Intralesional drug administration is a very common procedure which was performed nearly by all dermatologists worldwide. It is a very effective way in several dermatosis such as keloidal scars, acne keloidalis, oral lichen planus, alopecia areata, localized psoriasis and localized dermatitis
3-9. Recalcitrant plantar warts could be added to the list
10. So many agents have been utilized for the intralesional treatments. Factors including faster and better action, high patient compliance and short treatment time are superiorities of intralesional treatment
2.
To date, there is no reported article concerning a compilation of intralesional treatments in English or Turkish literature in major indexes. This study collected and summarized intralesional treatments carried out in a dermatology outpatient clinic.
Alopecia areata was the main indication of this retrospective study. This autoimmune skin disease is very commonly seen in dermatology outpatient departments. Intralesional corticosteroid treatment has both higher success and faster response rate compared to other treatments in this entity 6. Thus, a significant number of alopecia areata patients receives the intralesional corticosteroid treatment as the first choice.
The second common indication was onychodistrophias. Since the efficient treatment methods for noninfectious onychodistrophias are so limited, intralesional triamcinolone alone, dexpanthenol alone or combination of both agents became as a good modality to be able to get a satisfactory outcome in our practice.
Another common cause of intralesional injection in the study was palmoplantar pustulosis and psoriasis. After trying several inadequate topical therapies, those patients usually need systemic treatments which are sometimes intolerable due to their adverse effects 9. Therefore, intralesional steroid treatment was a better and significantly effective option in these circumstances.
Intralesional vitamin D injection is a recently proposed alternative treatment option in recalcitrant warts 10. In this study, eighteen patients received this therapy. Vitamin D is different from other intralesionally administrated agents due to its viscose property. Injection of such this viscose agent was more difficult in comparison to other drugs, so that only different syringes, 23 G or 25 G, were used in this injection.
Lichen simplex chronicus is a psychocutaneous disorder, which is challenging to control itching in a large number of patients. Several medications including from topical steroids to gabapentin have been used in the treatment of this disease 11. Intralesional corticosteroid therapy, mixed with saline or prilocaine is a good alternative in refractory cases.
Psoriasis vulgaris other than nail involvement, plantar localization and other localized forms have so many treatment options before considering an intralesional intervention. However, a selected group of patients with psoriasis vulgaris still obtain great benefit from intralesional applications. The study patients were controlled successfully with intralesional triamcinolone mixed with dexpanthenol therapy.
There is no reported case of ungium incarnatus responding intralesional treatment. In our practice, the edematous tissue covering nail plate significantly decreased in size and improved gradually after intralesional triamcinolone mixed with prilocaine administration, giving high satisfaction to the patients without any surgery.
This study contained first use of intralesional triamcinolone injection in severe axillary hyperhidrosis hoping to cause dermal atrophy that leads to less sweating. The patient was refractory to all topical therapies and was not be able to access to botox, iontophoresis and surgery. With the consent of the patient, that injection worked well in this patient at least for a certain time without any side effect.
Only one patient was injected tranexamic acid for treatmentresistant post inflammatory hyperpigmentation. In contrary to melasma which a success was reported 12, this patient did not satisfy the outcome despite a moderate bleaching was observed.
As seen in the table, post herpetic neuralgia, oral pemphigus vulgaris, hypertrophic lichen planus and several other skin diseases were treated intralesionally with different agents in properly selected patients.
There are still drugs, not used in the presented study, including bleomycin, methotrexate, cyclosporin, immunomodulators, fillers, botulinum toxin, interferon, verapamil etc. all having evidence of benefit in the intralesional treatment of any skin disorder 2.
Side effects of intralesional injections are generally local, but sometimes even anaphylaxis may be seen 13. Of 344 patients analysed in this study, only one case of unexpected reaction occurred. It was unilateral diffuse cheek swelling seen in a female patient who had long-standing recalcitrant oral lichen planus, after triamcinolone injection into her cheek mucosa. Thereaction subsided completely within six hours without any intervention. The other side effects were totally local including localized steroid atrophy and hypopigmentation which many of them improved gradually.
In conclusion, intralesional treatment is relatively safe, effective, fast and simple method to be performed in all dermatology departments needing no sophisticated or expensive tools. Although triamcinolone, betamethasone and other steroids are widely used for the intralesional treatments, It is shown in this study that there are so many underutilized agents which can be used for these purposes.