Subcutaneous calcification following injection of triamcinolone hexacetonide for plantar fasciitis.

Subcutaneous calcification following injection of triamcinolone hexacetonide for plantar fasciitis SIR, We report a patient who developed subcutaneous calcinosis and ulceration over the heel following injection of triamcinolone hexacetonide. This agent has the potential to cause complications many years after treatment. A 67-yr-old lady was referred with a weeping ulcer on the medial aspect of the left heel, which had developed slowly over the previous 12 months. She recalled two injections at the site for plantar fasciitis given 2 months apart $15 yrs earlier by her GP. Small gritty particles with the appearance of salt grains often appeared on the surface of the ulcer, which remained moist and required a dry dressing for comfort. Examination showed a 3 Â 3 cm ulcer with slightly raised edge. There was concern about malignancy and thus the lesion was excised. Histology showed focal ulceration with extensive scarring and multiple foci of dermal calcification with a histiocytic reaction (calcinosis cutis). There were no clinical features such as RP or arthritis to suggest a CTD and serum calcium, ANA and ENA were normal or negative. Plain X-rays (Fig. 1) showed calcification on the medial aspect of the left calcaneum. The General Practitioner confirmed that the patient had had two injections of triamcinolone hexacetonide (Lederspan, Lederle), dose unknown, 15 yrs earlier and commented that it was probably the last time he had used this agent. Triamcinolone hexacetonide was first associated with IA and peri-articular calcification in juvenile idiopathic arthritis in 1990 [1, 2], 2 although a study in 2000 found an incidence of only 3 in 194 children [3]. A single case report in 1991 demonstrated soft tissue calcifica-tion in the heel of a patient following multiple injections of triamcinolone hexacetonide to treat pain from a calcaneal spur; it was suggested that accumulation of insoluble steroid acted as a foreign body and induced a chronic granulomatous response with dystrophic calcification [4]. This case is similar to ours where we were able to confirm a foreign body (histiocytic) reaction. X-rays showed superficial calcification (reflecting 'salt grains' seen by the patient), which suggest either that the steroid was injected too superficially or that a proportion migrated back along the needle track. Triamcinolone hexacetonide has much lower solubility in water (0.0004% w/v at 258C) than methylprednisolone acetate (0.0014% w/v at 258C) and hydrocortisone (0.07% w/v at 258C) [5]. Whilst this may produce a longer lasting effect [6], it also …