Intralesional Steroid Injections: Look Before You Leap!

Sir,

Intralesional steroid injections (ILS), mainly triamcinolone acetonide, are standard treatment for many skin diseases including keloids, alopecia areata, and circumscribed plaques of dermatitis.[1] Though, the treatment is generally safe; side effects are known to happen including local hypo pigmentation and atrophy. We believe that inappropriate and indiscriminate use of ILS should be avoided. We present two cases in point where inappropriate ILS therapy was started with important implication for clinical practice.

First patient was a 21-year-old male who presented to us with an erythematous, asymptomatic, indurated plaque of size 14 × 6 cm over right elbow. The lesion started 2 month after a minor scrape injury and was treated as a case of keloid at a tertiary care hospital with three doses of intralesional steroids leading to central ulceration. The ulcer did not heal despite three courses of antibiotics and local dressing. X-rays of underlying joint and chest were normal. Tuberculin test was positive while other hematological and biochemical parameters were normal [Figure 1a]. Biopsy confirmed the clinical suspicion of lupus vulgaris and patient showed complete response to standard 6 month course of anti-tubercular treatment [Figure 1b].

Figure 1.

(a) Clinical picture of ulcerated lupus vulgaris plaque with positive tuberculin test (arrow); (b) Clinical picture of healed plaque after anti-tubercular treatment

Second patient was a 38-year-old male complaining of a 21 × 7 cm plaque over left gluteal fold which was misdiagnosed as a case of lichen simplex and treated with intralesional steroids at another hospital leading to erosions developing at the upper and lower poles [Figure 2a]. Anal verge was not involved and MRI of abdomen and pelvis was normal. Tuberculin was strongly positive and other routine laboratory parameters were normal. Again biopsy confirmed the diagnosis of lupus vulgaris and anti-tubercular treatment for 6 months lead to complete response [Figure 2b].

Figure 2.

(a) Clinical picture of lupus vulgaris plaque on the left gluteal fold; (b) Complete healing of the lesion with anti-tubercular treatment

ILS is routinely used by dermatologists for keloids, hypertrophic scars as well as lichen simplex chronicus.[1,2] Though generally well tolerated, various local and systemic side effects of ILS are well described in literature.[1] However, not enough emphasis is laid on the pre-treatment considerations. If inappropriate cases are selected for treatment, it may have serious repercussions. If mycobacterial infections like cutaneous tuberculosis are injected with steroids the possibility of spread by local immunosuppression, or hematogenous/lymphatic exposure cannot be ruled out. It seems entirely plausible that with ILS a cutaneous infection could also spread to deeper structures like bones, or gastrointestinal mucosa. Further, the atrophy consequent to steroid injection may lead to ulceration as in our first case and cause avoidable scarring and potential for spread in community. Recently, it has been reported that for Mycobacterium marinum tenosynovitis; inappropriate intralesional steroid led to poor functional outcome.[3] A case of subcutaneous abscess formation with Mycobacterium fortuitum following intralesional steroid injection into multifocal keloids has also been reported.[4]

The purpose of the present report is to raise awareness of potential complications of inappropriate case selection for ILS therapy. Special care should be taken to double-check the working diagnosis and consider other possible differentials and mimics before proceeding with the ILS therapy.