Several types of granulomatous reactions exist, and all are treated with injections of steroids. It is hypothesized that a higher initial dosage and/or frequent injections might increase the healing time (personal communication, G. Lemperle).
Initially patients are treated with triamcin-olonacetonid, either 10 mg in 1 ml or 40 mg in 1 ml. Please note that triamcinolonactonid 40 may induce severe atrophy in areas with underlying fatty tissue. Therefore, the steroid should
Injection of triamcinolonacetonid 10 mg or triamcinolonacetonid 40 mg if possible directly into or beneath the granuloma. A further dilution is not recommended. Injections at weekly intervals until an improvement can be seen or up to 10 injections
If there is no improvement, 5-fluoruracil can be added to triamcinolon 10 mg or 40 mg. Again, injections should be performed at weekly intervals until an improvement can be seen Osteoporosis prophylaxis with a combination of calcium carbonate 1.25 g and cholecalciferol (Vitamin D3) 10 ^g is advisable for patients at risk of osteoporosis if the treatment should continue.
If there is no improvement a surgical intervention should be considered.
be injected directly into or beneath the granuloma. If this is not possible (granulomas due to HEMA are particularly difficult to penetrate) the steroid should be injected around the granulo-matous tissue. Per granuloma the injected volume should not exceed 0,05-0,1 ml. Initially the injections should be performed weekly. If the granulomatous tissue reduces, subsequent injections can be carried out every 2 weeks. The duration of therapy varies between patients (Fig. 6.5). The aim of the treatment should be to make the granulomatous reaction less visible.
If there is no response after approximately eight injections over a 2-month period, 5-flu-oruracil (50 mg/ml) can be added to the steroid (triamcinolonactenoid 1 mg/ml). As for all other interventions, the efficacy of the addition of 5-fluoruracil is based on a case series in patients with hypertrophic scars and expert opinion (see Table 6.2; Fitzpatrick 1999). A further case report suggests that oral 200-600 mg allopurinol per day given over 16 weeks should be helpful. However, this particular patient was also treated with topical steroids and the results have never been confirmed by another paper (Reisberger et al. 2003). Based on the nature of these granuloma-tous reactions a livelong therapy - with remissions lasting several months - might be necessary in some patients.
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