- Email: [email protected]
Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma
G Model
FAS-888; No. of Pages 3 Foot and Ankle Surgery xxx (2016) e1–e3
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma Stefan N. van Vendeloo *, Harmen B. Ettema Department of Orthopaedic Surgery, Isala Hospital, Zwolle, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 October 2015 Received in revised form 14 December 2015 Accepted 5 January 2016
Steroid injection is frequently used in the treatment of interdigital neuroma and has a high rate of success. We report the case of a patient who develops skin depigmentation at the injection site and linear streaks of depigmentation over the foot, the ankle and half way up to the knee after a steroid injection for interdigital neuroma. Minor disadvantages such as subcutaneous fat atrophy and depigmentation of the skin at the injection site are well known problems following steroid injection. Depigmentation of the skin with a lymphatic distribution in the foot after steroid injection for interdigital neuroma however, has not yet been reported before. This complication is a serious aesthetic problem and clinicians should be aware of this complication when treating patients with steroid injections for interdigital neuroma. ß 2016 Published by Elsevier Ltd on behalf of European Foot and Ankle Society.
Keywords: Interdigital neuroma Morton’s neuroma Corticosteroid injection Depigmentation Lymph vessels
1. Introduction One of the most common causes of forefoot pain is interdigital neuroma. It is also known as Morton’s neuroma, named after Thomas George Morton [1]. After it was first described by Civinini in 1835 [2] it was later described by Gauthier as an entrapment syndrome where the nerve is compressed repeatedly between the intermetatarsal ligament and the plantar aspect of the foot during the last part of the stance phase of gait [3]. Although its exact cause has yet to be elucidated, a possible explanation for the pain found in patients with interdigital neuroma is chronic compression and thickening of the interdigital nerve between the metatarsal heads and the transverse metatarsal ligament [4]. Patients with interdigital neuroma often report pain in the ball of the foot, which can radiate out to the 2 corresponding toes. Pain can be elicited on physical examination by applying transverse pressure between the medial and lateral sides of the forefoot, thereby compressing the neuroma between the metatarsal heads. Although diagnosis is most often made on the history and the features of the pain found on physical examination, ultrasound or MRI can be helpful in identifying the neuroma [5].
* Corresponding author at: Department of Orthopaedic Surgery and Traumatology, Isala Hospital, PO Box 10500, 8000 GM Zwolle, The Netherlands. Tel.: +31 645016013. E-mail address: [email protected] (S.N. van Vendeloo).
Several treatments have been described [6,7]. Non-surgical treatment consists of changes in footwear (avoiding high-heeled and narrow shoes), metatarsal pads and arch supports. Other options are local steroid injections or surgery. In the treatment of interdigital neuroma, local injection therapy with corticosteroids has a reported success rate of 80% [8]. Rapid relieve of pain and its minimal invasiveness are advantages of steroid injections. Wellknown disadvantages however are subcutaneous fat atrophy [9], teleangiectasia [10] and altered local skin pigmentation [11]. These complications are described at the site of the steroid injection. We report the case of a patient with interdigital neuroma who was treated with a steroid injection and developed depigmentation of the skin at the injection side in combination with streaks of depigmentation along lymph vessels of the lower leg. 2. Case report A 25-year old woman presented with a 1-year history of forefoot pain, aggravated by walking and running. Simple footwear changes and the use of metatarsal pads did not relieve her symptoms. The clinical diagnosis of interdigital neuroma was made and an injection of 40 mg triamcinolone acetonide mixed with 2 ml 1% lidocaine was administered in the interdigital space between the 3rd and the 4th metatarsal head. The needle was inserted using a dorsal approach, perpendicular to the skin. Symptoms improved over several weeks but at 1-month follow-up, patient reported local skin depigmentation. On clinical examination thinning of the skin with atrophy of fat at the injection site
http://dx.doi.org/10.1016/j.fas.2016.01.002 1268-7731/ß 2016 Published by Elsevier Ltd on behalf of European Foot and Ankle Society.
Please cite this article in press as: van Vendeloo SN, Ettema HB. Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma. Foot Ankle Surg (2016), http://dx.doi.org/10.1016/j.fas.2016.01.002
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FAS-888; No. of Pages 3 e2
S.N. van Vendeloo, H.B. Ettema / Foot and Ankle Surgery xxx (2016) e1–e3
Fig. 1. Clinical photograph of the foot (A) and lower leg (B) demonstrating fat atrophy and depigmentation along lymph vessels.
were found. Although there was no complete resolution of the pain, patient was satisfied with the clinical results and no further treatment was considered. At 3 months follow-up however, the cutaneous changes had worsened, showing further local depigmentation and thinning of the skin in combination with pale streaks of depigmentation following a pattern of lymph vessels along the ankle and further half way up to the knee (Fig. 1). No swollen lymph nodes could be palpated at the knee or in the groin. Patient was referred to a dermatologist and the clinical diagnosis of steroid induced depigmentation along lymph vessels was confirmed clinically. At 6 months after the injection, pain had unfortunately returned and the aforementioned skin changes had not improved. Surgery was considered to treat the neuroma but because of the persistence of pain and adverse effects of the steroid injection patient was referred to another hospital to obtain a second opinion. The second opinion confirmed the diagnosis of interdigital neuroma and after several modifications of the insoles the symptoms were acceptable again. One year after the injection there was no pain and repigmentation had commenced over the hypopigmentated streaks. The thinning of the skin and fat atrophy at the injection site however showed no improvement. 3. Discussion Conservative measures are the mainstay in treating interdigital neuroma. Adjusting footwear and adding metatarsal supports can relieve most symptoms [6]. Sometimes this treatment is unsuccessful because pain persists or because patients find the metatarsal supports uncomfortable. Local corticosteroid injections are a good option in patients where other conservative measures are unsuccessful because of the high success rate and the relative low costs. Surgical removal of the neuroma is another possibility, but local injections are less invasive and therefore usually better tolerated. The disadvantages of corticosteroid injections, such as skin atrophy and depigmentation of the skin are more pronounced
with the use of relative insoluble and long-acting agents [12,13]. Although these local adverse events are well known [9,11], only very few reports on steroid injection induced depigmentation with a lymphatic distribution exist [14,15] and none describe this phenomenon after injection for interdigital neuroma. Lymphatic vessels in skin serve several functions. Most importantly, they play a role in maintaining osmosis by allowing protein and fluid clearance from the tissues. While the lymphatic vessels provide an exit pathway for macrophages and other cells that play a major role in immune responses, they also play an important role in the removal of macromolecules and large proteins [16]. Triamcinolone acetonide is such a macromolecule. It dissolves slowly in order to achieve a prolonged effect [17]. It is postulated that, in excess of steroids in a free state, the triamcinolone acetonide molecules can enter and spread along lymphatic vessels, thereby causing a pattern of linear rays, as seen in our patient. This complication has only been described in patients injected with triamcinolone acetonide [9–15]. Some authors describe the use of different agents (e.g. Methylprednisone) in intra-articular infiltrations [18] or in the treatment of de Quervain’s disease [19] and do not report hypopigmentation of the skin. However, the numbers of patients treated in these studies are small. The mechanism of skin depigmentation induced by corticosteroids is not well understood, but it is thought to be caused by down regulation of melanocytes [15,20]. Repigmentation occurs at varying rates. Some report repigmentation as early as 1 month but it may take up to at least 1 year before symptoms have significantly improved [21,22]. To our knowledge hypopigmentation following lymph vessels after steroid injection for interdigital neuroma is not previously reported in the literature. We consider this a serious aesthetic adverse event and we think although it is probably rare, clinicians should be aware of this risk when treating patients with interdigital neuroma.
Please cite this article in press as: van Vendeloo SN, Ettema HB. Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma. Foot Ankle Surg (2016), http://dx.doi.org/10.1016/j.fas.2016.01.002
G Model
FAS-888; No. of Pages 3 S.N. van Vendeloo, H.B. Ettema / Foot and Ankle Surgery xxx (2016) e1–e3
4. Conclusion We report the case of a patient with linear rays of depigmentation along lymphatic vessels of the skin following an injection with corticosteroids for interdigital neuroma. Interdigital neuroma is a common problem of the foot and it is frequently addressed by steroid injections. We advise clinicians to be aware of the rare but serious adverse effects of these injections. Conflict of interest None declared. Acknowledgement No sponsors or external enterprises provided funding for this study. References [1] Morton TG. A peculiar and painful affection of the fourth metatarsophalangeal articulation. Am J Med Sci 1876;71:37–9. [2] Civinini F. Su d’un nervoso gangliare rigonfiamento alla pianta del piede. In: Lettera anatomica al Dr. Salomone Lampronti. Pistoia, Tipografia Bracali; 1835. [3] Gauthier G. Thomas Morton’s disease: a nerve entrapment syndrome—a new surgical technique. Clin Orthop 1979;142:90–2. [4] Wu KK. Morton’s interdigital neuroma: a clinical review of its etiology, treatment, and results. J Foot Ankle Surg 1996;35:112–9. [5] Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol 2015;25:2254–62. [6] Bennett GL, Graham CE, Mauldin DM. Morton’s interdigital neuroma: a comprehensive treatment protocol. Foot Ankle Int 1995;16:760–3. [7] Jain S, Mannan K. The diagnosis and management of Morton’s neuroma: a literature review. Foot Ankle Spec 2013;6:307–17.
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[8] Greenfield J, Rea Jr J, Ilfeld FW. Morton’s interdigital neuroma. Indications for treatment by local injections versus surgery. Clin Orthop Relat Res 1984;185: 142–4. [9] Basadonna PT, Rucco V, Gasparini D, Onorato A. Plantar fat pad atrophy after corticosteroid injection for an interdigital neuroma: a case report. Am J Phys Med Rehabil 1999;78:283–5. [10] Distefano V, Nixon JE. Steroid-induced skin changes following local injection. Clin Orthop 1972;87:254–6. [11] Reddy PD, Zelicof SB, Ruotolo C, Holder J. Interdigital neuroma: local cutaneous changes after corticosteroid injection. Clin Orthop 1995;317:185–7. [12] Rogojan C, Hetland ML. Depigmentation—a rare side effect to intra-articular glucocorticoid treatment. Clin Rheumatol 2004;23:373–5. [13] Louis PS, Hankin FM, Eckenrode JF. Cutaneousatrophy after corticosteoid injection. Am Fam Physician 1986;33:183–6. [14] Schwartz C1, Javvaji S, Feinberg JS. Linear rays of hypopigmentation following intra-articular corticosteroid injection for post-traumatic degenerative joint disease. Dermatol Online J 2012;18:11. [15] Venkatesan P, Fangman WL. Linear hypopigmentaion and cutaneous atrophy following intra-articular steroid injections for de Quervain’s tendonitis. J Drugs Dermatol 2009;8:492–3. [16] Ryan TJ, Mortimer PS, Jones RL. Lymphatics of the skin. Neglected but important. Int J Dermatol 1986;25:411–9. [17] Habib GS, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin Rheumatol 2010;29:347–56. [18] Lanni S, Bertamino M, Consolaro A, Pistorio A, Magni-Manzioni S, Galasso R. Outcome and predicting factors of single and multiple intra-articular corticosteroid injections in children with juvenile idiopathic arthritis. Rheumatology 2011;50:1627–34. [19] Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment measures for de Quervain’s disease of pregnancy and lactation. J Hand Surg 2002;27A: 322–4. [20] Friedman SJ, Butler DF, Pittelkow MRI. Perilesional linear atrophy and hypopigmentation after intralesional corticosteroid therapy. J Am Acad Dermatol 1988;19:537–41. [21] Kaur S, Thami GP. Intralesional corticosteroid induced perilesional and perilymphatic hypopigmentation. Indian J Dermatol Venereol Leprol 2002;68: 356–7. [22] Saour S, Dhillon BS, Ho-Asjoe M, Mohanna PN. Ascending hypopigmentation of the forearm following injection of triamcinolone. J Plast Reconstr Aesthet Surg 2009;62:597–8.
Please cite this article in press as: van Vendeloo SN, Ettema HB. Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma. Foot Ankle Surg (2016), http://dx.doi.org/10.1016/j.fas.2016.01.002
FAS-888; No. of Pages 3 Foot and Ankle Surgery xxx (2016) e1–e3
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma Stefan N. van Vendeloo *, Harmen B. Ettema Department of Orthopaedic Surgery, Isala Hospital, Zwolle, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 October 2015 Received in revised form 14 December 2015 Accepted 5 January 2016
Steroid injection is frequently used in the treatment of interdigital neuroma and has a high rate of success. We report the case of a patient who develops skin depigmentation at the injection site and linear streaks of depigmentation over the foot, the ankle and half way up to the knee after a steroid injection for interdigital neuroma. Minor disadvantages such as subcutaneous fat atrophy and depigmentation of the skin at the injection site are well known problems following steroid injection. Depigmentation of the skin with a lymphatic distribution in the foot after steroid injection for interdigital neuroma however, has not yet been reported before. This complication is a serious aesthetic problem and clinicians should be aware of this complication when treating patients with steroid injections for interdigital neuroma. ß 2016 Published by Elsevier Ltd on behalf of European Foot and Ankle Society.
Keywords: Interdigital neuroma Morton’s neuroma Corticosteroid injection Depigmentation Lymph vessels
1. Introduction One of the most common causes of forefoot pain is interdigital neuroma. It is also known as Morton’s neuroma, named after Thomas George Morton [1]. After it was first described by Civinini in 1835 [2] it was later described by Gauthier as an entrapment syndrome where the nerve is compressed repeatedly between the intermetatarsal ligament and the plantar aspect of the foot during the last part of the stance phase of gait [3]. Although its exact cause has yet to be elucidated, a possible explanation for the pain found in patients with interdigital neuroma is chronic compression and thickening of the interdigital nerve between the metatarsal heads and the transverse metatarsal ligament [4]. Patients with interdigital neuroma often report pain in the ball of the foot, which can radiate out to the 2 corresponding toes. Pain can be elicited on physical examination by applying transverse pressure between the medial and lateral sides of the forefoot, thereby compressing the neuroma between the metatarsal heads. Although diagnosis is most often made on the history and the features of the pain found on physical examination, ultrasound or MRI can be helpful in identifying the neuroma [5].
* Corresponding author at: Department of Orthopaedic Surgery and Traumatology, Isala Hospital, PO Box 10500, 8000 GM Zwolle, The Netherlands. Tel.: +31 645016013. E-mail address: [email protected] (S.N. van Vendeloo).
Several treatments have been described [6,7]. Non-surgical treatment consists of changes in footwear (avoiding high-heeled and narrow shoes), metatarsal pads and arch supports. Other options are local steroid injections or surgery. In the treatment of interdigital neuroma, local injection therapy with corticosteroids has a reported success rate of 80% [8]. Rapid relieve of pain and its minimal invasiveness are advantages of steroid injections. Wellknown disadvantages however are subcutaneous fat atrophy [9], teleangiectasia [10] and altered local skin pigmentation [11]. These complications are described at the site of the steroid injection. We report the case of a patient with interdigital neuroma who was treated with a steroid injection and developed depigmentation of the skin at the injection side in combination with streaks of depigmentation along lymph vessels of the lower leg. 2. Case report A 25-year old woman presented with a 1-year history of forefoot pain, aggravated by walking and running. Simple footwear changes and the use of metatarsal pads did not relieve her symptoms. The clinical diagnosis of interdigital neuroma was made and an injection of 40 mg triamcinolone acetonide mixed with 2 ml 1% lidocaine was administered in the interdigital space between the 3rd and the 4th metatarsal head. The needle was inserted using a dorsal approach, perpendicular to the skin. Symptoms improved over several weeks but at 1-month follow-up, patient reported local skin depigmentation. On clinical examination thinning of the skin with atrophy of fat at the injection site
http://dx.doi.org/10.1016/j.fas.2016.01.002 1268-7731/ß 2016 Published by Elsevier Ltd on behalf of European Foot and Ankle Society.
Please cite this article in press as: van Vendeloo SN, Ettema HB. Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma. Foot Ankle Surg (2016), http://dx.doi.org/10.1016/j.fas.2016.01.002
G Model
FAS-888; No. of Pages 3 e2
S.N. van Vendeloo, H.B. Ettema / Foot and Ankle Surgery xxx (2016) e1–e3
Fig. 1. Clinical photograph of the foot (A) and lower leg (B) demonstrating fat atrophy and depigmentation along lymph vessels.
were found. Although there was no complete resolution of the pain, patient was satisfied with the clinical results and no further treatment was considered. At 3 months follow-up however, the cutaneous changes had worsened, showing further local depigmentation and thinning of the skin in combination with pale streaks of depigmentation following a pattern of lymph vessels along the ankle and further half way up to the knee (Fig. 1). No swollen lymph nodes could be palpated at the knee or in the groin. Patient was referred to a dermatologist and the clinical diagnosis of steroid induced depigmentation along lymph vessels was confirmed clinically. At 6 months after the injection, pain had unfortunately returned and the aforementioned skin changes had not improved. Surgery was considered to treat the neuroma but because of the persistence of pain and adverse effects of the steroid injection patient was referred to another hospital to obtain a second opinion. The second opinion confirmed the diagnosis of interdigital neuroma and after several modifications of the insoles the symptoms were acceptable again. One year after the injection there was no pain and repigmentation had commenced over the hypopigmentated streaks. The thinning of the skin and fat atrophy at the injection site however showed no improvement. 3. Discussion Conservative measures are the mainstay in treating interdigital neuroma. Adjusting footwear and adding metatarsal supports can relieve most symptoms [6]. Sometimes this treatment is unsuccessful because pain persists or because patients find the metatarsal supports uncomfortable. Local corticosteroid injections are a good option in patients where other conservative measures are unsuccessful because of the high success rate and the relative low costs. Surgical removal of the neuroma is another possibility, but local injections are less invasive and therefore usually better tolerated. The disadvantages of corticosteroid injections, such as skin atrophy and depigmentation of the skin are more pronounced
with the use of relative insoluble and long-acting agents [12,13]. Although these local adverse events are well known [9,11], only very few reports on steroid injection induced depigmentation with a lymphatic distribution exist [14,15] and none describe this phenomenon after injection for interdigital neuroma. Lymphatic vessels in skin serve several functions. Most importantly, they play a role in maintaining osmosis by allowing protein and fluid clearance from the tissues. While the lymphatic vessels provide an exit pathway for macrophages and other cells that play a major role in immune responses, they also play an important role in the removal of macromolecules and large proteins [16]. Triamcinolone acetonide is such a macromolecule. It dissolves slowly in order to achieve a prolonged effect [17]. It is postulated that, in excess of steroids in a free state, the triamcinolone acetonide molecules can enter and spread along lymphatic vessels, thereby causing a pattern of linear rays, as seen in our patient. This complication has only been described in patients injected with triamcinolone acetonide [9–15]. Some authors describe the use of different agents (e.g. Methylprednisone) in intra-articular infiltrations [18] or in the treatment of de Quervain’s disease [19] and do not report hypopigmentation of the skin. However, the numbers of patients treated in these studies are small. The mechanism of skin depigmentation induced by corticosteroids is not well understood, but it is thought to be caused by down regulation of melanocytes [15,20]. Repigmentation occurs at varying rates. Some report repigmentation as early as 1 month but it may take up to at least 1 year before symptoms have significantly improved [21,22]. To our knowledge hypopigmentation following lymph vessels after steroid injection for interdigital neuroma is not previously reported in the literature. We consider this a serious aesthetic adverse event and we think although it is probably rare, clinicians should be aware of this risk when treating patients with interdigital neuroma.
Please cite this article in press as: van Vendeloo SN, Ettema HB. Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma. Foot Ankle Surg (2016), http://dx.doi.org/10.1016/j.fas.2016.01.002
G Model
FAS-888; No. of Pages 3 S.N. van Vendeloo, H.B. Ettema / Foot and Ankle Surgery xxx (2016) e1–e3
4. Conclusion We report the case of a patient with linear rays of depigmentation along lymphatic vessels of the skin following an injection with corticosteroids for interdigital neuroma. Interdigital neuroma is a common problem of the foot and it is frequently addressed by steroid injections. We advise clinicians to be aware of the rare but serious adverse effects of these injections. Conflict of interest None declared. Acknowledgement No sponsors or external enterprises provided funding for this study. References [1] Morton TG. A peculiar and painful affection of the fourth metatarsophalangeal articulation. Am J Med Sci 1876;71:37–9. [2] Civinini F. Su d’un nervoso gangliare rigonfiamento alla pianta del piede. In: Lettera anatomica al Dr. Salomone Lampronti. Pistoia, Tipografia Bracali; 1835. [3] Gauthier G. Thomas Morton’s disease: a nerve entrapment syndrome—a new surgical technique. Clin Orthop 1979;142:90–2. [4] Wu KK. Morton’s interdigital neuroma: a clinical review of its etiology, treatment, and results. J Foot Ankle Surg 1996;35:112–9. [5] Bignotti B, Signori A, Sormani MP, Molfetta L, Martinoli C, Tagliafico A. Ultrasound versus magnetic resonance imaging for Morton neuroma: systematic review and meta-analysis. Eur Radiol 2015;25:2254–62. [6] Bennett GL, Graham CE, Mauldin DM. Morton’s interdigital neuroma: a comprehensive treatment protocol. Foot Ankle Int 1995;16:760–3. [7] Jain S, Mannan K. The diagnosis and management of Morton’s neuroma: a literature review. Foot Ankle Spec 2013;6:307–17.
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[8] Greenfield J, Rea Jr J, Ilfeld FW. Morton’s interdigital neuroma. Indications for treatment by local injections versus surgery. Clin Orthop Relat Res 1984;185: 142–4. [9] Basadonna PT, Rucco V, Gasparini D, Onorato A. Plantar fat pad atrophy after corticosteroid injection for an interdigital neuroma: a case report. Am J Phys Med Rehabil 1999;78:283–5. [10] Distefano V, Nixon JE. Steroid-induced skin changes following local injection. Clin Orthop 1972;87:254–6. [11] Reddy PD, Zelicof SB, Ruotolo C, Holder J. Interdigital neuroma: local cutaneous changes after corticosteroid injection. Clin Orthop 1995;317:185–7. [12] Rogojan C, Hetland ML. Depigmentation—a rare side effect to intra-articular glucocorticoid treatment. Clin Rheumatol 2004;23:373–5. [13] Louis PS, Hankin FM, Eckenrode JF. Cutaneousatrophy after corticosteoid injection. Am Fam Physician 1986;33:183–6. [14] Schwartz C1, Javvaji S, Feinberg JS. Linear rays of hypopigmentation following intra-articular corticosteroid injection for post-traumatic degenerative joint disease. Dermatol Online J 2012;18:11. [15] Venkatesan P, Fangman WL. Linear hypopigmentaion and cutaneous atrophy following intra-articular steroid injections for de Quervain’s tendonitis. J Drugs Dermatol 2009;8:492–3. [16] Ryan TJ, Mortimer PS, Jones RL. Lymphatics of the skin. Neglected but important. Int J Dermatol 1986;25:411–9. [17] Habib GS, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin Rheumatol 2010;29:347–56. [18] Lanni S, Bertamino M, Consolaro A, Pistorio A, Magni-Manzioni S, Galasso R. Outcome and predicting factors of single and multiple intra-articular corticosteroid injections in children with juvenile idiopathic arthritis. Rheumatology 2011;50:1627–34. [19] Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment measures for de Quervain’s disease of pregnancy and lactation. J Hand Surg 2002;27A: 322–4. [20] Friedman SJ, Butler DF, Pittelkow MRI. Perilesional linear atrophy and hypopigmentation after intralesional corticosteroid therapy. J Am Acad Dermatol 1988;19:537–41. [21] Kaur S, Thami GP. Intralesional corticosteroid induced perilesional and perilymphatic hypopigmentation. Indian J Dermatol Venereol Leprol 2002;68: 356–7. [22] Saour S, Dhillon BS, Ho-Asjoe M, Mohanna PN. Ascending hypopigmentation of the forearm following injection of triamcinolone. J Plast Reconstr Aesthet Surg 2009;62:597–8.
Please cite this article in press as: van Vendeloo SN, Ettema HB. Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma. Foot Ankle Surg (2016), http://dx.doi.org/10.1016/j.fas.2016.01.002