Rarely does injectable hyaluronic acid for soft tissue augmentation produce adverse skin reactions.^1,2 We report a unique case in which the patient not only had a delayed granulomatous reaction at the injection sites, but also developed scleromyxedema, which appeared to be temporally related to the intradermal injection of the hyaluronic acid.

In September 1999, the glabellar and melolabial folds of a 72-year-old woman with a history of tubercular pleurisy were injected with hyaluronic acid gel (Restylane) for the first time. In May 2000, a relapse of her pleurisy was promptly controlled, but soon afterward, indurated erythematous areas developed at the hyaluronic acid injection sites. A skin biopsy specimen revealed a foreign body–type granuloma encircling round and ovoid clear spaces of variable sizes and shapes. Under polarized light, no foreign birefringent material was seen. Alcian blue stain at a pH of 2.5 showed mucin deposits in the sclerotic stroma, but not in the vacuoles. Periodic acid–Schiff, Giemsa, and Fite-Faraco stains revealed no microorganisms. Skin infrared spectrophotometry (Spectrum One Infrared Spectrophotometer; Perkin Elmer Inc, Wellesley, Mass) did not reveal silicone characteristic bands.