Lasers in Surgery and Medicine 47:386–387 (2015)
Cutaneous Siderosis Secondary to Intramuscular Iron Dextran Treated With 755 nm Q-switched Alexandrite Laser: A Case Report Amanda A. Lloyd, MD, Michael S. Graves, MD, and Edward V. Ross, MD Scripps Clinic, La Jolla, California 92037
Background: Cutaneous siderosis is accumulation of iron in the dermis and the subcutaneous tissue secondary to extravasation of an intramuscular or intravascular iron injection. It presents as varying shades of brown macules with no distinct contours. The hyperpigmentation is permanent without treatment. Objective: Q-switched lasers have been used effectively to treat lentigines and tattoos however, there is little data on the treatment of cutaneous siderosis with lasers. Our objective was to effectively treat cutaneous siderosis with a Q-switched alexandrite laser. Results: A 50-year-old female had received nine injections of intramuscular iron dextran, one injection every 2 weeks alternating right buttock and left buttock over the course of 5 months. A couple of weeks after her 9th injection which was on the left, she noted brown hyperpigmentation in the injection area with the left worse than the right. She waited 3 months for the hyperpigmentation to self-resolve before presenting in our clinic. We utilized the Q-switched alexandrite laser to treat the patient with a test spot. One week later, there was nice partial clearance from the test spot so we commenced full treatment of the hyperpigmentation. There was significant improvement after the first treatment and she has been treated 4 times with continued improvement over the past 2 months. Conclusion: The Q-switched alexandrite laser is a useful tool in the treatment of cutaneous siderosis secondary to iron injection. Lasers Surg. Med. 47:386–387, 2015. ß 2015 Wiley Periodicals, Inc. Key words: deposition; hyperpigmentation; skin; staining of skin
persistent. Q-switched lasers are a well-established treatment option for tattoo pigment, however there are few reports of treatment of cutaneous siderosis with Qswitched lasers, and none with the Q-switched alexandrite laser [1,2]. We report successful treatment of cutaneous siderosis with the Q-switched alexandrite laser. Case Report A 50-year-old white female presented with hyperpigmentation on her buttocks, left worse than right. She had been receiving iron dextran intramuscular injections every 2 weeks over 5 months via the Z-track technique into alternating upper outer quadrants of the buttock as treatment for her iron deficiency anemia. The Z track is a technique of intramuscular injections where the skin and subcutaneous tissues are lifted to the side during the injection. They are then released after the injection so they can recoil back and cover the injection site to hold the medication intramuscularly. The patient reported that the hyperpigmentation began a couple weeks after her 9th intramuscular iron dextran injection and 3 months prior to her visit to our clinic. The iron dextran intramuscular injections were discontinued, however there was no improvement in the hyperpigmentation. Though the hyperpigmentation was asymptomatic, it was cosmetically unacceptable to the patient. On presentation, the patient was initially treated with a test spot on the left buttock with the Q-switched alexandrite laser at 4 J/cm2, a 4 mm spot size, and a 50 nanosecond pulse duration (Trivantage, Syneron-Candela, Wayland, MA). Refrigerated air (Zimmer) was used to increase patient comfort. The chosen fluence was the lowest that caused mild epidermal whitening. Two weeks
INTRODUCTION Cutaneous siderosis is a type of exogenous dyschromia. It results from the extravasation of elemental iron from dermal or subcutaneous placement of an intramuscular or intravascular iron injection [1,2]. The iron deposits in the dermis and subcutaneous tissue concentrate in dermal macrophages which aggregate perivascularly and periadnexally, with a special affinity for the eccrine glands [1]. The hyperpigmentation from the iron is often irregular with varying shades and appears weeks after treatment [1,3]. Unfortunately, the hyperpigmentation is ß 2015 Wiley Periodicals, Inc.
Financial Disclosures: Amanda Lloyd, MD, has no financial disclosures. Michael Graves, MD, has no financial disclosures. Edward Victor Ross, MD, has received honoraria from Syneron as a consultant and has received grant funding for a study with Syneron that is not related to this report. Correspondence to: Amanda Lloyd, MD, Scripps Clinic, 10666 N. Torrey Pines Road, MS112A, La Jolla, CA 92037. E-mail: [email protected] Accepted 24 February 2015 Published online 20 May 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22353
CUTANEOUS SIDEROSIS SECONDARY
387
after administering the test spot, there was good clearance of the hyperpigmentation. Accordingly, the bilateral hyperpigmentation was treated with the same settings as the test spot for a total of 200 pulses. Numbing cream was applied for one hour before treatment. The patient returned 1 month later and had a second treatment with the same settings, and on the patient’s third treatment session, the settings were increased to 5–5.5 J/cm2, 4 mm spot size, 50 nanosecond pulse and 300 pulses total, which were the same settings for the 4th treatment. After the fourth treatment, the patient had marked improvement in the hyperpigmentation (Fig. 1). There were no side effects from any of the laser treatments. DISCUSSION In cutaneous siderosis, the iron is deposited throughout the entire dermis and is located both outside and within dermal macrophages. The iron deposits are also quite deep, at about 5–7 mm at the dermal subcutaneous junction which makes treatment even with a laser difficult [1]. It is well established that dermal pigment can be reduced with use of Q-switched lasers. Examples are tattoos and nevus of Ota. The iron dextran that is administered intramuscularly is in the form of ferric oxyhydroxide. Iron in the Fe(3þ) state which absorbs the 755 nm wavelength [4]. There are previous reports of clinical improvement of cutaneous siderosis with the 532 nm Q-switched Nd:YAG and the 1,064 nm Nd:YAG lasers, as well as the 694 nm ruby laser [1,2]. The absorption of iron should be greatest at 532 nm, somewhat less at 755 nm, and even less at 1,064 nm [5]. However, as the iron particles might be as deep as 5–7 mm and still be visible, the Q-switched 532 nm laserwasnotchosenasitwouldbelesslikelytopenetratedeep enough to reach the iron. Also, the green light laser would cause more damage to the epidermis than its deeper penetrating 755 nm and 1,064 nm counterparts. The Qswitched1,064 nmlaserenjoyslessepidermaldamage(dueto decreased melanin absorption), and deeper penetration, but has less iron absorption when compared to 755 Q-switched alexandrite laser. The Q-switched ruby is a reasonable choice; however, we do not have that laser at our institution. The Q-switched alexandrite laser absorption and penetration characteristics lie between those of 532 and 1,064 nm lasers. The red light 755 nm laser beam penetrates deep enough to reach the dermal subcutaneous junction and effectively targets iron [6]. The iron dextran particle size is 10–40 nm, giving it a thermal relaxation time of about 10 nanoseconds which is within one order of magnitude of the 50 nanosecond pulse duration of the Q-switched alexandrite laser. In other conditions like hemosiderin staining secondary to venous stasis, an older hematoma or post-sclerotherapy, we frequently use the Q-switched alexandrite laser and in our experience it is quite effective. Our patient was satisfied with her result and had near complete clearance of the hyperpigmentation. We recommend use of the Qswitched alexandrite laser to treat cutaneous siderosis from iron dextran injections.
Fig. 1. Pre-treatment: Initial clinical presentation. Post-treatment: Clinical response after 4 treatments with the QS Alexandrite laser.
REFERENCES 1. Raulin C,Werner S, Greve B. Circumscripted pigmentations after iron injections-treatment with Q-switched laser systems. Lasers Surg Med 2001;28:456–460. 2. Hammami Ghorbel H, Lacour JP, Passeron T. Successful treatment with 532-nm Q-switched Nd:YAG laser of cutaneous siderosis following intravenous iron extravasation. J Eur Acad Dermatol Venereol 2015;29:818–819 3. Ozlu E, Karadag AS, Bilgili SG, Bagram I. Cutaneous siderosis after intramuscular iron injections: A case report. Cutan Ocul Toxicol 2014;33:348–350. 4. Danielson BG. Structure, Chemistry, and Pharmacokinetics of Intravenous Iron Agents. J Am Soc Nephrol 2004;15: S93–S98. 5. Glotch TD, Kraft MD. Thermal transformations of akaganeite and lepidocrocite to hematite: Assessment of possible precursors to Martian crystalline hematite. Phys Chem Min 2008;35:569–581. 6. Nouri K. Lasers in dermatology and medicine. 2012. Springer: London; New York. p. 626.
Cutaneous Siderosis Secondary to Intramuscular Iron Dextran Treated With 755 nm Q-switched Alexandrite Laser: A Case Report Amanda A. Lloyd, MD, Michael S. Graves, MD, and Edward V. Ross, MD Scripps Clinic, La Jolla, California 92037
Background: Cutaneous siderosis is accumulation of iron in the dermis and the subcutaneous tissue secondary to extravasation of an intramuscular or intravascular iron injection. It presents as varying shades of brown macules with no distinct contours. The hyperpigmentation is permanent without treatment. Objective: Q-switched lasers have been used effectively to treat lentigines and tattoos however, there is little data on the treatment of cutaneous siderosis with lasers. Our objective was to effectively treat cutaneous siderosis with a Q-switched alexandrite laser. Results: A 50-year-old female had received nine injections of intramuscular iron dextran, one injection every 2 weeks alternating right buttock and left buttock over the course of 5 months. A couple of weeks after her 9th injection which was on the left, she noted brown hyperpigmentation in the injection area with the left worse than the right. She waited 3 months for the hyperpigmentation to self-resolve before presenting in our clinic. We utilized the Q-switched alexandrite laser to treat the patient with a test spot. One week later, there was nice partial clearance from the test spot so we commenced full treatment of the hyperpigmentation. There was significant improvement after the first treatment and she has been treated 4 times with continued improvement over the past 2 months. Conclusion: The Q-switched alexandrite laser is a useful tool in the treatment of cutaneous siderosis secondary to iron injection. Lasers Surg. Med. 47:386–387, 2015. ß 2015 Wiley Periodicals, Inc. Key words: deposition; hyperpigmentation; skin; staining of skin
persistent. Q-switched lasers are a well-established treatment option for tattoo pigment, however there are few reports of treatment of cutaneous siderosis with Qswitched lasers, and none with the Q-switched alexandrite laser [1,2]. We report successful treatment of cutaneous siderosis with the Q-switched alexandrite laser. Case Report A 50-year-old white female presented with hyperpigmentation on her buttocks, left worse than right. She had been receiving iron dextran intramuscular injections every 2 weeks over 5 months via the Z-track technique into alternating upper outer quadrants of the buttock as treatment for her iron deficiency anemia. The Z track is a technique of intramuscular injections where the skin and subcutaneous tissues are lifted to the side during the injection. They are then released after the injection so they can recoil back and cover the injection site to hold the medication intramuscularly. The patient reported that the hyperpigmentation began a couple weeks after her 9th intramuscular iron dextran injection and 3 months prior to her visit to our clinic. The iron dextran intramuscular injections were discontinued, however there was no improvement in the hyperpigmentation. Though the hyperpigmentation was asymptomatic, it was cosmetically unacceptable to the patient. On presentation, the patient was initially treated with a test spot on the left buttock with the Q-switched alexandrite laser at 4 J/cm2, a 4 mm spot size, and a 50 nanosecond pulse duration (Trivantage, Syneron-Candela, Wayland, MA). Refrigerated air (Zimmer) was used to increase patient comfort. The chosen fluence was the lowest that caused mild epidermal whitening. Two weeks
INTRODUCTION Cutaneous siderosis is a type of exogenous dyschromia. It results from the extravasation of elemental iron from dermal or subcutaneous placement of an intramuscular or intravascular iron injection [1,2]. The iron deposits in the dermis and subcutaneous tissue concentrate in dermal macrophages which aggregate perivascularly and periadnexally, with a special affinity for the eccrine glands [1]. The hyperpigmentation from the iron is often irregular with varying shades and appears weeks after treatment [1,3]. Unfortunately, the hyperpigmentation is ß 2015 Wiley Periodicals, Inc.
Financial Disclosures: Amanda Lloyd, MD, has no financial disclosures. Michael Graves, MD, has no financial disclosures. Edward Victor Ross, MD, has received honoraria from Syneron as a consultant and has received grant funding for a study with Syneron that is not related to this report. Correspondence to: Amanda Lloyd, MD, Scripps Clinic, 10666 N. Torrey Pines Road, MS112A, La Jolla, CA 92037. E-mail: [email protected] Accepted 24 February 2015 Published online 20 May 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22353
CUTANEOUS SIDEROSIS SECONDARY
387
after administering the test spot, there was good clearance of the hyperpigmentation. Accordingly, the bilateral hyperpigmentation was treated with the same settings as the test spot for a total of 200 pulses. Numbing cream was applied for one hour before treatment. The patient returned 1 month later and had a second treatment with the same settings, and on the patient’s third treatment session, the settings were increased to 5–5.5 J/cm2, 4 mm spot size, 50 nanosecond pulse and 300 pulses total, which were the same settings for the 4th treatment. After the fourth treatment, the patient had marked improvement in the hyperpigmentation (Fig. 1). There were no side effects from any of the laser treatments. DISCUSSION In cutaneous siderosis, the iron is deposited throughout the entire dermis and is located both outside and within dermal macrophages. The iron deposits are also quite deep, at about 5–7 mm at the dermal subcutaneous junction which makes treatment even with a laser difficult [1]. It is well established that dermal pigment can be reduced with use of Q-switched lasers. Examples are tattoos and nevus of Ota. The iron dextran that is administered intramuscularly is in the form of ferric oxyhydroxide. Iron in the Fe(3þ) state which absorbs the 755 nm wavelength [4]. There are previous reports of clinical improvement of cutaneous siderosis with the 532 nm Q-switched Nd:YAG and the 1,064 nm Nd:YAG lasers, as well as the 694 nm ruby laser [1,2]. The absorption of iron should be greatest at 532 nm, somewhat less at 755 nm, and even less at 1,064 nm [5]. However, as the iron particles might be as deep as 5–7 mm and still be visible, the Q-switched 532 nm laserwasnotchosenasitwouldbelesslikelytopenetratedeep enough to reach the iron. Also, the green light laser would cause more damage to the epidermis than its deeper penetrating 755 nm and 1,064 nm counterparts. The Qswitched1,064 nmlaserenjoyslessepidermaldamage(dueto decreased melanin absorption), and deeper penetration, but has less iron absorption when compared to 755 Q-switched alexandrite laser. The Q-switched ruby is a reasonable choice; however, we do not have that laser at our institution. The Q-switched alexandrite laser absorption and penetration characteristics lie between those of 532 and 1,064 nm lasers. The red light 755 nm laser beam penetrates deep enough to reach the dermal subcutaneous junction and effectively targets iron [6]. The iron dextran particle size is 10–40 nm, giving it a thermal relaxation time of about 10 nanoseconds which is within one order of magnitude of the 50 nanosecond pulse duration of the Q-switched alexandrite laser. In other conditions like hemosiderin staining secondary to venous stasis, an older hematoma or post-sclerotherapy, we frequently use the Q-switched alexandrite laser and in our experience it is quite effective. Our patient was satisfied with her result and had near complete clearance of the hyperpigmentation. We recommend use of the Qswitched alexandrite laser to treat cutaneous siderosis from iron dextran injections.
Fig. 1. Pre-treatment: Initial clinical presentation. Post-treatment: Clinical response after 4 treatments with the QS Alexandrite laser.
REFERENCES 1. Raulin C,Werner S, Greve B. Circumscripted pigmentations after iron injections-treatment with Q-switched laser systems. Lasers Surg Med 2001;28:456–460. 2. Hammami Ghorbel H, Lacour JP, Passeron T. Successful treatment with 532-nm Q-switched Nd:YAG laser of cutaneous siderosis following intravenous iron extravasation. J Eur Acad Dermatol Venereol 2015;29:818–819 3. Ozlu E, Karadag AS, Bilgili SG, Bagram I. Cutaneous siderosis after intramuscular iron injections: A case report. Cutan Ocul Toxicol 2014;33:348–350. 4. Danielson BG. Structure, Chemistry, and Pharmacokinetics of Intravenous Iron Agents. J Am Soc Nephrol 2004;15: S93–S98. 5. Glotch TD, Kraft MD. Thermal transformations of akaganeite and lepidocrocite to hematite: Assessment of possible precursors to Martian crystalline hematite. Phys Chem Min 2008;35:569–581. 6. Nouri K. Lasers in dermatology and medicine. 2012. Springer: London; New York. p. 626.
