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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39 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY May 2018 • Volume 11 • Number 5 C A S E S E R I E S Data were recorded prospectively and analyzed retrospectively with IRB approval as a series of injection outcomes for quality improvement. Inclusion criteria included any patient with a painful or cosmetically deforming lipoma encountered on musculoskeletal examination in the rheumatology clinic who wanted to avoid surgical excision and preferred injection therapy. Exclusion criteria were concomitant infection or intolerance to the injected corticosteroid. Preprocedurally, the margins of the lipomas were palpated and identified by an ink marker, 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. Deep lipomas or lipomas in close proximity to large blood vessels, nerves, or the lungs/heart were performed under ultrasound guidance (Figure 4). For superficial lipomas, after the needle was inserted through the skin, the free hand was used to palpate the lipoma margins during the procedure to ensure the needle remained in the lipoma margins. Chorhexidine 2% was used for local antisepsis. A 22-gauge, two-inch needle (4710007050 – 22 GX2" [0.7mm × 50mm]; FINE-JECT®, Henke-Sass Wolf GmbH, Tuttlingen, Germany) was mounted on a 3mL syringe (3mL Luer-Lok™ syringe; BD, Franklin Lakes, New Jersey) filled with 40mg to 80mg of triamcinolone acetonide (maximum: 80mg) (Kenalog® 40; Bristol-Myers Squibb, New York, New York). The medication was injected deep into the center and deep areas of the lipomas in at least three separate areas, avoiding the superficial skin-side lipoma margins in order to decrease possible migration of the corticosteroid crystals via lymphatics to the skin (Figure 4). 10–15 The needle was then extracted, and firm pressure was applied to the puncture sites; sterile bandage strips were subsequently applied. The subjects were assessed at four months, one year, and two years after treatment. RESULTS The results are shown in Table 1 and Figure 5. The mean age of the subjects at the time of injection was 51±12 years. Each subject had a symptomatic lipoma, and the location of the lipoma differed between the individual subjects (e.g., forearm, upper arm, back, buttock, pelvis, or leg) (Table 1). Prior to the procedure, all eight subjects had symptoms related to impingement or pain with compression of the lipoma. At the four-month follow-up, none of the eight patients reported symptoms attributable to the lipoma (Z value for 95% confidence interval [CI]: 1.96; Pearson's p<0.001). The lipoma mean palpable dimension was 5.0cm±1.2cm prior to the injection and was 2.0cm±1.1cm at four months after the injection, with a mean 3.0cm±0.3cm (60%) reduction in lipoma dimension (95% CI of difference: 1.872 <3<4.128 (Wald); p<0.001). As seen in Figure 5 and Table 1, the lesions were reduced substantially in size without severe hypopigmentation or cosmetic deformity. Two subjects developed some mild hypopigmentation of the skin at the four-month follow-up visit; however, the hypopigmentation was much milder than that shown in Figure 3. Only one patient (12.5%) had complete resolution of the lipoma by palpation at the four-month follow-up visit (Table 1). Within two years, three lipomas symptomatically recurred, one of which was removed surgically and the remaining two of which were re-injected. There were no infections or other serious adverse reactions. DISCUSSION Subcutaneous lipomas are benign tumors present in superficial subcutaneous adipose tissue and are especially evident in the arms, legs, neck, back, and buttocks. 1–3 Although benign, subcutaneous lipomas can cause pain in weight-bearing areas, interfere with normal muscle movement, induce impingement of nerves resulting in neuropathic symptoms, and cause cosmetic concerns (Figures 1 and 5). 2–6 Resultant psychological stress might also occur, which might motivate many patients to seek excisement. 3 Surgical excision is the gold standard for treating lipomas. Yet, typically, large FIGURE 1. Typical subcutaneous lipoma that causes musculoskeletal complaints due to anatomic positioning, deep structures, and repetitive trauma FIGURE 2. Typical scarring that occurs after the surgical removal of a subcutaneous lipoma FIGURE 3. Toxicity of subcutaneously injected 40mg/ml triamcinolone acetonide, with hypopigmentation, skin atrophy, and lipoatrophy

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