Brief Report

Vol. 30, No. 5, 2018 617

Received August 14, 2017, Revised September 26, 2017, Accepted for publication October 2, 2017

Corresponding author: Joong Sun Lee, Department of Dermatology, School of Medicine, Eulji University, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea. Tel: 82-42-611-3039, Fax: 82-42-259-1111, E-mail: sun_lee@eulji.ac.krORCID: https://orcid.org/0000-0003-2562-4090

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology

https://doi.org/10.5021/ad.2018.30.5.617

Multiple Cholesterol Granulomas Arising on the Sites of Acupuncture Point Injection with Herbal Ingredient

Jae Hwa Kim, Kyung Eun Jung, Dae Won Koo, Joong Sun Lee

Department of Dermatology, School of Medicine, Eulji University, Daejeon, Korea

Dear Editor:Acupuncture point injection (API), emerged in China dur-ing the 1950s, has been widely accepted and used in vari-ous diseases in Oriental medicine1,2. API is a modified acupuncture technique, injecting liquid agent like herbal extracts into acupoints through acupuncture needles, mainly to relieve pain1,2. It is believed to have a more sus-tained effect than conventional acupuncture by playing a synergistic effect with acupoint stimulation, but has lim-ited clinical evidence2. Acupuncture associated dermatoses commonly manifest as infection and hypersensitivity reactions1, but its patho-physiology is still unclear. Cholesterol granuloma is a for-eign body reaction to crystallized cholesterol, induced by breakdown of blood components after trauma3,4. It shows male predominance and usually found in the frontal bones, zygomatic, and petrous temporal bones with a his-tory of trauma3,4. We present a rare case of multiple cho-lesterol granulomas arising from the site of API with herbal ingredient. We received the patient’s consent form about publishing all photographic materials.A 55-year-old Korean female presented with a fifteen-year history of multiple brownish subcutaneous firm nodules on the trunk. She had been treated with API by oriental medical doctor in order to relieve unexplained general-ized pain. Despite of a number of attempts of API with un-identified herbal ingredient, the symptom did not improve. Thereafter, small brownish firm nodules ap-peared on the trunk insidiously over the years, which were confined only to sites of injections and gradually in-

creasing in numbers and sizes up to 5 to 7 mm in diame-ter (Fig. 1A∼D). There were no laboratory findings sug-gestive of severe systemic adverse reactions, while the pa-tient had significant cosmetic disfigurement. The exci-sional biopsy was performed at the papular lesion on the abdomen. Histologic findings revealed a large number of spindle shaped cholesterol cleft surrounded by multi-nucleated giant cells, which were supportive for cholester-ol granulomas (Fig. 1E∼G). Dozens of subcutaneous nod-ules were removed at the patient’s request. She is being followed up at regular intervals without complications so far.In this case of our patient, multiple cholesterol granulomas were developed from acupuncture sites after API. Although the pathophysiology of cholesterol granuloma is not fully understood, a traumatic or inflammatory event can lead to tissue hemorrhage, followed by formation of crystalline complexes to cholesterol from the destroyed cell mem-branes4. As a result, a slow-growing mass can be devel-oped4. Xanthoma, cutaneous cholesterol emolization, nec-robiosis lipoidica diabeticorum, and necrobiotic xanthog-ranuloma, which can show cholesterol cleft on pathology, could be considered as differential diagnosis5. Acupuncture is a kind of traumatic event, but cholesterol granuloma does not necessarily occur after acupuncture in general. Since the lesions occurred in most sites of the API, we thought that herbal ingredient could have contributed to the development of cholesterol granuloma or could be a direct cause itself. There have been only a few reports about foreign body granulomas occurred after API with herbal ingredient1, but no report of cholesterol granuloma

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618 Ann Dermatol

Fig. 1. Clinical manifestations of the patient and histologic findings after excisional biopsy at the eryth-ematous papular lesion on the abdomen. (A) Multiple erythematous papules and nodules on the abdomen. (B) Closer inspection revealed some erythematous firm papules on the periumbilical area (arrow). (C) Multiple erythematous papules and nodules along the paravertebral area and lower back. (D) Presence of subcutaneous de-pressed nodules at the site of acu-puncture point injection (arrow). (E) There were well demarcated granulomas surrounded by dense fibrous tissue with foreign body reaction and accompanied by cal-cification (H&E, ×40). (F) Identi-fication of multinucleated giant cells at higher magnification (H&E, ×200). (G) There was a large number of spindle shaped choles-terol cleft in the center of granu-loma (H&E, ×200).

so far. Given the fact that acupuncture is widely used em-pirically in the absence of clinical consensus, we strongly suggest that the clinician should be concerned about the various skin diseases that may occur after acupuncture.

CONFLICTS OF INTEREST

The authors have nothing to disclose.

REFERENCES

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Adverse events associated with acupuncture: a clinicopathologic

review. Int J Dermatol 2016;55:757-763.2. Sha T, Gao LL, Zhang CH, Zheng JG, Meng ZH. An update

on acupuncture point injection. QJM 2016;109:639-641.

3. Shrirao N, Mukherjee B, Krishnakumar S, Biswas J. Cholesterol granuloma: a case series & review of literature.

Graefes Arch Clin Exp Ophthalmol 2016;254:185-188.

4. Ezzat TF, Alowami S. Cholesterol granuloma of the anterior mediastinum with osseous metaplasia. Rare Tumors

2012;4:e47.

5. Kim YS, Ju HJ, Park CJ, Lee KH. A case of cholesterol granuloma presenting as a cutaneous nodule. Ann Dermatol

2017;29:383-384.