Hyperpigmentation and atrophy

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Hyperpigmentation and atrophy

J Fam Pract. 2012 October;61(10):617-619

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References

1. Holt PJ, Marks R, Waddington E. ‘Pseudomorphoea’: a side effect of subcutaneous corticosteroid injection. Br J Dermatol. 1975;92:689-691.

2. Joshi R. Incidental finding of skin deposits of corticosteroids without associated granulomatous inflammation: report of three cases. Indian J Dermatol Venereol Leprol. 2008;74:44-46.

3. Reddy PD, Zelicof SB, Ruotolo C, et al. Interdigital neuroma. Local cutaneous changes after corticosteroid injection. Clin Orthop Relat Res. 1995;(317):185-187.

4. Stapczynski JS. Localized depigmentation after steroid injection of a ganglion cyst on the hand. Ann Emerg Med. 1991;20:807-809.

5. Okere K, Jones MC. A case of skin hypopigmentation secondary to a corticosteroid injection. South Med J. 2006;99:1393-1394.

6. Basadonna PT, Rucco V, Gasparini D, et al. Plantar fat pad atrophy after corticosteroid injection for an interdigital neuroma: a case report. Am J Phys Med Rehabil. 1999;78:283-285.

7. DiStefano V, Nixon JE. Steroid-induced skin changes following local injection. Clin Orthop Relat Res. 1972;87:254-256.

8. Friedman SJ, Butler DF, Pittelkow MR. Perilesional linear atrophy and hypopigmentation after intralesional corticosteroid therapy. Report of two cases and review of the literature. J Am Acad Dermatol. 1988;19:537-541.

9. Gallardo MJ, Johnson DA. Cutaneous hypopigmentation following a posterior sub-tenon triamcinolone injection. Am J Ophthalmol. 2004;137:779-780.

10. Jacobs MB. Local subcutaneous atrophy after corticosteroid injection. Postgrad Med. 1986;80:159-160.

11. Louis DS, Hankin FM, Eckenrode JF. Cutaneous atrophy after corticosteroid injection. Am Fam Physician. 1986;33:183-186.

12. Lund IM, Donde R, Knudsen EA. Persistent local cutaneous atrophy following corticosteroid injection for tendinitis. Rheumatol Rehabil. 1979;18:91-93.

13. Schetman D, Hambrick GW, Jr, Wilson CE. Cutaneous changes following local injection of triamcinolone. Arch Dermatol. 1963;88:820-828.

14. Myers SA, Sheedy MP. Lipodystrophy. In: Wolf KG, Lowell A, Katz SI, et al (eds). Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill Companies, Inc; 2003:586–590.

15. Falanga V, Killoran CE. Morphea. In: Wolf KG, Lowell A, Katz SI, et al (eds). Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill Companies, Inc; 2003:543–546.

16. Gomez EC, Berman B, Miller DL. Ultrasonic assessment of cutaneous atrophy caused by intradermal corticosteroids. J Dermatol Surg Oncol. 1982;8:1071-1074.

17. Shumaker PR, Rao J, Goldman MP. Treatment of local, persistent cutaneous atrophy following corticosteroid injection with normal saline infiltration. Dermatol Surg. 2005;31:1340-1343.

Diagnosis: Atrophy due to a steroid injection

During further discussion with the patient, she revealed that she had received a steroid injection 4 to 5 months before the lesion appeared. Although we felt reasonably certain that the steroid injection was the cause of the lesion, the patient had the lesion excised.

The most striking pathologic findings in the excised specimen were seen in the subcutaneous tissue; there was extensive fat necrosis, with abundant amorphous eosinophilic and amphophilic debris replacing, and interspersed between, adipocytes (FIGURE 3). Extensive lipomembranous changes were also seen. The constellation of pathologic findings was nonspecific.

FIGURE 3
Variation in adipocyte size

Low magnification of the excised specimen shows variation of adipocyte size, with some fat cells being replaced by amorphous eosinophilic and amphophilic material.

When treatment does harm
Steroid injections are commonly used to treat dermatologic and musculoskeletal conditions such as keloids, alopecia areata, neuromas, and inflamed bursas. However, these injections can have long-lasting dermatologic consequences such as altered pigmentation, dermal and fat atrophy, hypo- and hyperpigmentation, and telangiectasias.^1-13 Localized lipodystrophy, the loss of subcutaneous fat in a localized area, can also be a result of steroid injection, as well as the injection of other drugs such as insulin or antibiotics.¹⁴

Morphea-like change, which we saw in our patient, is less common, but has also been described in the literature.^1,2 Morphea presents with a single or several circumscribed indurated patches or plaques, usually with hypo- or hyperpigmentation.¹⁵

The timing of cutaneous changes due to steroid injection is variable. Case reports describe changes in pigmentation and atrophy beginning several weeks to several months after injection.^9,10,12,13 This delay may occur because depot steroid preparations can remain in the skin for prolonged periods; one study demonstrated that small amounts persisted for more than a year after injection.²