Steroid injections

Practical use in Dupuytren’s: many doctors use steroid injections to treat painful nodules in the palm and especially dorsal nodules on the knuckles. Usually single injections are given, in some cases under general anaesthetic. The injections can be repeated if the pain returns or does not settle.

NICE does not recommend steroid injections for Dupuytren’s ( http://cks.nice.org.uk/dupuytrens-disease#!scenario )

Plantar Fibromatosis or Ledderhose Disease

In practice many surgeons and podiatrists are reluctant to give more than one or two injections, maximum three, due to the risk of rupture of the fascia or underlying tendons. Some warn of the risk of the fibroma’s worsening or multiplying due to the injections.

Peyronie’s

In trials neither triamcinolone nor betamethasone gave better results than a placebo, and due to the risk of unwanted side effects steroid injections are not advocated for Peyronie’s.

Frozen Shoulder

Combined steroid (Kenalog or a similar depo preparation) and local anaesthetic injected into the affected joint especially in the early (freezing) stage can help reduce pain and inflammation, and get better results from physiotherapy and exercises. Most doctors warn not to give more than three steroid injections in weightbaring tissues or in joints.

Main articles publised

The main article published on this steroid injections for Dupuytren’s was by Ketchum (J Hand Surg Am 2000Nov, 25(6); 1157-1162)

This article describes the use of triamcinolone (a type of corticosteroid) into the nodules of a group of 63 patients, 75 hands. Three injections were done with a 6 week interval each time, and if patients needed an extra injection a break of 6 months was observed before giving another injection. Patients needed 3.2 injections on average. Tenderness was reported after the injections, lasting 24 hours. Other side effects reported by half of the patients were local loss of pigmentation and thinning of the (fatty) tissues under the skin. These effects lasted up to 6 months.

In this group no tendon ruptures were observed, though in the 30-40 years the injections were used as treatment in the same hospital department two cases were reported. The author stresses the importance of injecting the triamcinolone into the nodule and not under it, to reduce the risk of tendon rupture.

In 97% of patients the nodules softened and flattened by 60 – 80%. the disease re-activated after 1-3 years in 50% of patients, and a single injection was given that time. One patient progressed to form a contracture in the 4 year follow-up period.

Triamcinolone was the steroid of choice or two reasons:

1. Triamcinolone degrades insoluble collagen into salt- soluble collagen, which is then absorbed and excreted from the body (contrary to hydrocortisone which degrades collagen to acid-soluble collagen, which does not get absorbed)

2. Triamcinolone reduces the fibroblast response (and nodules are full of fibroblasts)

Not many articles are published on the use of steroid injections for plantar fibromas but Pentland and Anderson described the procedure (J Am Acad Dermatol 1985 Jan; 12 (1 Pt 2) 212-4 )

The article describes one case, a patient with a plantar fibroma who was given 5 monthly injections intralesional (into the lump), and improvement was noticed after 3-4 months.