Refractory lipoatrophy treated with autologous whole blood injection: A case report

Abstract

BACKGROUND

Intramuscular corticosteroid injection may cause adverse effects such as dermal and/or subcutaneous atrophy, alopecia, hypopigmentation, and hyperpigmentation. Although cutaneous atrophy can spontaneously resolve, several treatment options have been suggested for this condition.

CASE SUMMARY

In this paper, we report a case of corticosteroid injection induced lipoatrophy treated with autologous whole blood (AWB) injection, as the condition had been unresponsive to fractional laser therapy. A 29-year-old female patient visited the dermatology clinic complaining of skin depression on her right buttock area, which had appeared six months earlier. There had been only subtle improvement at the margins after fractional CO₂ laser treatment; therefore, after obtaining informed consent from the patient, AWB treatment was initiated. One month after the first AWB injection, the size and depth of the lesion had noticeably improved, and a slight improvement was also observed in discoloration.

CONCLUSION

Close observation is the initial treatment of choice for steroid induced skin atrophy; however, for patients in need of immediate cosmetic improvement, AWB injection may be a safe and cost-effective alternative.

Key Words: Atrophy; Corticosteroid; Subcutaneous fat; Autologous whole blood injection; Laser therapy; Case report

Core Tip: Intramuscular corticosteroid injection may cause adverse effects such as dermal and/or subcutaneous atrophy, alopecia, hypopigmentation, and hyperpigmentation. Although cutaneous atrophy can spontaneously resolve, several treatment options have been suggested for this condition. Here, we report a case of corticosteroid injections induced lipoatrophy treated with autologous whole blood (AWB) injection, which was unresponsive to fractional laser therapy. Close observation is the initial treatment of choice for steroid induced skin atrophy, however for patient in need of immediate cosmetic improvement, AWB injection may be a safe and cost-effective solution for treatment.

INTRODUCTION

In fields of medicine such as dermatology, plastic surgery and orthopedics, corticosteroid injections are frequently performed. Intramuscular corticosteroid injection may cause adverse effects such as dermal and/or subcutaneous atrophy, alopecia, hypopigmentation/depigmentation, and hyperpigmentation[1]. Previous reports have demonstrated that skin atrophy may resolve spontaneously, but no definite data are available, and the outcome may differ from person to person[2,3]. Several treatment options have been suggested for skin atrophy such as autologous fat grafting, intralesional saline injections, surgical excision, and poly-L-lactic acid injections, all with different success rates. Although the exact mechanism of action of autologous whole blood (AWB) injection remains unclear, in experimental and clinical models it seems to affect immune function. By injecting the patient’s AWB into the affected tissue, the body's own tissue-healing mechanisms may be stimulated possibly through activation of cellular and humoral mediators[4,5]. In this paper, we report a case of corticosteroid injection induced lipoatrophy treated with AWB injection.

CASE PRESENTATION

Chief complaints

A 29-year–old female patient visited the dermatology clinic complaining of skin depression on her right buttock area, which had appeared six months earlier.

History of present illness

The patient had previously received an intramuscular triamcinolone acetonide injection to alleviate a severely pruritic maculopapular rash that occurred after consuming some health products. She noticed the deformation approximately two months after the injection.

History of past illness

No known past history.

Personal and family history

Not applicable.

Physical examination upon admission

At the site of corticosteroid injection, depigmentation, epidermal/dermal atrophy, and subcutaneous fat atrophy were observed in the right gluteal region (Figure 1A).

Figure 1 Changes in the right gluteal region. A: At the site of corticosteroid injection, depigmentation, epidermal/dermal atrophy, and subcutaneous fat atrophy were noticed in the right gluteal region; B: Subtle improvement at the peripheral margins and postinflammatory hyperpigmentation is noticed after fractional laser treatment; C: Immediate improvement is noticed after autologous whole blood injection; D: Improvement in the depth and size of skin atrophy is maintained after two months follow-up.

Laboratory examinations

Not applicable.

Imaging examinations

Not applicable.

FINAL DIAGNOSIS

Localized subcutaneous lipoatrophy was diagnosed based on the patient's past history and clinical characteristics.

TREATMENT

Because the lesion was disfiguring and causing stress to the patient, several modes of treatment were explained and fractional CO₂ laser (eCO₂, Lutronic, Korea) treatment was initiated. Fluence ranging from 30 J/cm² was used at densities of 100-150 MTZ/cm², and single or double pass was used over the scar and also its margins. The patient received four laser treatments at three-week intervals (Figure 2). There was subtle improvement at the margins after the laser treatment, but the main depression was still quite noticeable (Figure 1B). In addition, the laser treatment induced post-inflammatory hyperpigmentation. Therefore, after obtaining informed consent, AWB injection was started. Using a 5 cc syringe with a 21-gauge 38 mm needle, 4 cc AWB was collected from peripheral antecubital veins. The AWB was injected into the subcutaneous fat tissue immediately after the blood was drawn. The needle was held at a 90° angle and 0.2-0.4 mL AWB was injected into the deep subcutaneous fat tissue and superficial subcutaneous fat tissue of the atrophic area (Figure 1C)[6].

Figure 2 Timeline. AWB: Autologous whole blood.

OUTCOME AND FOLLOW-UP

Other than mild bruising and slight induration one week after the injection, there were no side effects. One month after the first AWB treatment, the lesion size and depth had markedly improved, and the discoloration had also mildly resolved. At the 2-month follow-up, induration and purpura had improved, and the clinical effect was maintained (Figure 1D). The patient was content with the results of the treatment.

DISCUSSION

The pathomechanism of subcutaneous lipoatrophy after steroid injection is unclear; however, an increase in macrophage cells accompanied by a decrease in both the number and size of adipocytes has been observed[7,8]. Moreover, in histologic evaluations of animal models, microscopic corticosteroid crystals were found after a localized steroid injection[9].

Hyaluronic acid filler injections, fat grafting, saline solution injections and observation are possible options of treatment for cutaneous atrophy[10]. Fat grafting can restore the volume loss and, through the stem cells in fat tissue, stimulate tissue regeneration, hence it may be an effective solution[10]. Regrettably, the process can be complex and invasive[11]. Hyaluronic acid fillers are another common treatment, but these may induce inflammatory reactions at the injection site or cause granuloma formation[12]. Saline solution injections can be administered locally to dilute and/or dissolve the steroid crystals found in the tissues of patients with subcutaneous lipoatrophy[13]. However, several treatment sessions are often necessary, and the results sometimes reveal only minimal improvement. Platelet-rich plasma is collected by centrifuging patient’s blood in a specialized tube, following which a highly concentrated autologous solution of plasma is prepared. This acts as a natural reservoir of growth factors which stimulates tissue regeneration and repair. In addition, it has also been used to improve fat grafting outcomes because it increases stem cell differentiation and the survival rate of fat cells[14]. Multiple sessions, however, are necessary to ensure clinical improvement[15]. Fractional lasers have been used for atrophic scars or scar remodeling. Localized epidermal necrosis and collagen denaturation produced by the fractional columns of thermal injury may initiate a cascade of events that result in normalization of the collagenesis-collagenolysis cycle[16]. The fractional photothermolysis may induce proinflammatory cytokines and growth factors which result in dermal collagen remodeling[17]. Recently, fractional lasers have been used to treat children with insulin induced fat atrophy[18]; however, only mild improvement was observed in our patient. A new technique for obtaining a gel through the denaturation of albumin present in plasma was reported by Barros Mourão et al[19]. The platelet-poor plasma, mainly containing albumin, is heated at 75 °C for 10 minutes to allow denaturation and form an albumin gel (ALB-Gel). To increase regenerative power, the buffy coat (platelet-rich layer) removed from the tube after centrifugation is mixed with ALB-Gel and is then known as ALB-platelet-rich fibrin[20]. Activated plasma albumin gel increases dermal thickness and has shown to be an efficient solution for facial sculpting with sustained effects[21]. However, laboratory equipment and reagents are required to obtain this material.

During AWB treatment, the patient’s blood is drawn from the peripheral veins and then promptly injected into the affected regions. Immediate improvement may have been achieved through the volumetric filling effect of AWB injected at the affected site. Moreover, the growth factors from platelets, such as transforming growth factor-beta 1, platelet-derived growth factor alpha and beta, epithelial growth factor, and insulin-like growth factor I, are key factors for skin regeneration[20]. AWB also contains hormonal and cellular mediators that induce collagen regeneration, cell proliferation, and stimulate the production of angiogenic factors resulting in tissue healing[4,22]. AWB injections are frequently used in the treatment of musculoskeletal diseases such as patellar tendinopathy, lateral epicondylitis, and Achilles tendinopathy[23,24]. They are also used for chronic urticaria[25]. A number of patients visit the dermatology clinic complaining of steroid induced lipoatrophy in the ankle, elbow, and buttock areas resulting from various treatments. Thus, AWB injections may constitute both a curative and preventive form of treatment for these patients.

CONCLUSION

Close observation is the initial treatment of choice for steroid induced skin atrophy; however, for patients in need of immediate cosmetic improvement, AWB injections may be considered a safe and cost-effective alternative. Future clinical trials with large sample sizes are needed to draw more reliable conclusions.