Trichoscopy of Steroid-Induced Atrophy

Abstract

Intralesional corticosteroid (IL-CS) injections have been used to treat a variety of dermatological and nondermatological diseases. Although an important therapeutic tool in dermatology, a number of local side effects, including skin atrophy, have been reported following IL-CS injections. We recently noticed that a subset of patients with steroid-induced atrophy presented with ivory-colored areas under trichoscopy. We performed a retrospective analysis of trichoscopic images and medical records from patients presenting ivory-colored areas associated with atrophic scalp lesions. In this paper, we associate this feature with the presence of steroid deposits in the dermis and report additional trichoscopic features of steroid-induced atrophy on the scalp, such as prominent blood vessels and visualization of hair bulbs.

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Original Article
Skin Appendage Disord 2017;3:171–174
DOI: 10.1159/000471771
Trichoscopy of Steroid-Induced Atrophy
RodrigoPirmez  a LeonardoS.Abraham  b BrunaDuque-Estrada  a
PatríciaDamasco  b DéboraCadoreFarias  c YannaKelly  d IsabellaDoche  d 
a  Department of Dermatology, Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da
Misericórdia do Rio de Janeiro, Rio de Janeiro ,
b  Department of Dermatology, Hospital Regional da Asa Norte,
Brasília , c  Department of Dermatology, Universidade Federal de Santa Catarina, Florianópolis , and
d  Department
of Dermatology, Universidade de São Paulo, São Paulo , Brazil
Introduction
Intralesional corticosteroid (IL-CS) injections have
been used to treat a variety of dermatological and nonder-
matological diseases
[1] . IL-CS injections are, for exam-
ple, considered as a first-line therapy in patchy alopecia
areata
[2] . Although an important therapeutic tool in der-
matology, a number of local side effects, including skin
atrophy, have been reported following IL-CS injections
[1] . We recently noticed that a subset of patients with ste-
roid-induced atrophy presented with ivory-colored areas
under trichoscopy ( Fig.1 ). In this paper, we associate ivo-
ry-colored areas with the presence of steroid deposits in
the dermis and report additional trichoscopic features of
steroid-induced atrophy. To the best of our knowledge,
there are no other studies reporting such data.
Materials and Methods
We performed a retrospective analysis of trichoscopic images
and medical records from patients presenting ivory-colored areas
associated with atrophic scalp lesions. All patients had been seen
for different types of hair loss, including both scarring and non-
scarring alopecias, at 4 referral centers in Brazil. Diagnosis was
established clinically by dermatologists with experience in hair dis-
Keywords
Alopecia · Corticosteroid · Dermoscopy · Intralesional
injection · Skin atrophy · Steroids · Trichoscopy
Abstract
Intralesional corticosteroid (IL-CS) injections have been used
to treat a variety of dermatological and nondermatological
diseases. Although an important therapeutic tool in derma-
tology, a number of local side effects, including skin atrophy,
have been reported following IL-CS injections. We recently
noticed that a subset of patients with steroid-induced atro-
phy presented with ivory-colored areas under trichoscopy.
We performed a retrospective analysis of trichoscopic im-
ages and medical records from patients presenting ivory-
colored areas associated with atrophic scalp lesions. In this
paper, we associate this feature with the presence of steroid
deposits in the dermis and report additional trichoscopic
features of steroid-induced atrophy on the scalp, such as
prominent blood vessels and visualization of hair bulbs.
© 2017 S. Karger AG, Basel
Received: February 10, 2017
Accepted: March 15, 2017
Published online: April 28, 2017
Rodrigo Pirmez
Rua Visconde de Pirajá 330, salas 1001–1003
Rio de Janeiro, RJ 22410-000 (Brazil)
E-Mail rodrigopirmez  @  gmail.com
© 2017 S. Karger AG, Basel
www.karger.com/sad

Pirmez/Abraham/Duque-Estrada/
Damasco/Farias/Kelly/Doche
Skin Appendage Disord 2017;3:171–174
DOI: 10.1159/000471771
172
orders and, in doubtful cases, was confirmed through pathology.
Clinical information is summarized in Table1 . Trichoscopy and
photographic documentation were performed using either Foto-
Finder Dermoscope
® , FotoFinder Handyscope
® (Teachscreen
Software, Bad Birnbach, Germany), or DermLite
® Foto (3Gen,
San Juan Capistrano, CA, USA) attached to a Nikon
® J1 camera.
Results
Twenty-five lesions from 8 patients were retrieved. All
patients had been submitted to IL-CS injections as part of
their treatment. In 3 patients, biopsies from ivory-colored
areas were available and revealed circumscribed, fine pale
foamy material in the dermis, suggestive of steroid depos-
its ( Fig.2 )
[3] .
Another remarkable trichoscopic feature was the pres-
ence of prominent blood vessels in 23 (92%) lesions
( Fig.3 ), which were classified as thin (16 lesions; 64%)
and thick arborizing (15 lesions; 60%) and which in 3 le-
sions (12%) were so numerous as to form a vascular net-
work. Visualization of hair bulbs through the atrophic
skin was evident in 5 lesions (20%) ( Fig.4 a). Interesting-
ly, in 5 (out of 12) lesions of patients with alopecia areata,
regrowing hairs were organized as a collar that surround-
ed the steroid deposits ( Fig.4 b).
During our research, another 8 patients with 13 similar
lesions in areas other than the scalp were also identified.
Such patients had also been submitted to IL-CS injections
for different reasons (clinical information can be found
in Table2 ).
Discussion
The presence of steroid deposits has already been re-
ported after triamcinolone injections in different body
areas, such as the vocal cords and eyes
[4, 5] . In our case
series, the reason for such deposits can only be specu-
lated on. However, it is remarkable that in 25 lesions (out
of 28 in which the steroid used is known) the corticoste-
roid injected was triamcinolone hexacetonide, which is
known to be much less soluble than other steroids, in-
cluding triamcinolone acetonide
[6, 7] . Some authors
have even considered triamcinolone hexacetonide to be
unsuitable for intralesional injection due to its inordi-
nately long half-life
[1] . Furthermore, in the 25 lesions in
which triamcinolone hexacetonide was used, concentra-
tions were equal to or higher than 10 mg/mL in 24 lesions
(96%), which could serve as an additional risk factor for
steroid deposition and tissue atrophy. Another interest-
ing point to consider is that triamcinolone hexacetonide
should not be mixed with diluents or local anesthetics
containing preservatives, such as parabens or phenols,
since they may cause precipitation of the steroid
[1] .
Even though this information was not available, we can-
not exclude that the type of diluent used may have played
a role in the formation of cutaneous deposits in some
cases.
Steroid-induced atrophy may be self-limited [8] . It is
unknown whether the presence of steroid deposits in the
dermis may hinder resolution of cutaneous atrophy. Ac-
Table 1. Clinical information from patients with scalp lesions of
steroid-induced atrophy presenting ivory-colored areas
Patient Gender Age,
years
Lesions,
n
Condition Corticosteroid
and concentra-
tion, mg/mL
1 f 30 7 AA TH 10
2 f 26 1 HS BD 5 + BDS 2
3 f 68 2 DLE TH 10
4 f 41 2 AA TA 10
5 m 28 2 AA TH 20
6 f 74 1 LPP TH 05
7 f 68 9 FFA unknown
8 f 59 1 AA unknown
AA, alopecia areata; HS, hypertrophic scar; DLE, discoid lupus
erythematosus; LPP, lichen planopilaris; FFA, frontal fibrosing
alopecia; TH, triamcinolone hexacetonide; BD, betamethasone
dipropionate; BDS, betamethasone disodium phosphate; TA,
triamcinolone acetonide.
Fig. 1. Ivory-colored areas seen under trichoscopy in an alopecia
areata patient presenting corticosteroid-induced skin atrophy.
Original magnification: ×20.
Color version available online

Trichoscopy of Steroid-Induced Atrophy Skin Appendage Disord 2017;3:171–174
DOI: 10.1159/000471771
173
Table 2. Clinical information from patients with body lesions of steroid-induced atrophy presenting ivory-
colored areas
Patient Gender Age,
years
Lesions,
n
Body location Condition Corticosteroid and
concentration, mg/mL
1 m 31 2 abdomen HS TH 20
2 f 32 2 face/chest acne cysts TH 20
3 f 70 2 arms granuloma annulare TH 20
4 f 34 1 inframammary HS TH 10
5 f 41 1 abdomen HS TH 20
6 f 35 2 abdomen/arm HS TH 20
7 f 32 2 breasts HS TH 20
8 m 32 1 chest HS TH 20
HS, hypertrophic scarring; TH, triamcinolone hexacetonide.
ab
abc
Fig. 2. Biopsies from ivory-colored areas revealed circumscribed, fine pale foamy material present in the dermis
(
a ), which can be better visualized in b . HE staining. Original magnification: a ×100 and b ×200.
Fig. 3. Vascular changes in steroid-induced atrophy. Trichoscopy showed thin arborizing vessels ( a ), thick arbo-
rizing vessels (
b ), and blood vessels forming a vascular network ( c ). For classification purposes, vessels thinner
than the average hair were considered as “thin” and vessels thicker than the average hair as “thick.” Original mag-
nification: ×20.
Color version available onlineColor version available online

Pirmez/Abraham/Duque-Estrada/
Damasco/Farias/Kelly/Doche
Skin Appendage Disord 2017;3:171–174
DOI: 10.1159/000471771
174
cording to personal observations (B.D.-E. and L.S.A.),
surgical removal of the deposits leads to partial regression
of dermal atrophy, but prospective studies are necessary
to confirm this information.
One limitation of the study was the limited access to
patient data, since most of the patients were originally
treated by other physicians. Information lacking includes
the total number of injections received by each patient
and the duration of atrophy.
In conclusion, we describe ivory-colored areas as a
novel trichoscopic feature representing steroid deposits
in the dermis and suggest that their presence may indicate
the etiology of skin atrophy in cases in which a previous
history of IL-CS injections is not clear. We further report
additional features of steroid-induced atrophy on the
scalp, such as prominent vessels and visualization of hair
bulbs. Finally, we suggest the use of triamcinolone ace-
tonide rather than of its less soluble salt hexacetonide for
intralesional injections and at lower concentrations, typ-
ically at 2.5 and 5 mg/mL for scalp lesions.
Statement of Ethics
All patients have given their consent for their details to be de-
scribed in this article.
Disclosure Statement
The authors have no conflicts of interest to disclose.
Funding Sources
There were no funding sources for this work.
ab
Fig. 4. Additional trichoscopic features included visualization of hair bulbs ( a ) and collars of regrowing hairs
around the ivory-colored areas (
b ). Original magnification: ×20.
References
1 Firooz A, Tehranchi-Nia Z, Ahmed AR: Ben-
efits and risks of intralesional corticosteroid
injection in the treatment of dermatological
diseases. Clin Exp Dermatol 1995;
20: 363–
370.
2 Alkhalifah A, Alsantali A, Wang E, McElwee
KJ, Shapiro J: Alopecia areata update: part II.
Treatment. J Am Acad Dermatol 2010;
62:
191–202.
3 Kaur S, Amanjeet, Thami GP, Mohan H: In-
tralesional steroid induced histological
changes in the skin. Indian J Dermatol Vene-
reol Leprol 2003;
69: 232–234.
4 Wang CT, Lai MS, Hsiao TY: Comprehensive
outcome researches of intralesional steroid
injection on benign vocal fold lesions. J Voice
2015;
29: 578–587.
5 Okka M, Bozkurt B, Kerimoglu H, et al: Con-
trol of steroid-induced glaucoma with surgi-
cal excision of sub-Tenon triamcinolone ace-
tonide deposits: a clinical and biochemical ap-
proach. Can J Ophthalmol 2010;
45: 621–626.
6 Garg N, Perry L, Deodhar A: Intra-articular
and soft tissue injections, a systematic review
of relative efficacy of various corticosteroids.
Clin Rheumatol 2014;
33: 1695–1706.
7 Porter D, Burton JL: A comparison of intra-
lesional triamcinolone hexacetonide and tri-
amcinolone acetonide in alopecia areata. Br J
Dermatol 1971;
85: 272–273.
8 Chang KH, Rojhirunsakool S, Goldberg LJ:
Treatment of severe alopecia areata with in-
tralesional steroid injections. J Drugs Derma-
tol 2009;
8: 909–912.
Color version available online