, with an initial dose of 60 mg/d. Despite treatment,
she continued to exhibit livedoid, erythematous, hyper-
pigmented patches and was started on dapsone therapy of
100 mg/d following a steroid tapering. The panniculitis
improved within 3 weeks of starting therapy with dap-
sone and resolved after 3 months of treatment (Figure 2).
To our knowledge, this is one of only a few reported cases
of panniculitis resulting from mesotherapy and is the first
in which clinical resolution was achieved through the use
of dapsone.
Discussion
Mesotherapy, a procedure that involves the injection of
substances into the dermis and subcutaneous tissue, was
developed over 50 years ago by French physician Michel
Pistor.1 Although the technique has been used in Europe for
decades, it only recently became widely available in the
United States. Mesotherapy has been used in the treat-
ment of a myriad of conditions, including lipodystrophy,
xanthelasmas, keloids, vitiligo, telangiectasias, lymph-
edema, and pain syndromes, and also has cosmetic applica-
93
tions in the dissolution of fat deposits for weight loss,
cellulite reduction, and body sculpting.2 Although there
are few reports and virtually no clinical trials published
in the English-language literature suggesting safety and ef-
ficacy, the injections have become popular for fat and cel-
lulite reduction.3
The chemical composition of each injection varies with
the purpose of therapy, with popular cocktails often con-
taining a mixture of agents, including anesthetics, lipolytics
such as aminophylline, vitamins, corticosteroids, non-
steroidal anti-inflammatory drugs (NSAIDs), muscle relax-
ants, and plant derivatives.4 Mesotherapy injections may
be single or multiple and are often administered at varied
dosing. Phosphatidylcholine, a phospholipid extracted from
soybean lecithin, is commonly used to treat localized fat
deposits.2,5,6 The drug was initially developed for intra-
venous treatment of atherosclerotic plaques and is used in
certain European countries for the treatment of fat emboli
and morbidly elevated cholesterol.7 The US Food and Drug
Administration has not yet approved phosphatidylcholine,
and its use is widely debated in the medical community.8
Although controversy regarding the use of mesotherapy
appears to focus primarily on efficacy, there are also asso-
ciated risks to be considered. Complications may certainly
arise from treatment, although they appear rather un-
commonly when quantifying published studies and case
reports. As summarized by Rosina and colleagues, possible
systemic adverse effects include allergic reactions, vasovagal
syndromes, lipothymia, lichenoid eruptions, and hemato-
logically transmitted infections, such as hepatitis and
human immunodeficiency virus (HIV). Local side effects
include allergic reactions, atrophy, lipodystrophy, bleeding,
hematomas, necrosis, and infections. These local reactions
Figure 2. Photograph of the patient’s medial thigh after 3 months
of treatment with dapsone, 100 mg/d. Note clinical resolution of
panniculitis.
94 Tan and Rao
are often related to dosage, composition, and the quality of
the injected material.9
Hexsel and colleagues treated 205 patients with cos-
metic injections of phosphatidylcholine in the thighs,
abdomen, hips, flanks, and chin and 8 HIV-positive pa-
tients for buffalo humps or localized fat deposits.2 Within
the first 24 to 48 hours, transient erythema, moderate to
severe edema, and pruritus developed at the injection sites.
In this prospective study, adverse effects were attributed to
the antiseptic technique, physician’s experience, number of
doses, origin of substances used, distance between points,
depth of injection, and postinjection care. Rittes noted
burning with injection, infiltrative edema, and localized
erythema to occur in patients treated with phosphatidyl-
choline injections for lower eyelid fat reduction.6 In a
second study, patients developed localized swelling and
erythema at 6 to 72 hours, as well as nodule and hematoma
formation lasting 15 to 30 days; however, a 4-year follow-up
revealed no other complications.5 In a recently reported
study presented at the annual meeting of the American So-
ciety for Aesthetic Plastic Surgery, plastic surgeons investi-
gating the efficacy of mesotherapy for body contouring
and cellulite reduction reported localized erythema, ecchy-
mosis, and a single case of infection as adverse effects.10
In addition to injection-site erythema and induration,
a commonly reported side effect to mesotherapy is infec-
tion, often originating from either cutaneous bacterial flora
or atypical Mycobacterium species.11,12 French authors re-
ported two cases of cutaneous Mycobacterium bovis bacille
Calmette-Guérin (BCG) abscesses following mesotherapy,
one of which required surgical excision.12 A Mycobacterium
bovis infection also developed in a French woman who
received mesotherapy to the face. Analysis of the organism
revealed the same strain that was used to vaccinate a child
earlier in the day, emphasizing the importance of main-
taining aseptic technique when administering injections.13
Also attributed to poor antiseptic technique were three
cases of cutaneous infection with Mycobacterium fortuitum,
all of which resolved with extended multidrug therapy.11
Furthermore, a novel, rapidly growing Mycobacterium spe-
cies similar to Mycobacterium smegmatis was isolated from a
subdermal granulomatous lesion in a Venezuelan woman
undergoing mesotherapy.4
Mesotherapy has also rarely been associated with more
serious complications, often related to the aseptic tech-
nique but also linked to the substances used and to under-
lying medical conditions. Intradermal NSAID preparations
have been associated with a lichenoid drug eruption.14
French physicians reported the development of local urti-
caria pigmentosa on a patient’s thighs after multiple injec-
tions with procaine and plant extracts, suggesting either
an irritant mastocytic response to mesotherapy or possibly
an underlying case of mastocytosis with a resultant iso-
morphic Koebner response elicited by procaine.15 Interest-
ingly, an isomorphic Koebner response was observed in a
woman with a 10-year history of psoriasis. Several days
after mesotherapy for neuralgic sciatica, psoriatic lesions
developed at the injection site on her thigh, with the si-
multaneous development of pustular lesions on her palms
and soles and worsening psoriasis of the scalp, trunk,
and limbs.9
Panniculitis is also a rare adverse reaction to meso-
therapy, as evidenced by only one reported case series. A
group of dermatologists in Spain investigated seven cases
of cutaneous nodules that developed in patients who re-
ceived injections consisting of a mixture of hyaluronidase,
naftidrofuryl, sorbitol, procaine hydrochloride, and hepa-
rin.16 Multiple inflammatory, draining nodules developed
on the abdomen, buttocks, and lower extremities. Anti-
biotic and anti-inflammatory therapy failed to resolve the
nodules, which healed in a slow, spontaneous manner.
Since tissue stains and cultures were negative, traumatic
injection pressure and substance composition were cited
as possible causes of panniculitis. Histologic analysis dem-
onstrated an acute inflammatory infiltrate consisting of
normal-appearing neutrophils and multinucleated giant
cells within the deep dermis and subcutaneous tissue.
These histopathologic findings were similar to those
seen in our patient’s biopsy, which revealed septal pan-
niculitis with a mixed inflammatory cell infiltrate, includ-
ing neutrophils. Also similar to the case series reported by
Aliaga and colleagues,16 the precise panniculitis-inducing
agent in this case remains unclear. Possible etiologies in-
clude a hypersensitivity reaction to any of the injected
substances, a chemically induced inflammatory response,
localized trauma, injection pressure, or any combination
of these factors. Nonetheless, the presence of abundant
neutrophils on biopsy guided patient management.
Dapsone, a drug with well-known anti-inflammatory,
antimicrobial, and immunosuppressive properties,17 was
selected for use owing to its effects on neutrophils. Through
the inhibition of neutrophil adherence and thus migration
into areas of acute inflammation, dapsone also prevents
further tissue damage induced by the respiratory burst of
activated neutrophils.18 These properties make the drug
particularly useful in diseases associated with neutrophilic
infiltrates, including various autoimmune and bullous dis-
eases. We suspect that the antineutrophilic properties of
dapsone contributed to the resolution of the inflammatory
response elicited by mesotherapy in this patient.
 Mesotherapy-Induced Panniculitis Treated with Dapsone
In summary, we present a case of panniculitis induced
by mesotherapy that was initially unresponsive to steroid
therapy but resolved following treatment with dapsone.
This case and review of the reported side effects associated
with mesotherapy illustrate the numerous potential ad-
verse reactions that may result from the procedure.
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