Authors' response: Platelet-rich plasma injections and the development of cutaneous sarcoid lesions: A case report

To the Editor: We appreciate the opportunity to respond to the letter by Abrahams et al¹ regarding our recently published report “Platelet-Rich Plasma Injections and the Development of Cutaneous Sarcoid Lesions: A Case Report.”²

We would like to thank Abrahams et al¹ for presenting the idea that silicone oil may be the agent responsible for causing the clinical manifestations in our patient. Silicone oil is a commonly used lubricant for syringes, often present in their internal coating. Abrahams et al¹ hypothesized that syringes used during platelet-rich plasma injections may have contributed to the development of siliconomas in our patient, clinically mimicking sarcoidal granulomas. Although a feasible theory, we strongly believe that the clinical findings in our patient were secondary to the Koebner phenomenon in a patient with previously undetected sarcoidosis.

There is considerable evidence in the literature that silicone oil from silicone injections and silicone breast implants may cause systemic autoimmune reactions.³ Although Lemes et al⁴ described a case of syringe silicone oil causing local dermatologic reactions, to our knowledge there are no reports of silicone oil from a syringe that resulted in systemic autoimmune reactions. Therefore, although it might be plausible for our patient's cutaneous lesions to be due to siliconoma formation, it is highly unlikely that silicone oil caused the characteristic sarcoidosis finding of pulmonary lymph node granuloma formation observed in our patient.

Abrahams et al¹ mentioned that patients with exposure to silicone, often used in medical implants, are at risk for the development of autoimmune/inflammatory syndrome induced by adjuvants. Although this finding is pertinent, it is unlikely in our patient because the exposure was limited to silicone oil from syringes.

In contrast, there is documentation of the Koebner phenomenon in patients with sarcoidosis occurring after skin injury from both broadband light therapy and various cutaneous injections.^2,5 We stand by our assertion that the cutaneous lesions in our patient are the result of a Koebnerization reaction to the skin trauma caused by the needle during platelet-rich plasma injections.

Although uveitis is associated with silicone oil droplets after syringe agitation,⁶ our patient had a history of uveitis that existed before exposure to silicone oil. Additionally, uveitis can present as the only clinical manifestation in patients with sarcoidosis, making it more likely that our patient had undetected sarcoidosis. In cases of uveitis development after exposure to silicone oil, there was no evidence of progression to systemic involvement.⁶ In contrast, our patient received bronchoscopy, with biopsy revealing noncaseating granulomas, leading to the diagnosis of sarcoidosis.

An excellent point raised by Abrahams et al¹ was regarding the distinction of sarcoidal granulomas from siliconoma granulomas on pathology because silicone is washed off during slide processing. Although we agree with Abraham et al¹ that silicone oil syringe lubricant is both a foreign material and could cause cutaneous reactions, we believe that the accumulation of clinical findings in our patient's case suggests that the findings were secondary the Koebner phenomenon that occurred in a patient with systemic sarcoidosis.