Can steroid injections to tendons cause skin whitening?

Steroid Injections to Tendons Can Cause Skin Whitening

Yes, steroid injections to tendons can cause skin whitening or hypopigmentation at the injection site. This is a documented adverse effect that patients should be informed about before receiving injections, particularly those with darker skin tones who may experience more noticeable cosmetic changes.

Mechanism and Presentation

• Skin hypopigmentation (whitening) is a recognized adverse effect of corticosteroid injections, including those administered for tendon conditions 1, 2
• The exact mechanism is not fully understood but appears to involve decreased melanocyte function rather than actual loss of melanocytes 3
• Hypopigmentation typically appears within days to weeks after injection and can persist for several months 1
• The affected area may present as:
  • Localized whitening at the injection site 2
  • Linear rays of hypopigmentation extending from the injection site due to lymphatic or venous spread of steroid crystals 4, 3

Risk Factors and Incidence

• This side effect may be underreported in clinical practice 5
• Patients with darker skin tones are at higher cosmetic risk when hypopigmentation occurs 5
• The FDA drug label for triamcinolone acetonide (a commonly used injectable steroid) specifically lists hypopigmentation among potential dermatologic adverse reactions 6

Clinical Examples

• Case reports document hypopigmentation following steroid injections for various tendon conditions:
  • De Quervain's tenosynovitis: A 43-year-old man developed a 2 cm × 3 cm area of depigmentation one week after triamcinolone injection 1
  • Achilles tendinopathy: A 47-year-old African-American male developed hypopigmentation five months after triamcinolone acetonide injection 2
  • De Quervain's tendonitis: A 32-year-old female developed bilateral hypopigmented patches with unilateral linear extension following intra-articular corticosteroid injections 3

Resolution and Management

• In many cases, the hypopigmentation resolves spontaneously:
  • In one case report, complete resolution occurred after 9 months 1
• However, resolution can be unpredictable and may take months to years
• No specific treatments are available to reverse steroid-induced hypopigmentation
• Prevention strategies include:
  • Using the lowest effective dose of corticosteroid 7
  • Proper injection technique to ensure delivery to the intended target 1
  • Considering alternative treatments in patients concerned about cosmetic effects 5

Other Dermatologic Side Effects of Steroid Injections

• Besides hypopigmentation, steroid injections can cause:
  • Cutaneous atrophy 6, 3
  • Skin fragility 3
  • Striae 6
  • Hypertrichosis (excessive hair growth) 7
  • Acne 7

Patient Counseling

• Interventional pain physicians and other clinicians should counsel patients about the possibility of skin hypopigmentation before administering steroid injections 1, 5
• This is particularly important for patients with darker skin tones who may experience more noticeable cosmetic effects 5
• Patients should be informed that while hypopigmentation is usually temporary, resolution can take several months 1