Letter to the Editor
Linear atrophy and hypopigmentation after intralesional corticosteroid injection
Atrofia e hipopigmentación lineal cutánea por inyección intraarticular de corticosteroide
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Presentación de 4 casos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 624 "Ancho" => 1250 "Tamanyo" => 90365 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Plain X-ray of the left carpus corresponding to case 3 which shows marked sclerosis of the lunate bone (A, arrow). MR of the right carpus (T1 sequence) corresponding to case 2, which shows hypointensity signals in the lunate bone (B, arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sixto Zegarra-Mondragón, María Llop-Vilaltella, Walter Alberto Sifuentes-Giraldo, Carlos de la Puente Bujidos" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Sixto" "apellidos" => "Zegarra-Mondragón" ] 1 => array:2 [ "nombre" => "María" "apellidos" => "Llop-Vilaltella" ] 2 => array:2 [ "nombre" => "Walter Alberto" "apellidos" => "Sifuentes-Giraldo" ] 3 => array:2 [ "nombre" => "Carlos" "apellidos" => "de la Puente Bujidos" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X17302693" "doi" => "10.1016/j.reuma.2017.10.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X17302693?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574318301746?idApp=UINPBA00004M" "url" => "/21735743/0000001500000005/v1_201910260908/S2173574318301746/v1_201910260908/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Linear atrophy and hypopigmentation after intralesional corticosteroid injection" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e72" "paginaFinal" => "e73" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ignacio Hernández Aragüés, C. Ana Villanueva Álvarez-Santullano, Ricardo Suárez Fernández, Ana Pulido Pérez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Ignacio" "apellidos" => "Hernández Aragüés" "email" => array:1 [ 0 => "ignaciohdezaragues@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C. Ana" "apellidos" => "Villanueva Álvarez-Santullano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ricardo" "apellidos" => "Suárez Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Ana" "apellidos" => "Pulido Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital San Pedro, Logroño, La Rioja, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Atrofia e hipopigmentación lineal cutánea por inyección intraarticular de corticosteroide" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1180 "Ancho" => 1400 "Tamanyo" => 214991 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A–C) Hypopigmented atrophic patch on the elbow, with linear extension along the upper arm.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The presence of hypopigmented lesions on a patient is a diagnostic challenge. The causes of the lesions can vary, from the cutaneous manifestation of systemic diseases to local reactions to external agents.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 53-year-old female that came to the consultation because of a hypopigmented, depressed skin patch of 2 months’ evolution on her left arm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Relevant medical history included chronic migraine, idiopathic hyperprolactinemia and epicondylitis in both elbows. Her habitual treatment consisted of amitriptyline, paracetamol and also periodic intra-articular injections of triamcinolone in the 2 elbows—the last having been given 5 months before this consultation. The patient did not report any other relevant signs or symptoms. Examination revealed a hypopigmented atrophic skin patch on the left elbow that extended linearly along the inner side of the upper arm.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Cutaneous biopsy revealed atrophy of the epidermis. The dermis looked normal, without any associated sclerosis, changes in the adnexa or notable inflammatory infiltrates. No significant reduction was seen in the number of melanocytes.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given the clinical–histological findings, the diagnosis was linear skin hypopigmentation and atrophy after intra-articular injection of triamcinolone acetonide. The patient presented progressive improvement of the lesion until its complete resolution was seen at 8 months of follow-up.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Intralesional injection of corticosteroids is very common in standard clinical practice.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–3</span></a> This practice concentrates more of the drug in the area with a better safety profile, avoiding some of the characteristic systemic side effects, such as iatrogenic Cushing syndrome and the suppression of the hypothalamic–pituitary axis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Linear hypopigmentation following intralesional or intra-articular injection of corticoids has been described many times, usually associated with the use of triamcinolone acetonide.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> A similar condition was recently described in a patient with chronic foot eczema, who had applied a high-strength corticoid topically.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In a series of 440 paediatric patients that were given intra-articular injections of triamcinolone acetonide or methylprednisolone acetate, slightly less than 2% of the patients later developed cutaneous hypopigmentation or atrophy in the injection area.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The condition usually presents as an atrophic and hypopigmented skin patch with branching edges in the injection area; there is also linear extension of the lesion towards the perilesional area, normally following a pattern of lymphatic distribution. Differential diagnosis against other conditions such as linear morphea (localised scleroderma) or eosinophilic fasciitis should be considered, given the similarity in the clinical presentation of the condition that is described here.</p><p id="par0040" class="elsevierStylePara elsevierViewall">This condition manifests after a variable length of time, which can range from weeks to months, following the injection. It can appear after either a single injection or following multiple injections, above all if quantities more than 10<span class="elsevierStyleHsp" style=""></span>mg/ml are injected.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Skin atrophy from corticosteroids is due to their anti-proliferative effect on fibroblasts and keratinocytes, as well as from alterations in lipid synthesis and in the metabolism of extracellular matrix proteins. The mechanism behind hypopigmentation is less known; it might be due to an alteration in melanocyte secretion, without totally destroying the melanocytes.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The linear extension that is a feature of this condition probably stems from dispersion through the lymphatic system. Kikuchi and Horikawa<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> demonstrated this distribution after injecting colouring agents such as blue dye in the initial site of the lesion and confirming its later extension through the lymph vessels.</p><p id="par0055" class="elsevierStylePara elsevierViewall">There is no specific treatment. However, avoiding new injections is generally recommended. It usually takes months after condition onset for the hypopigmentation to disappear and the skin atrophy to improve.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández Aragüés I, Villanueva Álvarez-Santullano CA, Suárez Fernández R, Pulido Pérez A. Atrofia e hipopigmentación lineal cutánea por inyección intraarticular de corticosteroide. Reumatol Clin. 2019;15:e72–e73.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1180 "Ancho" => 1400 "Tamanyo" => 214991 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A–C) Hypopigmented atrophic patch on the elbow, with linear extension along the upper arm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous linear atrophy following intralesional corticosteroid injection in the treatment of tendonitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. 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Suh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ijd.13154" "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2016" "volumen" => "55" "paginaInicial" => "e315" "paginaFinal" => "e317" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26756396" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome and predicting factors of single and multiple intra-articular corticosteroid injections in children with juvenile idiopathic arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Lanni" 1 => "M. Bertamino" 2 => "A. Consolaro" 3 => "A. Pistorio" 4 => "S. Magni-Manzoni" 5 => "R. Galasso" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/rheumatology/ker165" "Revista" => array:6 [ "tituloSerie" => "Rheumatology" "fecha" => "2011" "volumen" => "50" "paginaInicial" => "1627" "paginaFinal" => "1634" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21561981" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perilymphatic atrophy of the skin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Kikuchi" 1 => "S. Horikawa" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1975" "volumen" => "11" "paginaInicial" => "795" "paginaFinal" => "796" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack431398" "titulo" => "Acknowledgements" "texto" => "<p id="par0060" class="elsevierStylePara elsevierViewall">We would like to thank Dr. Verónica Parra Blanco for the histopathological study.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001500000005/v1_201910260908/S2173574319301054/v1_201910260908/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001500000005/v1_201910260908/S2173574319301054/v1_201910260908/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574319301054?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 6 | 11 |
| 2024 October | 199 | 49 | 248 |
| 2024 September | 269 | 42 | 311 |
| 2024 August | 330 | 60 | 390 |
| 2024 July | 308 | 44 | 352 |
| 2024 June | 246 | 40 | 286 |
| 2024 May | 243 | 40 | 283 |
| 2024 April | 177 | 24 | 201 |
| 2024 March | 146 | 25 | 171 |
| 2024 February | 158 | 30 | 188 |
| 2024 January | 115 | 25 | 140 |
| 2023 December | 140 | 32 | 172 |
| 2023 November | 157 | 39 | 196 |
| 2023 October | 124 | 24 | 148 |
| 2023 September | 144 | 40 | 184 |
| 2023 August | 147 | 13 | 160 |
| 2023 July | 106 | 23 | 129 |
| 2023 June | 109 | 28 | 137 |
| 2023 May | 116 | 35 | 151 |
| 2023 April | 96 | 13 | 109 |
| 2023 March | 162 | 16 | 178 |
| 2023 February | 107 | 27 | 134 |
| 2023 January | 113 | 13 | 126 |
| 2022 December | 148 | 30 | 178 |
| 2022 November | 133 | 28 | 161 |
| 2022 October | 175 | 42 | 217 |
| 2022 September | 153 | 27 | 180 |
| 2022 August | 114 | 44 | 158 |
| 2022 July | 107 | 46 | 153 |
| 2022 June | 117 | 24 | 141 |
| 2022 May | 126 | 54 | 180 |
| 2022 April | 153 | 32 | 185 |
| 2022 March | 125 | 37 | 162 |
| 2022 February | 143 | 31 | 174 |
| 2022 January | 170 | 45 | 215 |
| 2021 December | 118 | 47 | 165 |
| 2021 November | 138 | 39 | 177 |
| 2021 October | 106 | 49 | 155 |
| 2021 September | 126 | 38 | 164 |
| 2021 August | 121 | 49 | 170 |
| 2021 July | 113 | 35 | 148 |
| 2021 June | 112 | 38 | 150 |
| 2021 May | 115 | 38 | 153 |
| 2021 April | 292 | 68 | 360 |
| 2021 March | 190 | 35 | 225 |
| 2021 February | 142 | 17 | 159 |
| 2021 January | 97 | 25 | 122 |
| 2020 December | 89 | 24 | 113 |
| 2020 November | 69 | 19 | 88 |
| 2020 October | 76 | 15 | 91 |
| 2020 September | 72 | 18 | 90 |
| 2020 August | 73 | 30 | 103 |
| 2020 July | 56 | 15 | 71 |
| 2020 June | 37 | 12 | 49 |
| 2020 May | 73 | 25 | 98 |
| 2020 April | 14 | 13 | 27 |
| 2020 March | 4 | 0 | 4 |
| 2019 November | 1 | 0 | 1 |
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