CASE REPORT
Treatment of steroid atrophy with hyaluronic
acid filler
Sigrid Barklund, MD,a and Mariah Brown, MDb
Iowa City, Iowa; and Aurora, Colorado
INTRODUCTION postoperative visit, the atrophic area was unchanged
Intralesional steroids are frequently used after and troubling to the patient. Treatment options
surgical reconstruction to treat abnormal wound discussed included laser therapy, excision, and hy-
healing, including hypertrophic scarring, keloid for- aluronic acid filler injection. Fat transfer is not
mation, flap trapdoor deformity, and excess scar performed at our institution, so it was not offered
tissue. Steroid-induced atrophy is a well-known as a treatment option. She found the contour change
complication of intralesional steroid use and, most noticeable, so she opted for hyaluronic acid
although typically self-limited, can be distressing to filler injection to restore normal convexity to the
patients. This case report describes the successful cheek. A total of 0.3 mL of Restylane Silk (Galderma,
treatment of cutaneous atrophy on the face second- Fort Worth, TX) was placed intradermally and at the
ary to an intralesional steroid injection using hyal- dermal-subcutaneous junction within the area of
uronic acid filler. atrophy. Immediate improvement was noted in the
appearance and contour of the atrophic area. At
follow-up 2 months later, the patient noted stable
CASE REPORT improvement in the appearance of the atrophic area
A 62-year-old woman presented for Mohs micro- (Fig 2), with some persistent skin telangiectasias but
graphic surgery of a biopsy-proven basal cell carci- return of normal contour.
noma of the lateral aspect of the left orbital rim. The
final surgical defect measured 1.1 3 1.4 cm and
was reconstructed with a rotation flap. At follow-up DISCUSSION
2 months postoperatively, she was noted to have Intralesional steroids are widely used after
firmness of the superior aspect of the flap along the dermatologic surgery to treat formation of excess
orbital rim. The patient thought that this scar tissue scar tissue. In this context, corticosteroids act by
created a subjective sense of pulling on her eyelid, inhibiting collagen I and III synthesis, as well as
although she had no ectropion of the lid. As a result, decreasing fibroblast growth and synthesis of acid
0.3 mL of triamcinolone acetonide at 20 mg/mL was mucopolysaccharides; however, this same process
injected into the firm scar tissue just above the orbital can result in cutaneous atrophy.1 Steroid-induced
rim at the superior aspect of the flap. The steroid was atrophy is typically self-limited but can take 1 to
injected under low pressure with a 25-gauge needle 2 years to fully resolve, and there are reports of it
retrogradely. Six weeks later, she returned to the lasting greater than 5 years. The degree of steroid
clinic and noted that the flap firmness had resolved atrophy depends on the potency and dose of
with the intralesional injection. However, she com- injected corticosteroid, body site (with the face
plained of a new onset of a divot that measured being more prone to steroid atrophy than other
approximately 1 cm and was several centimeters sites), and patient age.2
inferior to the injection site, with fat atrophy, skin There are multiple reported treatments for
thinning, and telangiectasias consistent with steroid- steroid-induced cutaneous atrophy, including fat
induced cutaneous atrophy (Fig 1). Clinical obser- grafting, surgical excision, and pulsed-dye laser.3
vation was recommended, but at her 6-month Other treatments for steroid atrophy include serial
From the Department of Dermatology, University of Iowa Carver JAAD Case Reports 2020;6:973-4.
College of Medicine, Iowa Citya; and Department of Derma- 2352-5126
tology, University of Colorado School of Medicine, Aurora.b Ó 2020 by the American Academy of Dermatology, Inc. Published
Funding sources: None. by Elsevier, Inc. This is an open access article under the CC BY-
Conflicts of interest: None disclosed. NC-ND license ([Link]
Correspondence to: Mariah Brown, MD, Department of 4.0/).
Dermatology, University of Colorado, Mail Stop F703, 1665 N [Link]
Aurora Ct, Aurora, CO 80045. E-mail: [Link]@ucdenver.
edu.
973
974 Barklund and Brown JAAD CASE REPORTS
OCTOBER 2020
Fig 1. Steroid atrophy 6 weeks after local injection of Fig 2. Improvement in appearance of steroid atrophy at
triamcinolone acetonide for treatment of hypertrophic 2 months after placement of hyaluronic acid filler.
surgical scar. Asterisk indicates the area of filler injection.
and entering normal tissue, where steroid effects will
injections of saline, with the goal of pulling steroid be unwanted and significant compared with the
crystals back into solution and allowing the body to response in the area of the scar, as occurred in
clear the medication from the affected site.4 Steroid this case. Ways to minimize steroid migration when
atrophy will often resolve with time, but patients may injecting scars include injecting small amounts of
be understandably reluctant to wait for spontaneous steroid and injecting retrogradely, deep, and under
resolution. There is a single published report of using low pressure. To our knowledge, this represents the
hyaluronic acid filler to correct defects secondary to first report of use of a hyaluronic acid filler to correct
steroid atrophy induced in the treatment of a keloid steroid atrophy on the face. In this case, the patient
scar.5 Hyaluronic acid fillers offer a good option for noted marked improvement in the appearance of her
treatment of steroid-induced atrophy because they steroid atrophy after a single treatment with dermal
replace lost volume and pull in significant amounts hyaluronic acid filler.
of water, which can theoretically help clear away
steroid crystals more rapidly. Disadvantages to their
REFERENCES
use include the risk of the Tyndall effect if placed too 1. Oishi Y, Fu ZW, Ohnuki Y, Kato H, Noguchi T. Molecular basis of
superficially, which may have a higher likelihood of the alteration in skin collagen metabolism in response to
occurring when atrophic areas are treated. There are in vivo dexamethasone treatment: effects on the synthesis of
also the usual risks associated with hyaluronic acid collagen type I and III, collagenase, and tissue inhibitors of
metalloproteinases. Br J Dermatol. 2002;147:859-868.
fillers, which include pain, bruising, and the rare risk
2. Hengee UR, Ruzicka T, Schwartz RA, Cork MJ. Adverse effects of
of necrosis caused by vascular occlusion. Cost can topical glucocorticosteroids. J Am Acad Dermatol. 2006;54:1-15.
also limit the use of this treatment. 3. Mansouri P, Ranibar M, Abolhasani E, Chalangari R,
In summary, steroid atrophy is a common adverse Martits-Chalangari R, Hejazi S. Pulsed dye laser in treatment of
effect of injected corticosteroids. However, derma- steroid-induced atrophy. J Cosmet Dermatol. 2015;14:E15-E20.
4. Shumaker PR, Rao J, Goldman MP. Treatment of local, persistent
tologic surgeons frequently inject high concentra-
cutaneous atrophy following corticosteroid injection with
tions of intralesional steroids to improve postsurgical normal saline infiltration. Dermatol Surg. 2005;31:1340-1343.
scarring without adverse effects. There is the risk of 5. Elliott L, Rashid RM, Colome M. Hyaluronic acid filler for steroid
intralesional steroid separating from the surgical scar atrophy. J Cosmet Dermatol. 2010;9:253-255.