Post-implantation erythema (PIE) is a benign cutaneous entity that has been scarcely reported and is associated with the insertion of a foreign body in contact with the adjacent skin, traditionally electronic and metallic devices.1–3 Its appearance on the breasts is uncommon, and no additional associated symptoms are usually present.4,5

A 47-year-old woman, with no relevant past medical history, and a 4-month history poorly defined erythematous macules located symmetrically over the inferior and outer-lateral aspects of both breasts (Fig. 1A–C). Directed history taking revealed that she had undergone breast implant surgery 12 years earlier. The patient did not identify any other potential trigger and denied pruritus or other accompanying symptoms. Histologic examination showed a nonspecific inflammatory dermal infiltrate composed of lymphocytes and histiocytes with superficial perivascular distribution, without eosinophils, along with lymphatic vascular ectasia (Fig. 1D, E). No spongiosis or parakeratosis was observed. Patch testing—including the extended European baseline series, plastic and adhesive series, and silicone from breast implants—revealed no relevant findings. The lesions were treated with clobetasol propionate 0.5mg/g cream once daily, achieving complete resolution within two months (Fig. 2A–C).

Fig. 1.

(A–C) Initial clinical presentation: Diffuse erythematous macules located on the inferior and outer lateral regions of both breasts. Clinical images. (D) Superficial perivascular dermatitis with predominant lymphohistiocytic inflammatory infiltrate and lymphatic vascular ectasia with prominent endothelial cells (Hematoxylin–Eosin ×400). (E) Ectatic lymphatic vessels demonstrated by immunohistochemical staining (D2-40 ×200).

Fig. 2.

(A–C) Clinical response after treatment. Complete resolution of the lesions is observed.

Until several years ago, these eruptions were classified under the term reticular telangiectatic erythema, without a clearly established pathogenesis. It was suggested that heat generated by electronic devices, together with the electromagnetic fields they produce, could contribute to local changes in the microvasculature adjacent to the implant, leading to erythema.1,2 Currently, the description of cases associated with non-electronic and non-metallic foreign bodies has led to the adoption of the broader term PIE. Our case supports a later etiologic theory proposing that lesions result from mechanical obstruction of local circulation due to pressure exerted by the foreign body on the skin.3–5 Clinically, PIE presents as asymptomatic erythematous macules that blanch with pressure, located in areas adjacent to the prosthetic material.4–6 It is a diagnosis of exclusion based on compatible clinical findings, histology showing a lymphohistiocytic inflammatory infiltrate with dermal vascular ectasia, negative patch testing, and a history of foreign-body implantation (with a temporal relationship that may extend several years after implantation).4,5,7

Table 1 illustrates the 12 published cases of PIE associated with non-electronic foreign bodies along with our own. PIE has been associated with knee, shoulder, and elbow joint prostheses; suture material; intrathecal drug delivery systems; hernia meshes; and breast implants. Analysis of the data shows a slight female predominance (7/13). Patient age ranged from 22 to 77 years, with most being older than 50 years (10/13). In 7 cases, PIE occurred within the first month after implantation, whereas in 3 cases it appeared>1 year later (2 associated with breast implants). The present case displays the longest latency period reported, appearing 12 years after implant placement. Histologically, dilation of dermal capillaries was observed in 7/13 cases, with lymphatic vessel ectasia specified in 2 reports. Sporadically, reactive dermal vascular proliferation and erythrocyte extravasation have been described. These findings further support the theory of compression and mechanical obstruction as a likely etiopathogenic mechanism. Various therapeutic approaches have been described. In 4 cases, a watch-and-wait strategy with close follow-up was adopted, with spontaneous resolution in 2 cases.1,4,5 Treatment with medium- to high-potency topical corticosteroids has also been used, achieving complete response in our patient. Pulsed dye laser therapy has been reported with good results after two sessions.4,5 Removal of the prosthetic material is generally not required. It was performed only in 4 cases in which device accessibility facilitated removal (3 involving drug-delivery systems and 1 related to non-absorbable suture material).8–10 All cases resolved completely, although only 2 reported the time to full resolution (2 weeks and 2 months).

In conclusion, PIE is a recently described entity and represents a therapeutic challenge. We present the third reported case of PIE due to breast implants and compile all cases attributed to non-electronic devices, along with the therapeutic strategies employed. Recognition and further study of this entity will provide a solid foundation for advancing understanding of its still-unclear etiopathogenesis and optimal management.