Problems after Mesotherapy: Infection, Nodules and Granulomas, Allergy, Panniculitis and Pigmentation — What Can Be Done?

What problems can occur after mesotherapy?

Mesotherapy is the delivery of various substances into or beneath the skin by a large number of small injections. It is not a single procedure but a group of treatments whose contents and technique vary widely; for details and the state of the evidence, see our article “Mesotherapy”. This article focuses on the problems that can arise after the procedure.

An international consensus report on mesotherapy groups adverse effects into three: those due to the minor trauma caused by the needle (pain, bruising), local or general reactions due to the product injected, and those arising from failure to follow hygiene rules or from faulty technique. This distinction is useful, because most of the problems in the second and third groups can be prevented with the right product and the right conditions.

We have dealt separately with the particular problems of 'fat-dissolving' injections targeting fat tissue (marked swelling, skin ulceration, nerve effects, surface indentation) in our article “Problems after Fat-Dissolving Injections and Mesotherapy”; we do not repeat them here.

How long do redness, swelling and bruising last?

Small bumps, redness, a burning or stinging sensation and mild itching at the injection points are usual in the first hours. Small bruises and mild swelling, especially around the eyes, may last a few days. These symptoms should lessen a little each day; for their course, you can look at our article “Bruising and Swelling”.

Redness, warmth, pain or discharge that increases rather than lessens, new raised areas appearing days later, and firm areas that have not disappeared after weeks are outside the expected course.

How can infection after mesotherapy be recognised?

Every injection opens a small route in the skin through which germs can enter; in mesotherapy the number of these points is very large. Early bacterial infections usually show themselves in the first days with increasing redness, warmth, pain, pus-like discharge and sometimes fever. You can find details of these symptoms in our article “Infection after Aesthetic Treatments”.

The real problem specific to mesotherapy, however, is infection that appears late. Weeks after the procedure, numerous red-purple, painful, firm and sometimes discharging swellings appear at the injection points. There is often no fever or general feeling of being unwell; for this reason they may be taken for spots, insect bites or an allergy, and time may be lost.

What do the outbreaks of atypical mycobacteria show?

A significant proportion of these late infections are caused by germs called atypical mycobacteria, which are found in water and the environment and often do not respond to ordinary antibiotics. A systematic review examining these mesotherapy-associated infections identified a total of 423 patients in 30 publications. Most of the patients were women; the lesions were seen mostly on the abdomen, buttocks and thighs. Most infections resolved with treatment with medicines, but many patients needed more than one medicine or course of treatment, healing took weeks and scars were often left.

Outbreak reports show that the source is often preventable. In an outbreak in France, the germ was recovered both from patients and from the environment; cleaning of the multiple-injection device with tap water was identified as the likely source. In another cluster, reported by the U.S. Centers for Disease Control and Prevention (CDC), the injections were given in a house by a person who was not licensed to practise medicine. Patients reported that hand cleansing, skin antiseptic and gloves were not used and that medicine was drawn from multi-dose vials; when they were interviewed, 10 to 16 weeks after the procedure, the lesions were still present in 11 of 14 patients.

In this picture, the physician needs to request special culture tests for the correct diagnosis. For this reason, when you see a physician about swellings that appear weeks later, be sure to say that you have had mesotherapy, and where and when.

What are nodules and granulomas, and how do they differ from infection?

A nodule is a firm lump that can be felt in or beneath the skin. A granuloma is inflammatory tissue formed by the immune system surrounding a substance that has entered the tissue and that it cannot clear away. After mesotherapy, foreign-body-type granulomas developing in response to the substance injected have been reported. These usually appear weeks or months later as firm, red or skin-coloured raised areas corresponding to the injection points.

In one published case, numerous granulomas developed on the face after a product that was not manufactured for injection and not approved for that purpose was delivered into the face by mesotherapy. Injecting into the skin cosmetic products that were manufactured to be applied to its surface is particularly risky in this respect.

A granuloma and an atypical mycobacterial infection can look very alike from the outside, but their treatments are entirely different. The distinction is made by examination and, if necessary, imaging, a tissue sample (biopsy) and culture. This is why trying to treat nodules on your own with corticosteroid or antibiotic medicines both delays the diagnosis and can make matters worse.

What is inflammation of the fat tissue (panniculitis) like?

Panniculitis is inflammation of the fat tissue beneath the skin. After mesotherapy, especially with treatments to the body, it has been reported as deep, painful, red-purple firm areas at the injection sites. It is thought that this may be due to the pressure of the injection, to local trauma or to the injected substances themselves; mycobacterial infection can also present with the appearance of panniculitis.

In the tissue samples taken in the cluster investigated by the CDC, damage and inflammation were found in the fat tissue; although the findings were consistent with infection, the possibility of a chemical or allergic reaction could not be ruled out because the injected substances could not be recovered. As it heals, panniculitis can leave depressions, scars and darkening in the skin; for this reason early assessment is important.

Can mesotherapy cause an allergy?

It can. Mesotherapy mixtures often contain more than one substance, such as vitamins, plant extracts, local anaesthetics and preservatives. As the number of substances increases, so does the likelihood of an allergy to one of them, and when a reaction develops it becomes harder to find the substance responsible. 'Natural' or 'herbal' contents do not mean that there will be no allergy.

An allergy may remain local, as itchy raised areas at the injection points that last longer than expected and hives; very rarely it may turn into a severe condition affecting the whole body (anaphylaxis). For details of the symptoms and what to do, see our article “Allergic Reactions in Aesthetic Treatments”. Be sure to mention your known allergies and any reactions you have had to an injection before the procedure.

Does mesotherapy leave marks?

Small brown marks may be left at the injection points. The most common reason is that inflammation or bruising in the skin leaves darkness behind as a mark while healing (post-inflammatory hyperpigmentation). It is more common in darker skin and in skin exposed to the sun during the healing period. Darkening left after infection, granulomas and panniculitis may be more noticeable and longer-lasting.

Most marks of this kind fade over months; sun protection affects the process markedly. Do not use skin-lightening products on your own; for the general causes of pigmentation and the options, see our article “Dark Spots and Melasma”.

Why are mixtures with unknown contents the real problem?

There is no common, standard formula for the mixtures used in mesotherapy. The international consensus report states that mixtures cannot be said to be more effective than individual substances, because the mixtures are so varied and the components have not been compared one by one. The report recommends that mixtures be made only with products authorised for use together, and that different substances be given with separate syringes and at separate points.

A mixture whose contents are unknown creates three separate problems: its sterility and purity are not known; whether you are allergic to one of the components cannot be assessed in advance; and when a problem arises, the physician cannot know what they are dealing with. In the cluster investigated by the CDC, patients were told that plant extracts had been injected, but because the vials could not be found the real contents were never established. For details, see our article “Counterfeit Products and Unlicensed Treatments”.

Normal, consult a physician, or an emergency?

What can your physician do?

The physician first examines you and asks when, where, by whom and with which product the procedure was done. Depending on the situation, the following approaches may be considered:

• For expected side effects: monitoring and aftercare advice.
• For an allergic reaction: the treatment the physician considers appropriate; for a severe reaction, emergency treatment and afterwards referral to the relevant specialty to investigate the substance responsible.
• Where infection is suspected: taking a sample from the discharge or tissue; for swellings that start late, requesting special culture for mycobacteria.
• For an atypical mycobacterial infection: treatment conducted together with an infectious diseases specialist, in which more than one medicine is often used together over a long period, and surgical drainage if necessary.
• Where a nodule, granuloma or panniculitis is suspected: imaging such as ultrasound, a biopsy if necessary, and treatment chosen by the physician according to the result.
• For marks and scars that remain: discussion of suitable options once the inflammation has completely settled.

For the general steps you can follow when you have a problem, our article “What Should You Do If a Complication Occurs after an Aesthetic Treatment” may be a useful guide.

What can you do at home, and what should you not do?

• Follow the aftercare instructions your physician gives you; keep the area clean and wash your hands before touching it.
• Find out the name and contents of the product given and the date of treatment; if you have the packaging, a photograph or a record, keep it.
• Record changes with dated photographs taken in the same light; if you have a fever, measure it and note it down.
• Protect the area from the sun while it heals.

Do not do the following:

• Do not squeeze swellings and nodules or pierce them with a needle; do not pick off crusts.
• Do not start antibiotics, corticosteroid cream or allergy medicine on your own; the wrong treatment can delay the diagnosis.
• Unless your physician recommends it, do not apply massage, heat or ice to the area.
• Do not have a new injection or another procedure on the same area before the problem has been resolved.
• Do not leave swellings that appear weeks later, thinking 'they will go away by themselves'.

To reduce the risk

• Have the treatment done after a physician’s examination, by a physician and in a licensed healthcare facility; do not accept injections in settings such as a home, a hotel or a beauty salon.
• Ask the name and contents of the product to be given and whether it was manufactured for injection; ask for the information in writing.
• Ask for the product to be opened in front of you from its sealed, labelled original packaging; do not accept mixtures whose contents are not disclosed or unlabelled mixtures prepared in advance.
• See that the skin is cleaned with an antiseptic solution and that gloves and single-use sterile needles are used; if a device is used for the treatment, ask whether the parts that touch the skin are single-use.
• Mention your allergies, the medicines you take, any conditions affecting your immune system and your history of cold sores.
• If there is an active infection, an acne flare, a cold sore or an open wound in the area, postpone the procedure.

When choosing where to have the treatment, our article “A 10-Point Safety Checklist for Choosing a Clinic and Physician for Medical Aesthetics” may be useful to you.

Where is scientific knowledge limited?

The adverse effects of mesotherapy are known largely from case reports, case series and outbreak reports; there is no reliable rate showing in how many treatments a problem arises. Because the mixtures and techniques used are so varied, the results in one publication cannot be generalised to another product or treatment. Nor are there comparative studies on which substances nodules, granulomas and panniculitis are seen with more often, or on what the most appropriate treatment is. For this reason you cannot be given a personal risk rate; this page is for information and does not replace an examination.