Branch-shaped Cutaneous Hypopigmentation and Atrophy after Intralesional Triamcinolone Injection

Intra-articular injection of stigmasterol-loaded nanoparticles reduce pain and inhibit the inflammation and joint destruction in osteoarthritis rat model: A pilot study

Stigmasterol, a plant-derived sterol, sharing structural similarity with cholesterol, has demonstrated anti-osteoarthritis (OA) properties, attributed to its antioxidant and anti-inflammatory capabilities. Given that OA often arises in weight bearing or overused joints, prolonged localized treatment effectively targets inflammatory aspects of the disease. This research explored the impact of stigmasterol-loaded nanoparticles delivered via intra-articular injections in an OA rat model. Employing mesoporous silica nanomaterials (MSNs) combined with β-cyclodextrin (β-CD) as a vehicle, stigmasterol was loaded in conjunction with tannic acid, forming stigmasterol/β-CD-MSNs to facilitate a sustained stigmasterol release. The study employed RAW 264.7 cells to examine the in vitro cytotoxicity and anti-inflammatory effect of stigmasterol/β-CD-MSNs. For in vivo experimentation, we used healthy control rats and monosodium iodoacetate (MIA)-induced OA rats, separated into five groups, varying the injection substances. In vitro findings indicated that stigmasterol/β-CD-MSNs suppressed the mRNA expression of key pro-inflammatory mediators such as interleukin-6, tumor necrosis factor-α, and matrix metalloproteinase-3 in a dose-dependent manner. In vivo experiments revealed a substantial decrease in the mRNA levels of pro-inflammatory factors in the stigmasterol(50 µg)/β-CD-MSN group compared to the others. Macroscopic, radiographic, and histological evaluations established that intra-articular injections of stigmasterol/β-CD-MSNs inhibited cartilage degeneration and subchondral bone deterioration. Therefore, in a chemically induced OA rat model, intra-articular stigmasterol delivery was associated with reduction in both local and systemic inflammatory responses, alongside a slowdown in joint degradation and arthritic progression.

Effect of platelet-rich plasma versus steroid injection in plantar fasciitis: a randomized clinical trial

BACKGROUND

Plantar fasciitis (PF) is a common orthopaedic problem, with heel pain worsening the quality of life. Although steroid injection is often used if the conservative treatment fails, Platelet-Rich Plasma (PRP) injection is gaining popularity due to its safety and long-lasting effect. However, the effect of PRP versus steroid injection in PF has not been studied yet in Nepal. Therefore, this study aimed to assess the effect of PRP compared with steroid injection in the treatment of PF.

METHODS

This study was a single-center, hospital-based, open-label, parallel-group randomized clinical trial to compare the effect of PRP injection with steroid injection in plantar fasciitis between August 2020 and March 2022. A total of 90 randomly selected participants aged 18 to 60 years suffering from plantar fasciitis with failed conservative treatment were intervened. The American Orthopaedic Foot and Ankle Society (AOFAS) and the Visual Analog Scale (VAS) scoring system were used to evaluate functional mobility and pain before and after the intervention for three and six months, respectively. Statistical analyses were performed using a Student's two-sample t-test. P-value < 0.05 was considered statistically significant.

RESULTS

The PRP injection showed a better outcome than the steroid injection in six months follow-up. The mean (± SD) VAS score was significantly decreased in the PRP group (1.97 + 1.13) than in the steroid group (2.71 ± 0.94) with the group difference of -0.73 (95% CI: -1.18 to -0.28) at six months. Similarly, there was a significant increase in the AOFAS scores in the PRP group (86.04 ± 7.45) compared to the steroid group (81.23 ± 9.60) at six months of follow-up with a group difference of 4.80 (95% CI: 1.15 to 8.45). There was also a significant reduction of plantar fascia thickness in the PRP group compared to that of the steroid group (3.53 ± 0.81 versus 4.58 ± 1.02) at six months of follow-up with the group difference of -1.04 (95% CI: -1.44 to -0.65).

CONCLUSION

The PRP injection showed better outcomes than steroid injection in plantar fasciitis treatment over the course of six months. Further research with a larger population and longer follow-up than six months is needed to generalize the findings and their long-term efficacy.

TRIAL REGISTRATION

NCT04985396. First registered on 02 August 2021. ( https://clinicaltrials.gov/ct2/show/NCT04985396 ).

Vision Loss Secondary to Facial and Periorbital Steroid Injection: A Systematic Review

PURPOSE

The risk of ophthalmic and retinal artery occlusions following facial and periorbital steroid injection has not been explored. This systematic review examines the prevalence, risk factors, and treatment outcomes of steroid-induced vision losses.

METHODS

A literature search in Evidence Based Medicine Reviews, MEDLINE, Embase, Pubmed, ClinicalTrials, and WHO ICTRP was performed for vision loss following facial and periorbital corticosteroid injections through July 2020.

RESULTS

Of 35 case reports, series, and reviews, 49 patients (56 eyes) with steroid-induced vision loss were analyzed. Injection sites predominantly involved the nose (45%) and periocular regions (10%). The most common type of steroid is triamcinolone (54%). Most cases were unilateral, except 7 cases of bilateral vision losses, 4 of which resulted from unilateral steroid injection. Symptoms were reported during or immediately after injections in 49% of cases. Most occlusions occurred in the ophthalmic (53%) or central retinal artery (33%). Vision most commonly presented as no light perception (37%), and 90% were 20/200 or worse. Final visual outcomes varied from 20/200 or worse (56%), 20/40 or better (30%), to in between (13%).

CONCLUSION

Most vision losses resulted from steroid injections in the nasal and periorbital area. Triamcinolone was the most common offending agent, likely due to large particle size, low solubility, and extensive particle aggregation. Dexamethasone has the opposite pharmacologic properties and has never been reported in association with vascular occlusion related vision loss. Careful steroid selection, injection techniques, and treatment strategies should be considered to prevent and treat artery occlusion.

Dermatologist Use of Intralesional Triamcinolone in the Treatment of Acne

OBJECTIVE: Despite common administration of intralesional triamcinolone to acne lesions, there is little published data or consensus on best practices. This study aimed to evaluate specific characteristics of intralesional triamcinolone for acne among various dermatology healthcare professionals. DESIGN: One hundred participants (82 attending physicians, 9 physician assistants, 8 other healthcare professionals, and 1 unidentified) from private practices and academic centers completed a 10-question survey to assess specific characteristics of intralesional triamcinolone injections, including frequency, indication, depth of injection, concentration, volume, as development of adverse events. RESULTS: The most common reported concentration of intralesional triamcinolone was 2.5mg/mL (52.5%). The most frequently used volume injected was 0.05mL (42.3%). In total, 61.6 percent of those surveyed answered that they inject into the center of the lesion. Additionally, 50.5 percent of respondents counsel patients on potential adverse effects of hypopigmentation and atrophy before every injection. The majority of respondents (88.8%) reported that less than one percent of their patients returned for adverse events resulting from triamcinolone usage, and 48.4 percent reported that atrophy lasted over six months (48.4%). CONCLUSION: The data collected from this study can offer guidance on best practices in administering intralesional kenalog to patients. While consistency exists for the concentration of triamcinolone used, there was significant discordance in the volumes and depth of triamcinolone injection. Observed skin atrophy rates are extremely low, but they are long lasting when it occurred. We can use these data to refine our treatment techniques as well as improve treatment outcomes and patient satisfaction.

A linear forehead lesion caused by intralesional injection of triamcinolone acetonide and treated with hyaluronic acid filler: Case report

Intralesional steroid injection is a treatment method frequently used to resolve a large number of orthopedic, rheumatological, dermatological, and neurological disorders. Although this treatment is very effective, it is not without possible side effects, both systemic and local, among which we can mention pain, bleeding, ulceration, atrophy, pigmentary changes, calcification, secondary infections, formation of granulomas, allergic reactions and, in very rare cases, the development of linear atrophy, and hypopigmentation. Here, we present a case of frontal linear skin atrophy after intralesional steroid injection for the treatment of alopecia areata (AA) in a 29 year-old patient, successfully treated with a hyaluronic acid filler.

Linear Depigmentation After an Intralesional Corticosteroid Injection

Corticosteroid injections are an effective treatment for many medical conditions. However, clinicians must be aware of potential side effects of this treatment modality so that proper patient counseling can take place. Patients with pigmentary alteration after intra-articular or intralesional corticosteroid injections have rarely been reported in literature. We present an adult male patient with linear depigmentation after an intralesional corticosteroid injection for a Morton's neuroma.

Branching hypopigmentation following intralesional corticosteroid injection: Case report and review of the literature

Intralesional corticosteroid injections are frequently used to treat various musculoskeletal and dermatologic conditions, including keloid scarring. While a number of adverse events may be associated with these injections, hypopigmentation without atrophy is rare. We report a case of a pediatric patient with temporary cutaneous hypopigmentation without atrophy following intralesional corticosteroid injection in a keloid scar.

The color of skin: white diseases of the skin, nails, and mucosa

White diseases are a heterogenous group characterized by hypopigmentation or depigmentation. Skin and eye color are determined by the number and size of melanosomes present. Melanin is produced by melanosomes in the melanocytes present within the epidermis of the skin, uvea, and retinal pigmented epithelium (RPE). Conditions altering the number of melanocytes or concentration of melanin result in a lack of pigmentation, appearing as "white diseases" ranging from the well-known albinism and vitiligo to more esoteric white hand syndrome and Degos disease.

Reflectance confocal microscopy and histological features of depigmentation after local corticosteroid injection

BACKGROUND

Clinically, depigmentation after local corticosteroid injection is not rare. But there are less articles about its reflectance confocal microscopy (RCM) and histological features. This study aimed to define the RCM features and histopathologic findings of hypopigmentation after local corticosteroid injection and to analyze the correlations between the above two methods.

METHODS

Forty cases with hypopigmentation after local corticosteroid injection were used to analyze the clinical and RCM features. Subsequently, for 20 of 40, an excision biopsy of the same imaged areas for histopathologic examination was executed.

RESULTS

Our results showed that all 40 cases had round or ellipse hypopigmented macules with obscure boundary and 26 of 40 lesions' long diameter went along limbs. The RCM features and the histological findings revealed all patients had variable degrees of epidermal thinning, flattening rete ridges, reduced melanin, and no inflammatory cell infiltration. MART-1 analysis revealed the number of melanocytes was normal but with no or less melanin by Fontana-Masson staining.

CONCLUSIONS

Depigmentation after local corticosteroid injection was a kind of disease with intact melanocytes, whose function was impaired. RCM features offer a high consistency with histopathologic findings. It thus constitutes a promising adjuvant tool for its diagnosis and for therapeutic follow-up.

Randomized, Double-Blinded, Sham-Controlled, Split-Hand Trial Evaluating the Safety and Efficacy of Triamcinolone Acetate Injection After Calcium Hydroxylapatite Volume Restoration of the Dorsal Hand

BACKGROUND

Calcium hydroxylapatite (CaHA) is currently the only FDA-approved soft-tissue filler indicated for augmentation of the dorsal hand. Although the treatment is generally safe and effective, adverse side effects such as swelling and edema postinjection are common and can sometimes be debilitating.

OBJECTIVE

In this study, the authors explore the utility of triamcinolone acetate coinjection with CaHA to the dorsal hands to mitigate adverse effects and improve patient experience.

PATIENTS AND METHODS

After obtaining informed consent, 20 subjects were enrolled in this double-blind, randomized, split-hand, sham-controlled clinical trial. Subject hands were randomized to receive either CaHA with triamcinolone acetate or CaHA with sham saline coinjection. Follow-up evaluations were performed by a blinded investigator at Days 7, 14, 30, 90, 180, 270, and 360 and consisted of the validated Merz Hand Grading Scale and assessments of erythema, edema, modules, bruising, and skin atrophy. Subjects also kept a daily diary for the first 30 days postinjection documenting bruising, itching, pain, redness, swelling, difficulty in performing activities with hands, and sensory alteration in hands.

RESULTS

There were no significant differences in treatment efficacy between the 2 groups. Post-treatment swelling was significantly reduced between Days 6 and 19 in the triamcinolone acetate coinjection group.

CONCLUSION

The addition of triamcinolone acetate coinjection with CaHA for dorsal hand augmentation did not negatively impact treatment efficacy but significantly reduced adverse side effects. This strategy represents a safe and effective way to improve patient experience and treatment tolerability.

Intralesional triamcinolone injections for the treatment of preauricular sinus infections

OBJECTIVES

The aim of this study is to confirm the effect of adjuvant intralesional triamcinolone acetonide injections (TRIAM) for the treatment of an infected preauricular sinus (PAS).

METHODS

The medical charts of 103 patients diagnosed with PAS from March 2013 to December 2015 were reviewed and documented. The mean duration of treatment and postoperative follow-up period were compared between patients who received TRIAM and patients who received conventional treatment.

RESULTS

Fifteen patients received TRIAM. The mean duration of treatment was 12.5±11.0days in patients treated with TRIAM, which was significantly shorter than patients without TRIAM (25.5±25.7days, p=0.010). In addition, the percentage of patients experiencing early recovery (within 10days) was 4.15 times higher with TRIAM (95% confidence interval: 1.07-16.13, p=0.040). The mean postoperative follow-up period revealed a similar tendency; patients treated with TRIAM required a shorter follow-up period (8±2.6days) than patients not treated with TRIAM (13.5±7.4days). However, this difference was not significant (p=0.242).

CONCLUSION

Although the sample was small, patients with PAS infections who were treated with TRIAM as an adjuvant therapy required a significantly shorter treatment duration than patients receiving conventional treatment alone. This finding suggests a beneficial effect of TRIAM for the short-term control of PAS infections. Clinicians should consider TRIAM as an adjuvant treatment option.

A single-blind, dose escalation, phase I study of high-fluence light-emitting diode-red light (LED-RL) on human skin: study protocol for a randomized controlled trial

Background

Skin fibrosis is involved in a variety of pathologic conditions ranging from scar formation secondary to surgery or trauma to immune-mediated processes. Skin fibrosis is a significant international health problem with an estimated incidence of greater than 100 million people affected per year worldwide with few effective treatment options available. Preliminary in vitro data generated by our research group suggests that red light can function as a stand-alone treatment for skin fibrosis. To our knowledge, no prior clinical trials have been performed to determine the safety of high-fluence (dose) light-emitting diode-red light (LED-RL) phototherapy. The goal of this study is to evaluate the safety of LED-RL fluences from 160 J/cm² up to 640 J/cm² in healthy subjects.

Methods/design

This is a single-blind, dose escalation, randomized controlled, phase I study to evaluate the safety of high-fluence LED-RL on human skin. The protocol for dose escalation requires subjects be enrolled sequentially in groups of five. Within each group, three subjects will be randomized to LED-RL phototherapy and two subjects randomized to mock therapy. Subjects in group 1 randomized to LED-RL phototherapy will receive the maximum recommended starting dose (160 J/cm²). LED-RL dose will be escalated in subsequent groups (320 J/cm², 480 J/cm² and 640 J/cm²). The maximally tolerated dose (MTD) is defined as the dose level below the dose producing unacceptable but reversible toxicity and is considered to be the upper limit of subject tolerance. After either a MTD has been established, or the study endpoint of 640 J/cm² has been achieved, an additional 27 LED-RL phototherapy subjects (for a total of 30) and 18 mock therapy subjects (for a total of 20) (determined randomly) will be enrolled. Each subject will receive a total of nine procedures, three times per week for three consecutive weeks.

Discussion

This study may provide important safety information on the effects of high-fluence LED-RL phototherapy on human skin and help facilitate future phase II studies to evaluate the efficacy of high-fluence LED-RL as a potential noninvasive, safe, portable, at-home therapy for treatment of skin fibrosis.

Trial registration

ClinicalTrials.gov NCT02630303. Registered on 9 December 2015. 

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1518-7) contains supplementary material, which is available to authorized users.

Characteristics of particulate and non-particulate corticosteroids. Indications for their use in chronic pain treatments

Corticosteroids been used frequently in pain treatments since the middle of last century (1952). Due to a review of the complications as a result of their application in epidural injections, the United States of America Food and Drug Administration (FDA) issued an «alert controversy» requesting that a warning label should be added to injectable corticosteroids, where risks must be described (loss of sight, brain damage, paralysis and death) when administering by this route. It must be mentioned that there are different types of corticosteroids with diverse characteristics, which as a result, may produce different side-effects. Due to the aforementioned developments, the controversies that have arisen, and the lack of well-conducted studies on the use of steroids in epidural injections, we must begin by reviewing their indications in different pain conditions.

Growth Hormone-Releasing Peptide 6 Enhances the Healing Process and Improves the Esthetic Outcome of the Wounds

In addition to its cytoprotective effects, growth hormone-releasing peptide 6 (GHRP-6) proved to reduce liver fibrotic induration. CD36 as one of the GHRP-6 receptors appears abundantly represented in cutaneous wounds granulation tissue. The healing response in a scenario of CD36 agonistic stimulation had not been previously investigated. Excisional full-thickness wounds (6 mmØ) were created in the dorsum of Wistar rats and topically treated twice a day for 5 days. The universal model of rabbit's ears hypertrophic scars was implemented and the animals were treated daily for 30 days. Treatments for both species were based on a CMC jelly composition containing GHRP-6 400 μg/mL. Wounds response characterization included closure dynamic, RT-PCR transcriptional profile, histology, and histomorphometric procedures. The rats experiment indicated that GHRP-6 pharmacodynamics involves attenuation of immunoinflammatory mediators, their effector cells, and the reduction of the expression of fibrotic cytokines. Importantly, in the hypertrophic scars rabbit's model, GHRP-6 intervention dramatically reduced the onset of exuberant scars by activating PPARγ and reducing the expression of fibrogenic cytokines. GHRP-6 showed no effect on the reversion of consolidated lesions. This evidence supports the notion that CD36 is an active and pharmacologically approachable receptor to attenuate wound inflammation and accelerate its closure so as to improve wound esthetic.