Safe and Efficacious Use of Intralesional Steroids for the Treatment of Focally Resistant Mycosis Fungoides

May 2015 | Volume 14 | Issue 5 | Original Article | 466 | Copyright © 2015

Deede Y. Liu MD,a* Tarek Shaath BA,b* Anand N. Rajpara MD,a Cody Hanson BS,c
Garth Fraga MD,d Ryan Fischer MD,a and Daniel J. Aires MDa

aDivision of Dermatology, University of Kansas Medical Center, Kansas City, KS
bSchool of Medicine, University of Kansas Medical Center, Kansas City, KS
cKansas City University of Medicine and Biosciences, Kansas City, MO
dDepartment of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
*Dr. Liu and Mr. Shaath contributed equally to this work.

Abstract

Cutaneous T-cell lymphoma is a cancer of skin-homing T cells, of which mycosis fungoides (MF) is the most common variant. MF treatments range from topical steroids to systemic chemotherapy. Resistant cutaneous MF nodules can present a special challenge in that typical topical therapies may not penetrate thick lesions, and increasing systemic therapy brings added risk of side effects. We report successful use of intralesional steroids (ILS) for treatment-resistant MF, including tumor-stage plaques and nodules in 4 consecutive patients with focally resistant MF. ILS have been widely used to treat a broad range of cutaneous conditions such as alopecia areata and keloids. Side effects of ILS include hypopigmentation, atrophy, telangiectasias, lilac discoloration, acne, and striae. Rarely, and in circumstances involving unusually large doses, ILS may cause Cushing’s syndrome, hypothalamus-pituitary-adrenal axis suppression, and reduced bone mineral density. The MF patients tolerated treatment well without any of the above side effects other than local hypopigmention in a single patient. These results point toward further exploration into ILS as a treatment for focally resistant MF.

J Drugs Dermatol. 2015;14(5):466-470.

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INTRODUCTION

Intralesional steroid injections are used to treat a variety of dermatologic conditions. Intralesional steroids (ILS) can be an effective therapy when topical steroids fail and systemic steroid therapy is not indicated.1 In trials and large reviews, ILS has shown efficacy in treating keloids, hypertrophic scars, acne, alopecia areata, hemangiomas, psoriasis, granuloma annulare, and hidradenitis suppurativa. ILS has also been reported to be efficacious in other dermatoses such as pyoderma gangrenosum, sarcoidosis, and discoid lupus.2

Manuskiatti and Fitzpatrick demonstrated clinical improvement of keloidal and hypertrophic scars with ILS treatment.3 Levine and Rasmussen effectively treated nodulocystic acne with intralesional triamcinolone (TAC), reporting equal efficacies at concentrations of 0.63 mg/mL, 1.25 mg/mL, and 2.50 mg/mL.4 Porter and Burton reported significant hair regrowth within steroid-injected sites of patients with alopecia areata.5 Recently, Nantel-Battista et al confirmed intralesional triamcinolone as a safe and effective treatment of nail psoriasis in a clinical trial of 17 patients.6 In 45 patients with granuloma annulare, Sparrow and Abell demonstrated complete clearance of nearly 70% of granuloma annulare lesions treated with ILS compared with 44% lesion clearance with normal saline injections.7 Scheinfeld reviewed the use of multiple therapies in over 350 hidradenitis suppurativa patients, finding that ILS decreases pain and inflammation by collapsing sinus tracts within active lesions.8

Hughes et al demonstrated efficacy of intralesional triamcinolone into the ulcer margin of peristomal pyoderma gangrenosum in 2 patients.9 Sullivan et al explored the injection of hydrocortisone and cortisone into papules of cutaneous sarcoidosis, revealing unequivocal regression in all treated lesions vs no observable change in controls.10

Cutaneous T-cell lymphoma (CTCL) is a cancer of skin-homing T cells; mycosis fungoides (MF) is the most common variant.11 Treatments for MF include multiple modalities that range from topical steroids to systemic chemotherapy. Resistant cutaneous MF nodules can be especially challenging because typical topical therapies often fail to penetrate thick lesions, and increasing systemic therapy brings added risk of undesired side effects.

We now report successful ILS treatment for resistant MF lesions in 4 consecutive patients with such lesions. Our first patient was a 57-year-old Caucasian female with a 2-year history of MF who presented to an academic outpatient dermatology clinic for further management. The patient was treated with

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