Journal of Clinical and Aesthetic Dermatology

MAY 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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38 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY May 2018 • Volume 11 • Number 5 C A S E S E R I E S I In dermatology and rheumatology practice, patients occasionally present with "lumps and bumps" that, on physical examination, turn out to be gouty tophi, rheumatoid nodules, enlarged lymph nodes, panniculitis, malignant tumor masses, or benign masses, including lipomas. 1,2 Subcutaneous lipomas, although benign, can cause considerable neurologic pain through nerve impingement, musculoskeletal pain, especially on weight-bearing areas or if the lipoma is resident on the edge of a muscle or between muscles, and cosmetic disturbances (Figure 1). 3–6 Symptomatic lipomas are traditionally treated with wide, deep excision, but surgical extirpation frequently results in the loss of adjacent soft tissue with permanent scarring, which can lead to adverse cosmetic outcomes (Figure 2). 3 The injection of triamcinolone acetonide is typically used to locally treat inflammatory conditions of the skin, joints, and other musculoskeletal structures, but major toxicities of injection with potent corticosteroid esters include depigmentation, atrophy of the skin, and lipoatrophy (Figure 3). Thus, dermatologists tend to avoid 40mg/mL triamcinolone acetonide and instead use the 10mg/mL strength to avoid these problems. 7–10 We hypothesized that the adverse effect of lipoatrophy predictably caused by 40mg/mL triamcinolone acetonide could be used beneficially to nonsurgically atrophy symptomatic subcutaneous lipomas, resulting in symptomatic improvement. METHODS This research was approved by an institutional review board (IRB) and was in compliance with the Declaration of Helsinki and subsequent revisions. This was a cohort study consisting of a case series of eight patients with symptomatic subcutaneous lipoma who wished to avoid surgical extirpation and thus asked to have the lesions injected. Eight subjects (7 women and 1 man), each with a solitary lipoma were treated with injection therapy. Each subject provided written informed consent prior to the procedure. A B S T R A C T Objective: Benign subcutaneous lipomas can cause musculoskeletal pain and nerve impingement. We hypothesized that the potent lipolytic and atrophic effect of 40mg/mL triamcinolone acetonide would atrophy symptomatic lipomas so surgical excision could be avoided. Design: This was a cohort study. Setting: This study took place in an ultrasound injection clinic. Participants: Eight subjects with painful symptomatic lipoma were included. Measurements: Preprocedurally, the margins of the lipomas were palpated and marked with ink, then measured in centimeters (cm). Small lipomas (1–3cm) were injected with 40mg triamcinolone acetonide, while large lipomas (4–6cm) were injected with 80mg of triamcinolone acetonide. The subjects were reassessed at a four-month follow-up appointment and then again at one year and two years after the procedure. Results: Pre- injection, all eight subjects had symptoms related to impingement or pain with compression of the lipoma. At four months post-injection, none of the patients had symptoms attributable to the lipoma (p<0.001). The mean lipoma palpable dimension was 5.0±1.2cm prior to the injection and was 2.0±1.1cm at four months after the injection, with a significant mean 3.0±0.3cm (60%) reduction in lipoma dimensions (p<0.001). Two subjects demonstrated some mild hypopigmentation of the skin at four months post-injection. Within two years, three lipomas had symptomatically recurred, one of which was removed surgically and the two of which were reinjected. There were no infections or other serious adverse reactions that occurred. Conclusions: For individuals with painful subcutaneous lipoma, intralesional injection of 40mg/mL of triamcinolone acetonide is an effective and safe alternative to surgical excision or injection of sclerosing agents and should be considered as a reasonable therapeutic alternative in select patients. KEYWORDS: Lipoma, musculoskeletal, injection, corticosteroids, neurologic Intralesional Injection of Triamcinolone Acetonide for Subcutaneous Lipoma causing Musculoskeletal and Neurologic Symptoms by WILLIAM A. HAY WARD, PhD, MSC; WILMER L. SIBBITT, JR, MD; RANDY R. SIBBITT, MD; MAHESWARI MURUGANANDAM, MBBS; NOELLE A. ROLLE, MD; MONTHIDA FANGTHAM, MD; N. SUZANNE EMIL, MD; and SCARLETT K. KETTWICH, MS Dr. Hayward is with the Department of Exercise and Sport Sciences at New Mexico Highlands University in Las Vegas, New Mexico. Drs. W. Sibbitt, Muruganandam, Rolle, and Fangtham are with the Department of Internal Medicine, Division of Rheumatology and School of Medicine at University of New Mexico Health Sciences Center in Albuquerque, New Mexico. Dr. R. Sibbitt is with Montana Interventional and Diagnostic Radiology in Helena, Montana. Ms. Kettwich is with the School of Dentistry at Oregon Health & Science University in Portland, Oregon. J Clin Aesthet Dermatol. 2018;11(5):38–42 FUNDING: No funding was provided for this article. DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article. CORRESPONDENCE: Wilmer L. Sibbitt, Jr., MD, MSC; Email: wsibbitt@salud.unm.edu

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