injections of botulinum toxin a ( btx - a ) targeting the facial muscles is widely used in the treatment of hyperdynamic facial lines , and it could be completely useful to correct the glabellar , forehead , temporal and crow s feet lines . as overall use of btx - a increases , it is not far from expectation to come across unusual complications of this product . local irritation and bruising at the site of injections are the most common side effects . unfortunately , the use of fake brands of btx - a has been reported mainly due to their lower cost . herein , we present a case of vasculitis with panniculitis after a patient underwent a cosmetic procedure that included injection of purported botulinum toxin a. a 45-year - old female presented to our dermatology clinic with the complaint of progressive periorbital edema and erythema since the night before . she mentioned btx - a injection for periorbital and glabellar rhytides for the first time in a private skin care office two weeks before that . she has been told to return after two weeks for further follow up and btx - a reinjection . two hours after the second injection , she noticed progressive swelling and redness in the injection sites as well as periorbital area . . there are limited registered brands of btx - a in iran , including dysport ( ipsen biopharmaceuticals ltd , uk ) and neuronox ( medytoxinc , south korea ) . the patient mentioned that the injected btx - a was not of these registered brands and that she had had this injection done at a very low cost . after calling the clinic where this procedure was performed , we found the injected product to be canitox , which is an unlicensed chinese brand of btx - a available in iran . on admission , her vital signs were stable . the only abnormal finding in the physical examination was the prominent edema , purpuric papules and erythema in periorbital region and at the sites of btx - a injection in the forehead ( figure 1 ) . on the ophthalmological consult , her best corrected visual acuity , intraocular pressure and examination of anterior segment were normal . the histopathological examination revealed transmural infiltration of neutrophils and eosinophils with endothelial swelling and fibriniod necrosis of the vessel walls . leukocytoklasia and extravasation of rbc were the other findings . moreover , there was infiltration of neutrophils and eosinophils in the subcutaneous fat . treatment was initiated with oral prednisolone at the dose of 0.5 mg / kg and hydroxyzine 25 mg daily . according to the previous reports , a variety of skin reactions , such as exanthematous reactions , edema , pruritus , alteration in skin color at the site of injection , psoriasiform eruption and anaphylactic reactions can occur after btx - a injection for both therapeutic and cosmetic purposes . there is also a recent report of severe allergic reaction caused by chinese botulinum toxin a injection to treat facial wrinkles . one explanation is the allergic potential of the toxin itself that may induce an immunologic reaction like any other protein . the other explanation is the effect of human serum albumin or gelatin added to the toxin in stimulating the immune reaction . the immune reactions toward biopharmaceutical products such as btx - a can be categorized in two main types : classical immune reactions to neo - antigens that mainly occur after injection of animal products and a breakdown of immune tolerance . several factors influence the immunogenic potential of btx - a including its biochemical structure ( e.g. , denaturation through oxidation ) , storage setting , impurities in the preparation , dose and frequency of injections , site of application , and genetic predisposition of patients themselves . these mentioned mechanisms might also have taken part in the reaction in our patient . according to the injection of btx - a by a non - professional in this patient , the possibility of contamination or reactions to non - standard additive products , such as gelatin or sucrose , should also be considered . in conclusion , it should be kept in mind that cosmetic procedures that involve injection of various agents may cause severe reactions , such as vasculitis that , although rare , are clinically significant to healthcare professionals .
botulinum toxin a injection is performed most frequently for facial rejuvenation all over the world . 
 some bizarre and severe side effects have been reported after botulinum toxin a injection . 
 herein , we present a case of vasculitis with panniculitis after a patient underwent a cosmetic procedure that included injection of purported botulinum toxin a.