Steroid Injections: Atrophy (dents, depressions, holes)

Atrophy (dents, depressions, holes)

Steroid injections are a relatively common treatment for many inflammatory and autoimmune scalp conditions. There is rarely a day in the office that I don’t perform steroid injections. These are very valuable treatments for many patients with alopecia areata, scarring alopecias and even some forms of traction alopecia.

One of the side effects of steroid injections is atrophy. Atrophy appears as an indentation in the skin at the site of injection. The patient may refer to it as a “dimple” or a “depression.” Others may call it a “dent” or even a “hole” The indentation can often be better felt than seen.

The chance of developing indentations (atrophy) depends on the concentration of steroid the doctor uses. Higher concentrations (10 mg/mL) give a greater risk of causing atrophy than lower concentrations (2.5 or 5 mg/mL). Some studies suggested that the risk may be as high as 3 in 10 patients when a dose of 10 mg/mL is used. 
The indentations occur because the steroid affects collagen and elastin underneath the skin. The steroids inhibit the growth of fibroblasts, which are the cells that collagen and elastin. Studies have shown there is less collagen made and it’s degraded more quickly. There is a reduction in diameter of collagen fibrils. The collagen bindles become atrophic snd separated. Similar to collagen, elastin fibers become thin and fragmented.

Atrophy typically is seen by 3 weeks if it’s going to occur. An important point to be made is that the atrophy is generally reversible provided more injections aren’t given to an area already showing atrophy. The skin usually returns to normal in 3-4 months. Steroid injections should not be readministered too soon to an area that has not “recovered” as further atrophy can occur - some of which can be very long lasting.

Treatment for steroid atrophy is mainly to wait for the body to start making more collagen and elastin again in a few months. If this does not happen, saline injections, dermal fillers and fat injections can be considered.