Hair Loss by Intralesional Triamcinolone

pISSN 1013-9087ㆍeISSN 2005-3894

Ann Dermatol Vol. 31, No. 2, 2019 https://doi.org/10.5021/ad.2019.31.2.217

CASE REPORT

A Permanent Hair Loss in a Patient with

Hypersensitivity to Intralesional Triamcinolone Injection
Young In Lee, Minseok Lee, Sewon Lee1, Do Young Kim

Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, 1Yonsei Leeand Skin Clinic,
Seoul, Korea

Despite multiple possible side effects, mesotherapy with a di- alopecia, despite the lack of data regarding its potential
verse mixture of unapproved products has been performed adverse effects. Here, we present a case of permanent hair
for the treatment of hair loss. In this case report, we present loss on injection sites due to a delayed type IV hyper-
a rare case of permanent hair loss due to an allergic reaction sensitivity reaction from a mesotherapy mixture that in-
from a mesotherapy mixture including triamcinolone cludes triamcinolone acetonide. This report highlights the
acetonide. The patient showed a positive intradermal aller- possible risk of mesotherapy as a treatment modality for
gic skin test result for triamcinolone and therefore was diag- hair loss.
nosed with scarring alopecia due to delayed type IV hyper-
sensitivity to corticosteroid. This case study suggests that der- CASE REPORT
matologists should always be fully aware that both IgE-medi-
ated and non-IgE-mediated hypersensitivity reactions from A 26-year-old woman with a history of female pattern alo-
the corticosteroids as well as their mesotherapy excipients pecia presented to the dermatology clinic with edema, er-
are possible in an effort to prevent irreversible adverse event ythema, and numbness on her entire face after her first in-
from the mesotherapy. (Ann Dermatol 31(2) 217∼220, 2019) tralesional injection on the scalp of a mesotherapy mixture
at a private clinic (Fig. 1). She was healthy with no past
-Keywords- medical history or atopic disease. According to her medi-
Alopecia, Delayed hypersensitivity, Intralesional injections, cal records from the clinic, a painful edema and redness
Mesotherapy, Triamcinolone acetonide on her forehead developed on the day after the injection
and later extended downward to her entire face. Edema
and pain persisted for more than a week, and finally atro-
INTRODUCTION phic scars with crusts were formed at each injection site
(Fig. 2). An intradermal allergic skin test for possible culprit
Mesotherapy has been widely applied in the treatment of agents was performed, and a positive reaction to 0.25 ml
triamcinolone acetonide (Dongkwang Pharm, Seoul, Korea)
Received January 26, 2018, Revised April 4, 2018, Accepted for publication at the concentration of 10 mg/ml after 24 hours was iden-
April 11, 2018 tified (Fig. 3). The patient was diagnosed with alopecia
Corresponding author: Do Young Kim, Department of Dermatology and due to a delayed hypersensitivity reaction to intralesional
Cutaneous Biology Research Institute, Yonsei University College of
Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. Tel: 82-2- triamcinolone acetonide injection. Our clinic prescribed
2228-2083, Fax: 82-2-393-9157, E-mail: [email protected] treatment with 3% topical minoxidil and intermittent
ORCID: https://orcid.org/0000-0002-0194-9854 non-ablative fractional laser therapy for the regeneration of
This is an Open Access article distributed under the terms of the Creative
the scalp dermis, but no sufficient improvement was
Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, noticed. We received the patient’s consent form about
distribution, and reproduction in any medium, provided the original work publishing all photographic materials.
is properly cited.
Copyright © The Korean Dermatological Association and The Korean
Society for Investigative Dermatology

Vol. 31, No. 2, 2019 217

YI Lee, et al

Fig. 1. Initial photographs of hyper-

sensitivity reaction. Swelling on (A)
face and (B) scalp developed after
intralesional injection of the meso-
therapy mixture.

Fig. 2. A permanent hair loss shown at each intralesional corti- Fig. 3. Intradermal allergic skin test results showed positive re-
costeroid injection site 1 month after the injection. action to 10 mg/ml triamcinolone acetonide: A, 100,000:1 mix-
ture of 2% lidocaine+epinephrine; B, 2:1 mixture of normal
saline+NaHCO3; C, normal saline (0.9% sodium chloride); D,
DISCUSSION antibiotics (lincomycin); E, 8:1 mixture of normal saline+10
mg/ml triamcinolone acetonide; F, 5 mg/ml dexamethasone.
In contrast to the extremely frequent application of corti-
costeroids in many dermatologic diseases, the reported in-
cidence of allergic reactions to these compounds is rela- served hypersensitivity reaction, occurring in 4%∼5% of
tively uncommon1. Recently, however, the adverse events the population3.
from the use of corticosteroids are increasingly recognized Corticosteroids are also known to cause sensitization
worldwide as a problem with considerable clinical import- when used systemically, albeit this mode of sensitization
ance. Both type I and type IV hypersensitivity reactions is much more rare4. The prevalence of IgE-mediated, type
have been reported following exposure to corticosteroids2. I hypersensitivity reactions to systemic corticosteroids is
Especially, the allergic contact dermatitis after the topical reported to be approximately 0.3%5. One of the earliest
application of corticosteroids is the most commonly ob- reports of the immediate type I reaction to systemic corti-

218 Ann Dermatol

 Hair Loss by Intralesional Triamcinolone

costeroids described urticaria, angioedema, and broncho- nent hair loss following a severe type IV delayed hyper-
spasm after injections of corticosteroids in 20 of 2,256 pa- sensitivity reaction to intralesional triamcinolone aceto-
tients6. nide as part of a mesotherapy mixture. Although multiple
A type IV hypersensitivity reaction to systemic and intrale- side effects have been reported, mesotherapy with a di-
sional steroids presents typically as a generalized dermati- verse mixture of unapproved products has gained popular-
tis or an exanthematous eruption, occasionally with blis- ity for the treatment of alopecia16. To prevent irreversible
ters and purpuras7. Bircher et al.8 reported a delayed hy- side effects, physicians should always be fully aware that
persensitivity to the oral administration of prednisone, in- both IgE-mediated and non-IgE-mediated hypersensitivity
ducing a generalized exanthem in the patient. Räsänen reactions from the corticosteroids or their mesotherapy
and Hasan3 also documented delayed hypersensitivity re- mixtures are possible. Especially, patients with atopic dis-
actions to oral or intralesional corticosteroids in five pa- ease or previous history of drug allergy should be consid-
tients, who developed diffuse erythema in a few to 24 hours ered for testing to the corticosteroid as well as the ex-
after patch or intradermal skin tests. cipients, because patterns of hypersensitivity reactions to
There are 5 classes of structurally distinct corticosteroids, mesotherapy are not fully uncovered at this point.
termed as class A, B, C, D1, and D29,10. These groups
were defined according to substitutions on the cortico- CONFLICTS OF INTEREST
steroid structure and clinical characteristics. However, less
is known about the classification and cross-reactivity pat- The authors have nothing to disclose.
tern of the less common reactions following systemic ad-
ministration of corticosteroids11. Our patient developed ORCID
marked edema and erythema a few hours after the intrale-
sional injection of triamcinolone acetonide, which belongs Young In Lee, https://orcid.org/0000-0001-6831-7379
to the class B corticosteroids. We performed an allergic in- Minseok Lee, https://orcid.org/0000-0002-1886-489X
tradermal skin test for suspected drugs, including triam- Sewon Lee, https://orcid.org/0000-0002-6675-6180
cinolone, the excipients (100,000:1 mixture of 2% lido- Do Young Kim, https://orcid.org/0000-0002-0194-9854
caine/epinephrine, sodium bicarbonate, and 0.9% sodium
chloride), antibiotics (lincomycin), and dexamethasone. After REFERENCES
24 hours, the patient presented with a positive intradermal
skin test result solely at the triamcinolone site. Although a 1. Laisuan W, Wongsa C, Dchapaphapeaktak N, Tongdee M,
strong positive reaction to triamcinolone was noted, the Chatmapanrangsee J, Rerkpattanapipat T. Anaphylaxis fol-
intradermal skin test for dexamethasone, which belongs to lowing intralesional triamcinolone acetonide (Kenacort)
injection. Asia Pac Allergy 2017;7:115-118.
the class C corticosteroids, was negative. This result sup-
2. Laberge L, Pratt M. Immediate and delayed hypersensitivity
ports the recent study on reaction patterns to corticoste- to systemic corticosteroids: 2 case reports. Dermatitis 2012;
roids, which indicated that reactivity to only one type of 23:288-290.
corticosteroid is much more common than reactivity to 3. Räsänen L, Hasan T. Allergy to systemic and intralesional
multiple types12. Therefore, even though a patient reports corticosteroids. Br J Dermatol 1993;128:407-411.
no adverse events with previous steroid use, a dermatolo- 4. Saff DM, Taylor JS, Vidimos AT. Allergic reaction to intra-
gist should still consider the possibility that the patient lesional triamcinolone acetonide: a case report. Arch Der-
matol 1995;131:742-743.
may undergo a hypersensitivity reaction to other types of
5. Comaish S. A case of hypersensitivity to corticosteroids. Br J
steroids.
Dermatol 1969;81:919-925.
Several previous reports on triamcinolone acetonide hy- 6. Kilpiö K, Hannuksela M. Corticosteroid allergy in asthma.
persensitivity have reported that the culprit agent could be Allergy 2003;58:1131-1135.
not only the corticosteroid itself but also its excipients, 7. Browne F, Wilkinson SM. Effective prescribing in steroid al-
such as carboxymethylcellulose, benzyl alcohol, and poly- lergy: controversies and cross-reactions. Clin Dermatol 2011;
sorbate 8013-15. As the limitation to our study, we did not 29:287-294.
extensively analyze the excipients added to the triamcin- 8. Bircher AJ, Bigliardi P, Zaugg T, Mäkinen-Kiljunen S. De-
layed generalized allergic reactions to corticosteroids. Der-
olone mesotherapy mixture. It is crucial to perform aller-
matology 2000;200:349-351.
gologic testing of individual pharmaceutical excipients as
9. Coopman S, Degreef H, Dooms-Goossens A. Identification
well, since allergic reactions are not purely caused by the of cross-reaction patterns in allergic contact dermatitis from
active pharmaceutical constituents. topical corticosteroids. Br J Dermatol 1989;121:27-34.
In conclusion, our report presents a rare case of perma- 10. Matura M, Goossens A. Contact allergy to corticosteroids.

Vol. 31, No. 2, 2019 219

YI Lee, et al

Allergy 2000;55:698-704. 2000;28:332-333.

11. Baeck M, Goossens A. Immediate and delayed allergic 14. Al Hadithy A, van Maaren M, Vermes A. Anaphylactic
hypersensitivity to corticosteroids: practical guidelines. Con- reactions following Kenacort-A® injection: carboxymethyl-
tact Dermatitis 2012;66:38-45. cellulose is involved once again. Contact Dermatitis 2011;
12. Pratt MD, Mufti A, Lipson J, Warshaw EM, Maibach HI, 64:179-180.
Taylor JS, et al. Patch test reactions to corticosteroids: retro- 15. Bigliardi PL, Izakovic J, Weber JM, Bircher AJ. Anaphylaxis
spective analysis from the North American Contact Der- to the carbohydrate carboxymethylcellulose in parenteral
matitis Group 2007-2014. Dermatitis 2017;28:58-63. corticosteroid preparations. Dermatology 2003;207:100-103.
13. Montoro J, Valero A, Elices A, Rubira N, Serra-Baldrich E, 16. Duque-Estrada B, Vincenzi C, Misciali C, Tosti A. Alopecia
Amat P, et al. Anaphylactic shock after intra-articular injection secondary to mesotherapy. J Am Acad Dermatol 2009;61:
of carboxymethylcellulose. Allergol Immunopathol (Madr) 707-709.

220 Ann Dermatol