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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cutaneous hypopigmentation is a common local adverse effect associated with corticosteroid treatment&#46; A much less common effect associated with intralesional corticosteroid injections is linear atrophy and hypopigmentation along the path of the lymphatic channels&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 60-year-old woman presented with asymptomatic hypopigmentation of 3 months&#8217; duration on the dorsum of the right foot&#46; Three months earlier&#44; she had been diagnosed with a painful interdigital neuroma that was treated with 2<span class="elsevierStyleHsp" style=""></span>mL of triamcinolone acetonide &#40;40<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41; injected into the third interdigital space of the right foot&#46; The treatment relieved the pain&#46; Physical examination showed a hypopigmented&#44; atrophic patch on the dorsum of the foot and atrophy of the underlying muscles&#46; The patch was triangular in shape and had well-defined borders&#59; its base was located between the second and fourth metatarsals and ascended toward the ankle&#44; running parallel to the lymphatic channels &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; The local temperature and pedal pulses were normal&#46; Based on the patient&#39;s medical history and the clinical findings&#44; a diagnosis of perilymphatic atrophy and hypopigmentation secondary to intralesional corticosteroid injections was made&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Intralesional corticosteroids are an effective&#44; widely used treatment in dermatology and rheumatology&#46; They can&#44; however&#44; cause local adverse effects&#44; such as pain&#44; bleeding&#44; infection&#44; hair loss&#44; local calcification&#44; cutaneous hypopigmentation or hyperpigmentation&#44; and atrophy&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> Atrophy and hypopigmentation typically occur at the site of injection&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> unlike perilesional&#47;perilymphatic atrophy and hypopigmentation&#44; which form a linear pattern and are less common&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Clinical findings include a linear or branch-shaped pattern&#44; although the final morphology varies according to the distribution of the lymphatic channels in the injection area&#46; Perilesional&#47;perilymphatic atrophy and hypopigmentation can occur after the administration of both intralesional<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> and topical<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> corticosteroids&#44; with a time to onset of several weeks or even months&#46; There have been some reports of this adverse effect following the treatment of epicondylitis&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> keloid scars&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> and tenosynovitis<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> with intralesional corticosteroids&#46; Cases such as ours &#40;interdigital neuroma treated with intralesional triamcinolone acetonide&#41; have been described less frequently&#46; The main pathogenic factor involved is probably lymphatic spread of the corticosteroid suspension&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;3</span></a> Using Evans blue dye&#44; the authors of a 1975 report linked atrophic lesions secondary to triamcinolone acetonide injections to the distribution of the lymph vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> These lesions have only been described after triamcinolone acetonide injections&#46; Triamcinolone acetonide is a macromolecule that dissolves slowly in order to achieve a prolonged effect&#46; The lymph vessels could play an important role in the appearance of hypopigmentation along the course of the vessels by removing excess fractions of the molecule in its free state&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Another explanation could be that intralesional triamcinolone acetonide is more widely used than other corticosteroid injections&#46; Diagnosis is clinical&#46; Histology shows atrophy of the epidermis and reduced melanin content without a loss of melanocytes&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> although a reduction in melanocyte numbers has been described&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Treatment options are limited&#44; and spontaneous repigmentation has been described between 6 and 12 months after diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; we have described a rare adverse effect associated with the treatment of interdigital neuroma with intralesional corticosteroid injections&#46; Familiarity with the characteristic morphologic features of this effect is important&#44; as it helps avoid unnecessary tests&#46; It is also important to inform patients of the risk of hypopigmentation&#44; especially those with darker skin types&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letter
Linear Atrophy and Cutaneous Hypopigmentation After an Intralesional Corticosteroid Injection: A Rare Adverse Effect
Atrofia e hipopigmentación lineal cutánea tras inyección intralesional de corticoides: un efecto secundario poco frecuente
S. Porcar Sauraa,
Corresponding author
saray.porcar@gmail.com

Corresponding author.
, A. Eixarch Dualdeb, M. Pons Benaventa, S. Guillén Climenta
a Servicio de Dermatología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
b Servicio de Oftalmología, Centro Ocular Quirúrgico de Terrassa, Terrassa, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cutaneous hypopigmentation is a common local adverse effect associated with corticosteroid treatment&#46; A much less common effect associated with intralesional corticosteroid injections is linear atrophy and hypopigmentation along the path of the lymphatic channels&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 60-year-old woman presented with asymptomatic hypopigmentation of 3 months&#8217; duration on the dorsum of the right foot&#46; Three months earlier&#44; she had been diagnosed with a painful interdigital neuroma that was treated with 2<span class="elsevierStyleHsp" style=""></span>mL of triamcinolone acetonide &#40;40<span class="elsevierStyleHsp" style=""></span>mg&#47;mL&#41; injected into the third interdigital space of the right foot&#46; The treatment relieved the pain&#46; Physical examination showed a hypopigmented&#44; atrophic patch on the dorsum of the foot and atrophy of the underlying muscles&#46; The patch was triangular in shape and had well-defined borders&#59; its base was located between the second and fourth metatarsals and ascended toward the ankle&#44; running parallel to the lymphatic channels &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; The local temperature and pedal pulses were normal&#46; Based on the patient&#39;s medical history and the clinical findings&#44; a diagnosis of perilymphatic atrophy and hypopigmentation secondary to intralesional corticosteroid injections was made&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Intralesional corticosteroids are an effective&#44; widely used treatment in dermatology and rheumatology&#46; They can&#44; however&#44; cause local adverse effects&#44; such as pain&#44; bleeding&#44; infection&#44; hair loss&#44; local calcification&#44; cutaneous hypopigmentation or hyperpigmentation&#44; and atrophy&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> Atrophy and hypopigmentation typically occur at the site of injection&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> unlike perilesional&#47;perilymphatic atrophy and hypopigmentation&#44; which form a linear pattern and are less common&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Clinical findings include a linear or branch-shaped pattern&#44; although the final morphology varies according to the distribution of the lymphatic channels in the injection area&#46; Perilesional&#47;perilymphatic atrophy and hypopigmentation can occur after the administration of both intralesional<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> and topical<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> corticosteroids&#44; with a time to onset of several weeks or even months&#46; There have been some reports of this adverse effect following the treatment of epicondylitis&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> keloid scars&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> and tenosynovitis<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> with intralesional corticosteroids&#46; Cases such as ours &#40;interdigital neuroma treated with intralesional triamcinolone acetonide&#41; have been described less frequently&#46; The main pathogenic factor involved is probably lymphatic spread of the corticosteroid suspension&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;3</span></a> Using Evans blue dye&#44; the authors of a 1975 report linked atrophic lesions secondary to triamcinolone acetonide injections to the distribution of the lymph vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> These lesions have only been described after triamcinolone acetonide injections&#46; Triamcinolone acetonide is a macromolecule that dissolves slowly in order to achieve a prolonged effect&#46; The lymph vessels could play an important role in the appearance of hypopigmentation along the course of the vessels by removing excess fractions of the molecule in its free state&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Another explanation could be that intralesional triamcinolone acetonide is more widely used than other corticosteroid injections&#46; Diagnosis is clinical&#46; Histology shows atrophy of the epidermis and reduced melanin content without a loss of melanocytes&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> although a reduction in melanocyte numbers has been described&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Treatment options are limited&#44; and spontaneous repigmentation has been described between 6 and 12 months after diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; we have described a rare adverse effect associated with the treatment of interdigital neuroma with intralesional corticosteroid injections&#46; Familiarity with the characteristic morphologic features of this effect is important&#44; as it helps avoid unnecessary tests&#46; It is also important to inform patients of the risk of hypopigmentation&#44; especially those with darker skin types&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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ISSN: 00017310
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