Facial Oil-Granuloma due to Almond Oil and Vitamin E Oil Injection

Dear Editor,

Foreign body granuloma (FBG) is a reaction pattern marked by granulomatous inflammation in response to retained exogenous material. Such a foreign body reaction in the skin, when occurs in response to exogenously derived lipids or oil-like substances, is known as lipogranuloma or oil granuloma.[1] Here, we describe one such case of oil granuloma on the face induced by a self-injected mixture of almond oil and vitamin E oil.

A 40-year-old male presented with the complaint of swelling around his eyes, making it difficult to open them completely. On examination, we noted multiple round yellowish-brown papulo-nodular lesions overlying a dusky erythematous background in the bilateral periorbital and temporal regions [Figures 1, 2a and b]. On palpation, diffuse woody-hard induration was felt around the eyes. There was no associated complaint of pain or pruritus.

Figure 1.

Multiple round yellowish-brown papulo-nodules on a dusky erythematous background in the periorbital region

Figure 2.

(a and b) Left and right lateral views showing yellowish-brown papulo-nodules in the lower part of the temporal region

He gave a history of beestings in the involved area a few weeks ago, which led us to think of pseudo lymphoma as one of the possible diagnoses. Since the diffuse involvement and nature of induration did not seem consistent with an insect bite reaction, we further elicited the history. He finally admitted to having given a spurious history previously and revealed that he had infact self-injected sweet-almond oil mixed with oil extracted from Vitamin E capsules in the periorbital skin around 8 weeks ago for treatment of wrinkles after watching a YouTube video advising the same.

Suspecting a FBG, a biopsy was taken to rule out other differentials like xanthogranuloma and pseudo lymphoma. The histopathological examination showed a clear ‘holes in Swiss cheese’ pattern throughout the dermis and extending into the subcutis, reminiscent of an oil-injection granuloma [Figure 3]. In the center, a moderately dense neutrophilic infiltrate with edema was seen between the holes, while the periphery of the section displayed a lymphohistiocytic infiltrate with scattered foamy histiocytes. Thus, the diagnosis of suppurative and foreign body-oil injection granuloma was confirmed.

Figure 3.

‘Swiss cheese pattern’ with multiple round to ovoid vacuoles encompassing the dermis (H and E, 100×)

The patient was prescribed oral prednisolone 40 mg and minocycline 100 mg once daily. He was counseled about the benign yet chronic nature of the condition and advised to follow up at bi-weekly intervals while exercising further patience and caution.

FBG formed as a result of the introduction of exogenous oil or oil-like substances in the skin is known as lipogranuloma, or simply, oil granuloma. Other descriptive terms like oleoma or paraffinoma have also been ascribed to it. Inciting agents could include paraffin, petrolatum, lanolin, vegetable oils, beeswax, etc.[2] Even though intradermal or subcutaneous injection of oil is not medically indicated for aesthetic purposes, it has been notoriously used by overenthusiastic patients for the same.

Oil granuloma may clinically resemble conditions like xanthogranuloma, pseudo lymphoma, sarcoidosis, subcutaneous granuloma annulare, implant nodules (from dermal fillers), atypical mycobacteria, and deep fungal infections. Histological differentials include paraffinoma and signet-ring cell carcinoma. The typical histopathological features of FBG vary with the filler substance used. Hyaluronic acid (HA) fillers may lead to the formation of cystic granuloma due to the encapsulation of HA and the subsequent formation of palisading granulomas consisting of giant cells and macrophages. Granulomas formed due to collagen fillers show similar features (cystic granulomas). Silicone and polyacrylamide gel fillers lead to lipogranulomas with clear vacuoles surrounded by mixed inflammatory infiltrates and giant cells. Calcium hydroxyapatite naturally occurs in human bones and teeth and, thus, doesn’t incite granuloma formation due to its biocompatibility. Paraffin and similar oily substances cause ‘Swiss-cheese’- patterned lipogranulomas.[3] There is a characteristic replacement of the dermal tissue by round to ovoid clear vacuolar structures, giving it a ‘Swiss cheese’ appearance.[4] These vacuoles are presumed to have previously contained the injected lipid, which is lost during tissue processing. An interspersed granulomatous infiltrate is common, but giant cells are usually not found.

Though the exact pathogenesis of this entity remains elusive, an interplay of various factors, like substance purity or lack thereof, individual susceptibility, site, and the amount injected, has been suspected to lead up to the reaction pattern.[5] Pathologically, oil granulomas have three sequential phases: the inflammatory phase, the latency phase, and the final phase of granulomatous inflammation, which is mainly responsible for the chronicity of the condition.[4]

Treatment of oil granulomas and other FBGs poses a major challenge to clinicians in the current age of internet quackery. Medical treatment includes oral and/or intralesional corticosteroids, broad-spectrum antibiotics, retinoids, pentoxifylline, and allopurinol. Tetracyclines, particularly minocycline (upto 100 mg twice daily), have proven to be useful in the treatment of FBGs due to their anti-inflammatory, immunomodulatory, and anti-granulomatous effects.[6] Surgical excision offers a quick solution with less downtime but may not always be practical in cases with extensive involvement.

Lipograuloma, or oil-granuloma, is a seldom-reported peculiar condition that can be encountered in dermatological practice. Based on the site and clinical appearance, it may mimic a number of spontaneous or reactionary skin conditions. This clinical confusion may be compounded by the reluctance of an anxious patient to admit administration of a foreign substance without having sought any medical advice. Through this case of oil-granuloma precipitated by self-injected almond oil and vitamin E oil, we aim to not only contribute to the available literature but also highlight the importance of detailed history in case of any suspicion. Prompt diagnosis with histopathological examination and timely medical and/or surgical intervention may help prevent further complications.

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Conflicts of interest

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