Objectives: Autoimmune/inflammatory syndrome induced by adjuvants (ASIA syndrome) is a debated entity triggered by foreign substances such as polycaprolactone (Ellansé®). This paper presents a case of delayed nodular reactions following polycaprolactone injections in the cheeks, later associated with granulomas appearing on pre-existing tattoos, ultimately leading to a diagnosis of systemic sarcoidosis. We explore whether polycaprolactone acted as a trigger for sarcoidosis or if the patient had a pre-existing predisposition, raising the question: “The Egg or the Chicken?”
Introduction: Polycaprolactone (PCL)-based fillers, widely used for facial rejuvenation, have been associated with delayed-onset nodular reactions due to a foreign body granulomatous response. In rare cases, these reactions may be part of ASIA syndrome, where exogenous adjuvants stimulate an exaggerated immune response. The overlap between ASIA syndrome and sarcoidosis is controversial, as both conditions share granulomatous inflammation as a hallmark feature. This case highlights the diagnostic challenge of distinguishing a foreign body reaction from an underlying systemic granulomatous disease.
Materials / method: A retrospective case study of a female patient who presented with:
Delayed-onset nodules in the cheeks several months after polycaprolactone injections.She refused boipsy, but ultrasounds confirmed nodules consistent with a sarcoid-like reaction.
Further systemic investigations (chest CT, ACE levels, PET scan) leading to the diagnosis of sarcoidosis.
Review of existing literature on polycaprolactone and its role in granulomatous immune responses, including cases of ASIA syndrome associated with dermal fillers
Results: The patient’s nodular reactions were initially suspected to be foreign body granulomas but progressed to systemic sarcoidosis, evidenced by granulomatous involvement of her tattoos.
Given the absence of prior sarcoidosis history, two hypotheses were considered:
The patient had a latent predisposition to sarcoidosis, and polycaprolactone acted as an immune trigger, revealing the disease.
Polycaprolactone itself induced ASIA syndrome, mimicking sarcoidosis or initiating a systemic autoimmune response that spread to other foreign substances (tattoos).
Corticosteroid therapy led to partial resolut
Conclusion: This case raises an important clinical question: Did polycaprolactone unmask an underlying sarcoidosis, or did it act as a primary immune trigger, leading to ASIA syndrome? The distinction is critical, as it influences both treatment strategies and patient counseling on filler-associated immune responses. Further research is needed to clarify the immunogenicity of polycaprolactone fillers and their potential to induce systemic granulomatous diseases. Clinicians should remain vigilant when treating nodular complications post-filler injections, especially when associated with multisite granuloma
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