Cortisone Shot Atrophy VERIFIED
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A previously 46-year-old woman, who had a splint for approximately one month due to right wrist pain caused by a car accident in April 2012, visited an orthopaedic clinic due to continuing pain after one month. A corticosteroid was injected (triamcinolone acetonide 20 mg) into the transverse carpal ligament once. The patient had numbness for 2 days after injection, and had pain, hypopigmentation, muscle atrophy one month after the corticosteroid injection (Fig. 1A). The patient visited our pain clinic in September 2012. She had pain of visual analogue scale (VAS) 2 in the medial region of the right wrist in the resting state, and had increased pain of VAS 4-5 during contact on the right wrist or wrist motion. No sensory deficit or hyperalgesia was observed in the right wrist.
(A) Hypopigmentation and subcutaneous atrophy and muscle atrophy in the wrist after local corticosteroid injection. (B) Resolved symptoms in the wrist at one year after local corticosteroid injection.
As she was suspected to have nerve injury due to corticosteroid injection, she underwent three phase bone scan, electromyography, and the nerve conduction test. The results showed normal findings. Her muscle atrophy was severe. Accordingly, the patient underwent electromyography and the nerve conduction test specifically on the atrophied muscle after discussion with the department of rehabilitation and the department of neurology. As a result, nerve injury was observed in the focal deep branch of the ulnar nerve that governs the opponens digiti minimi muscle.
Gabapentin (Neurontin, Pfizer Inc., New York, NY, USA) 100 mg, tramadol 37.5 mg/acetaminophen 325 mg 1 tablet, and clonazepam 0.5 mg 0.5 tablet were administered to the patient twice a day. After drug administration, pain was reduced, but discomfort persisted during contact. Thus, she was referred to the department of plastic surgery for autologous fat injection. Approximately one year after the onset of her symptom, she visited our clinic and showed spontaneous recovery of hypopigmentation and fat and muscle atrophy and decrease in pain to VAS 0-1 during contact (Fig. 1B). Thus, we decided to observe residual symptom without any procedure.
Local corticosteroid injection has complications such as infection, sepsis, facial flushing, hypopigmentation, perilymphatic atrophy, bleeding, tendon rupture, steroid flare, soft tissue atrophy, and hypersensitivity reaction. In this case study, the patient had hypopigmentation, subcutaneous fat and muscle atrophy, and nerve injury. Skin hypopigmentation has been reported to occur in 1.3-4% of patients who underwent local corticosteroid injection [2]. Although the exact mechanism of hypopigmentation is unclear, steroids or biologically inactive components of steroids have been known to be involved in hypopigmentation [3]. In addition, dermal complications after corticosteroid injection are also explained by mechanical effects caused by edema, changes in ground substances, or vasoconstriction. Hypopigmentation occurs 1-4 months after corticosteroid injection, and then resolves 6-30 months after the injection. However, it can be prevented if intradermal and subcutaneous injections are avoided [4]. Subcutaneous fat atrophy and hypopigmentation may occur by injection of any type of steroid into the soft tissue. However, if steroids with suitable solubility and potency are used, the risk of subcutaneous fat atrophy and hypopigmentation can be reduced. Therefore, steroids with low solubility, such as triamcinolone acetonide, are preferably injected into the joint of deep structures such as the knee, elbow, and shoulder, whereas steroids with high solubility, such as betamethasone sodium and dexamethasone, are preferably injected into soft tissues such as the bursa, tendon sheath, metacarpophalangeal joint, proximal phalangeal joint, and carpal tunnel. Steroids cause fewer complications if their efficacy duration is shorter. In addition, for the prevention of subcutaneous fat atrophy, compressing the injection site with gauze is recommended after pulling out the needle to prevent steroid leakage along the needle track [1]. Subcutaneous fat atrophy has been known to last for 6-12 months after corticosteroid injection, and it is known to be reversible and resolved within one year. If subcutaneous fat atrophy lasts for more than one year, surgical treatments such as fat graft and fat injection can be considered [5]. Thus, in the present case study, the necessity of surgical treatment was explained to the patient, followed by treatment under collaboration with the department of plastic surgery.
Few studies have been conducted to investigate the incidence of nerve injury after corticosteroid injection. Via microneuronal circulation studies and histological studies, steroids were reported to have neurotoxicity. Injection site is one of the important factors in the occurrence of nerve injury. In particular, intrafacicular injection causes nerve injury. Besides, the severity of nerve injury may vary depending on the drug used. Hydrocortisone and triancinolone acetonide cause more extensive axon and myelin degeneration compared to dexamethasone.
Discussion. Corticosteroid injections are a common therapy that can infrequently cause adverse effects, such as fat atrophy. The injections are used to treat several conditions, particularly dermatologic, musculoskeletal, and allergic conditions including arthritis, bursitis, tendinitis, alopecia, psoriasis, keloids and hypertrophic scars, and severe allergies. Although these injections are considered low risk, they can cause well-known adverse effects, such as tendon weakening or rupture, infection, bleeding, skin discoloration, skin and fat atrophy, and damage to cartilage and bone.1 The incidence of fat atrophy is not well known but has been estimated to be between 3% and 41%.1 This adverse effect is more frequent with intramuscular injections, such as those used to treat allergies; however, fat atrophy has been reported in intra-articular and peritendinous injections, as well as with oral corticosteroids.3,4 These risks are increased with larger or multiple doses and with corticosteroids of high concentration or low solubility.5 For unclear reasons, corticosteroid-induced skin and fat atrophy appears to occur more frequently in premenopausal women than in men.2,3
Fat atrophy that results from corticosteroid use typically self-resolves in 6 to 12 months.5 After this time, if the atrophy persists, surgical intervention such as fat grafting or injection is often performed if the areas are bothersome to the patient. Because fat atrophy is known to resolve spontaneously, acute treatment is often not pursued. However, these lesions can be significant, located in cosmetic areas, and problematic for the patient, which are all reasons why acute treatment may be pursued. Several case reports demonstrate the efficacy of normal saline injections for treatment of corticosteroid-induced fat atrophy.6-8 In this case report, we provide further evidence for an infrequently considered treatment method, as well as methods to decrease the risk of atrophy with corticosteroid use.
Our case demonstrates the utility of normal saline injections for corticosteroid-induced fat atrophy. Although fat atrophy may resolve spontaneously, these lesions may be unsightly and undesirable to the patient, who may wish for them to be reversed more quickly. In this case, our patient was a young woman with 2 of the atrophic plaques in a cosmetically sensitive area. Lesions on the facial area can be distracting and obvious, even when relatively small. These plaques were not only significant in size, but they were also in an area that was difficult to camouflage with hair or hats; makeup is poorly effective in disguising blemishes of such depth.
Over time, these effects will gradually dissipate as the body reabsorbs the corticosteroid crystals and the adipocytes return to normal number and size. Usually, this will be evident within the first year, but sometimes the atrophy is permanent.5 In these situations, if correction is desired, then other procedural techniques are required to restore normal skin topography, such as filler placement or fat grafting.
Although we could find no published comparative studies, utilizing certain techniques may decrease the chance of fat atrophy based on our current understanding of the pathophysiology of this condition. For deeper structures, an insoluble formulation such as triamcinolone acetonide or hexacetonide may be used. For more superficial injections such as tendons and skin lesions, more soluble compounds such as betamethasone sodium phosphate and acetate or dexamethasone sodium phosphate could be considered.3,12 Care should be taken to ensure as much of the injection reaches the intended site, while minimizing the chance of spread.2 This can be optimized by choosing a properly sized needle and completing the injection in one push. Multiple injections or injecting while withdrawing the needle should be avoided. Intramuscular injections should be injected at an appropriate depth to reach the muscle, typically 1.5 to 2 inches but varies with body habitus, to avoid injecting corticosteroid into adipose tissue.5 In addition, the clinician should visibly inspect the medication before and during injections to ensure it has not precipitated.
Conclusions. Medical practitioners should be aware of the less common adverse effects of steroid injections, such as fat atrophy. A history of corticosteroid injections should be elucidated if a patient presents with fat atrophy of unknown cause, as this can prevent misdiagnosis and an otherwise lengthy, invasive, and expensive medical workup for other causes. When performing corticosteroid injections, care should be taken to minimize the risk of fat atrophy. Although fat atrophy is generally not dangerous and frequently resolves on its own, it can present in cosmetically sensitive areas requiring more rapid reversal. For these cases, serial normal saline injections can provide a simple, safe, and effective method to permanently reverse corticosteroid-induced fat atrophy. 153554b96e
Cortisone shot atrophy refers to a rare side effect where the skin or fat tissue near the injection site thins, causing dimpling or a visible depression. While this condition can be concerning, it is typically temporary and resolves over time. Proper injection technique and using the lowest effective dose of cortisone can help minimize this risk. If you’re undergoing treatments involving injections, such as cortisone shots or testosterone cypionate for sale purchased online, it’s crucial to ensure that the product is of high quality and administered by a qualified professional. Always consult a healthcare provider to address any concerns and follow post-injection care instructions to reduce the likelihood of side effects, ensuring safe and effective treatment.