White Spot on the Wrist
Am Fam Physician. 2017 Sep 1;96(5):329-330.
A 50-year-old woman presented with an asymptomatic white patch on her wrist that appeared two months earlier. There was no itching, pain, or swelling in the area. Her medical history included ulcerative colitis, asthma, carpal tunnel syndrome, and osteoarthritis. Her family history included a maternal aunt with extensive vitiligo.
Physical examination revealed a single, irregularly shaped, well-defined, hypopigmented patch involving the lateral, dorsal, and ventral surfaces of the right wrist with an area of proximal linear extension along the ventral forearm (Figure 1). The area was smooth and not raised. The remainder of the physical examination was unremarkable.
Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?
A. Idiopathic guttate hypomelanosis.
B. Pityriasis alba.
C. Steroid-induced hypopigmentation.
The answer is C: steroid-induced hypopigmentation. A single patch of hypopigmented skin over a joint space leads to high suspicion for an exogenous condition. Hypopigmentation caused by corticosteroids presents as an irregularly shaped but well-defined hypopigmented patch. Further questioning of the patient revealed that she received a triamcinolone acetonide injection in the right carpometacarpal joint to treat osteoarthritis four months before presentation.
Triamcinolone acetonide is commonly used for intra-articular injections. It is a macromolecule with reduced solubility, which leads to more prolonged duration of action but a higher risk of hypopigmentation.1 Possible adverse effects of steroid injections include local irritation, infections, telangiectasia, cutaneous and subcutaneous atrophy, and epidermal dyspigmentation.1 Steroid-induced hypopigmentation is a
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This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.
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