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Ascending hypopigmentation of the forearm following injection of triamcinolone
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e597ee598
CORRESPONDENCE AND COMMUNICATION
Ascending hypopigmentation of the forearm following injection of triamcinolone Corticosteroid injections are used to treat a range of conditions that include keloid scarring, trigger finger and tenosynovitis refractive to other conservative interventions. Despite the common usage of steroid injections patients may not be adequately counselled and consented for their potential side effects. We report a case of hypopigmentation following treatment for De Quervain’s tenosynovitis which resulted in significant behavioural changes. A 23 year old right hand dominant African Engineer presented to the Accident and Emergency department with sudden onset of radial sided wrist pain and stiffness of his right thumb with no associated history of trauma. On examination tenderness was elicited over the first extensor compartment by palpation and passive movement of the thumb and a positive Finkelstein Test was exhibited. De Quervain’s tenosynovitis was diagnosed and the patient was initially prescribed oral non steroidal antiinflammatories and placed in a thumb spica splint. With no improvement after one month a peritendinous Triamcinolone injection (10 mg) was administered to the first extensor compartment with a further injection 6 weeks later. Complete resolution of symptoms occurred 4 weeks
on, however an unusual pattern of depigmentation gradually developed over the anatomical snuff box and continued to extend proximally in a linear fashion towards the cubital fossa (Figure 1). The patient became increasingly distressed to the point were he would only wear long sleeve shirts and gloves in an attempt to conceal the ‘offending area’ and refused to go to work. Despite this he declined a referral to the camouflage nurse specialist. Seven months following the initial steroid injection there was complete resolution of the hypopigmentation with no symptomatic recurrence of the De Quervain’s tenosynovitis and the patient returned to work. Hypopigmentation following the injection or topical application of corticosteroids has been previously reported however the pathophysiological mechanism of action has not been identified in humans. Reports in humans have suggested that the linear pattern of hypopigmentation observed may occur either as a result of lymphogenous spread or vascular spread of the corticosteroid.1,2,4 Proximal extension of hypopigmentation overlying a superficial vein is thought to be due to the accidental extravasation of the drug into the perivascular tissues or the intra-advential layers of the superficial vein.4 Such cases are more likely to be associated with atrophy,5 whilst those due to lymphogenous spread are not.1 Our patient demonstrated no short-term side effects as a result of the steroid injections, with pigmentary changes developing over two months following the initial administration. This parallels previous reports which showed a similar delay in presentation.3 In our case the hypopigmentation spontaneously resolved after 7 months corresponding to reported regression times of 6e9 months.3,4 We hope that this report serves as a reminder that all patients undergoing corticosteroid injections should be adequately informed and consented regarding the possible risk of hypopigmentation. As this may have important cultural and behavioural implications for dark-skinned patients, it is essential that they are reassured regarding its natural history, with the majority of cases spontaneously resolving within 9 months.
Conflict of interest statement Figure 1 Extensive depigmentation over the anatomical snuff box extending proximally towards the cubital fossa.
None.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.059
e598
References 1. Goldman L, Nathan A, Goldman J. Linear hypopigmentation after digital intra-articular injection of corticosteroid. Arch Dermatol 1981;117:605. 2. Friedman SJ, Bytler DF, Pittelkow MR. Perilesional linear atrophy and hypopigmentation after intralesional corticosteroid therapy. Report of two cases and a review of literature. J Am Acad Dermatol 1988;19:537e41. 3. Evans AV, McGibbon DH. Correspondence: symmetrical hypo pigmentation following triamcinolone injection for de Quervain’s tenosynovitis. Clin Exp Dermatol 2002;27:247e51. 4. Gahankari D, Rana RE, Tambwekar SR. An unsual complication following intralesional triamcinolone injections. Plast Reconstr Surg 1996;97:1076.
Correspondence and communication 5. Kumar P, Adolph S. Hypopigmentation along subcutaneous veins following intrakeloid triamcinolone injection: a case report and review of literature. Burns 1998;24:487e8.
S. Saour B.S. Dhillon M. Ho-Asjoe P.-N. Mohanna Department of Plastic Surgery, Guy’s and St.Thomas’ NHS Trust, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, UK E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION
Ascending hypopigmentation of the forearm following injection of triamcinolone Corticosteroid injections are used to treat a range of conditions that include keloid scarring, trigger finger and tenosynovitis refractive to other conservative interventions. Despite the common usage of steroid injections patients may not be adequately counselled and consented for their potential side effects. We report a case of hypopigmentation following treatment for De Quervain’s tenosynovitis which resulted in significant behavioural changes. A 23 year old right hand dominant African Engineer presented to the Accident and Emergency department with sudden onset of radial sided wrist pain and stiffness of his right thumb with no associated history of trauma. On examination tenderness was elicited over the first extensor compartment by palpation and passive movement of the thumb and a positive Finkelstein Test was exhibited. De Quervain’s tenosynovitis was diagnosed and the patient was initially prescribed oral non steroidal antiinflammatories and placed in a thumb spica splint. With no improvement after one month a peritendinous Triamcinolone injection (10 mg) was administered to the first extensor compartment with a further injection 6 weeks later. Complete resolution of symptoms occurred 4 weeks
on, however an unusual pattern of depigmentation gradually developed over the anatomical snuff box and continued to extend proximally in a linear fashion towards the cubital fossa (Figure 1). The patient became increasingly distressed to the point were he would only wear long sleeve shirts and gloves in an attempt to conceal the ‘offending area’ and refused to go to work. Despite this he declined a referral to the camouflage nurse specialist. Seven months following the initial steroid injection there was complete resolution of the hypopigmentation with no symptomatic recurrence of the De Quervain’s tenosynovitis and the patient returned to work. Hypopigmentation following the injection or topical application of corticosteroids has been previously reported however the pathophysiological mechanism of action has not been identified in humans. Reports in humans have suggested that the linear pattern of hypopigmentation observed may occur either as a result of lymphogenous spread or vascular spread of the corticosteroid.1,2,4 Proximal extension of hypopigmentation overlying a superficial vein is thought to be due to the accidental extravasation of the drug into the perivascular tissues or the intra-advential layers of the superficial vein.4 Such cases are more likely to be associated with atrophy,5 whilst those due to lymphogenous spread are not.1 Our patient demonstrated no short-term side effects as a result of the steroid injections, with pigmentary changes developing over two months following the initial administration. This parallels previous reports which showed a similar delay in presentation.3 In our case the hypopigmentation spontaneously resolved after 7 months corresponding to reported regression times of 6e9 months.3,4 We hope that this report serves as a reminder that all patients undergoing corticosteroid injections should be adequately informed and consented regarding the possible risk of hypopigmentation. As this may have important cultural and behavioural implications for dark-skinned patients, it is essential that they are reassured regarding its natural history, with the majority of cases spontaneously resolving within 9 months.
Conflict of interest statement Figure 1 Extensive depigmentation over the anatomical snuff box extending proximally towards the cubital fossa.
None.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.059
e598
References 1. Goldman L, Nathan A, Goldman J. Linear hypopigmentation after digital intra-articular injection of corticosteroid. Arch Dermatol 1981;117:605. 2. Friedman SJ, Bytler DF, Pittelkow MR. Perilesional linear atrophy and hypopigmentation after intralesional corticosteroid therapy. Report of two cases and a review of literature. J Am Acad Dermatol 1988;19:537e41. 3. Evans AV, McGibbon DH. Correspondence: symmetrical hypo pigmentation following triamcinolone injection for de Quervain’s tenosynovitis. Clin Exp Dermatol 2002;27:247e51. 4. Gahankari D, Rana RE, Tambwekar SR. An unsual complication following intralesional triamcinolone injections. Plast Reconstr Surg 1996;97:1076.
Correspondence and communication 5. Kumar P, Adolph S. Hypopigmentation along subcutaneous veins following intrakeloid triamcinolone injection: a case report and review of literature. Burns 1998;24:487e8.
S. Saour B.S. Dhillon M. Ho-Asjoe P.-N. Mohanna Department of Plastic Surgery, Guy’s and St.Thomas’ NHS Trust, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, UK E-mail address: [email protected]