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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41 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY May 2018 • Volume 11 • Number 5 C A S E S E R I E S injection, there is a lymphatic spread of the corticosteroid crystals along the lymphatic channels and resulting linear atrophy of the adjacent tissues (Figure 2). 11–13 Lipoatrophy is characterized histologically by reduced cellularity at the site of corticosteroid injection, presence of apoptotic lipocytes, and activated perivascular macrophages engulfing segments of apoptotic adipose and stromal tissue. 35–37 Corticosteroids also can cause local vasoconstriction, capillary closure, and tissue hypoxia, resulting in lipoatrophy. 8 Additionally, corticosteroids can have a direct antiproliferative effect on keratinocytes and fibroblasts, accelerate catabolism of extracellular matrix proteins, cause apoptosis of fat cells, and decrease synthesis of skin lipids. 8–15 All of these effects might explain the lipoma shrinkage and symptomatic improvement after corticosteroid injection. Research has shown that there is a considerable risk of dermal atrophy and hypopigmentation when 40mg/mL of triamcinolone is injected into skin lesions instead of the dermatologic standard of triamcinolone 10mg/mL. 15 Based on our study and the report by Lamagna et al, the usually toxic lipolytic effect of a 40mg/ mL injection of triamcinolone acetonide was used therapeutically to atrophy symptomatic lipomas (Figure 5). 15,34 Since the technique of lipoma injection keeps the triamcinolone acetonide deep into the mass of the lipoma where lymphatics were less likely to carry the crystal to the skin surface (Figure 4), skin hypopigmentation and atrophy were only a minor problem (Table 1) in comparison to superficial injections (Figure 3). Thus, triamcinolone acetonide injection of symptomatic lipomas appears to be a reasonable, viable, effective, and safe alternative to surgical excision for the treatment for lipomas. Limitations. Limitations of this study include the relatively small number of patients and the nonrandomized, nonblinded series design, but sequential paired studies wherein patients are studied before and after an intervention is a practical trial design often used in case studies of any interventional technique. Also, it should be noted that, prior to injection, the clinician should exclude the presence of malignant lesions of the connective tissue including liposarcoma, lymphoma, osteosarcoma, and skin; metastatic malignant tumors; and other causes of soft tissue mass including infection, sebaceous cyst, foreign body granuloma, rheumatoid nodule, and tophus. These lesions usually have distinct, palpable, symptomatic, anatomic, and imaging characteristics compared to benign lipomas. 1–3 If there is any question that the lesion is not a benign lipoma, excisional biopsy, needle biopsy, or additional imaging should be performed before attempting injection therapy. CONCLUSION For individuals with musculoskeletal and neurologic complaints due to superficial subcutaneous lipomas, intralesional injection of 40- to 80mg of triamcinolone acetonide appears to be an effective and safe alternative to surgical excision and injection of sclerosing agents in select patients. TABLE 1. Clinical characteristics of subjects PATIENT AGE, YEARS ANATOMIC LOCATION OF LIPOMA PRE-INJECTION SYMPTOMS POST-INJECTION SYMPTOMS PRE-INJECTION DIMENSION, CM POST-INJECTION DIMENSION, CM CHANGE IN DIMENSION AT FOUR MONTHS, CM PERCENT CHANGE Mean 51±12 Mean 1(10/10) Mean 0 (0/10) Mean 5.0±1.2 Mean 2.0±1.1 Mean 3.0±0.3 Mean -63±12 1 56 Buttock Pain with sitting, sciatica Resolved 7 3 4 -57 2 34 Paraspinous Pain with sitting in chair Resolved 5 2 3 -60 3 37 Upper extremity Cosmetic deformity Resolved 4 1 3 -75 4 38 Upper extremity Pain with abduction Resolved, reinjected at two years 5 3 2 -40 5 56 Volar arm Carpal tunnel symptoms Resolved, reinjected at one year 3 0 3 -100 6 58 Paraspinous Neuropathic symptoms Resolved 4 1 3 -75 7 68 Pelvis Pain rom lipoma impinging in beltline Resolved, but recurred eight months later; surgically removed 6 3 3 -50 8 65 Leg Pain Resolved 6 3 3 -50

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