madman
Super Moderator
Testosterone-replacement therapy (TRT) is indicated for hypogonadism. The benefits of TRT are well documented, with multiple options available for delivery. Testosterone pellet implantation (TPI) is an effective treatment option for hypogonadism with minimal adverse reactions. Availability of TRT is increasing, as facilities are offering off-label applications. Although TPI generally is well tolerated, cutaneous reactions have been documented. We present a patient with drug-induced dermatitis following TPI.
A 51-year-old man with hypogonadism presented with an extremely pruritic rash that began on the left buttock 3 days after receiving his fourth TPI. The patient had received subcutaneous insertions of 8 testosterone pellets (75 mg per pellet every 6 months) to the left buttock. He denied any history of a similar rash. His medical history was remarkable for hyperlipidemia, which was controlled with niacin and omega-3 fatty acids (fish oil). Other medications included glucosamine. Before presenting to our clinic, he was given a 40-mg intramuscular injection of triamcinolone acetonide and trimethoprim-sulfamethoxazole twice daily for 7 days, a methylprednisolone dose pack, and triamcinolone ointment 0.1% twice daily by his primary care physician, all without improvement of the rash.
Physical examination revealed multiple well-circumscribed, coalescing clusters of darkly erythematous papules and dermal plaques of varying size on the buttocks with extension to the lower back, abdomen, and thighs (Figure 1). The differential diagnosis included the lichenoid eruption, pseudolymphoma, sarcoidosis, and granuloma annulare.
Histologic examination of a punch biopsy revealed an epidermis with a normal stratum corneum and subtle cell-poor vacuolar interface dermatitis with rare necrotic keratinocytes. There was a mild perivascular lymphocytic infiltrate with slight edema within the dermis without notable eosinophils or findings indicative of a vasculitic process (Figure 2).
Oral prednisone 60 mg daily and betamethasone ointment 0.05% applied twice daily were started, with the notable improvement of the rash in 1 week (Figure 3). Given the temporal relationship of the TPI, histologic findings suggestive of drug eruption, and resolution of symptoms shortly after treatment, a diagnosis of testosterone pellet– induced generalized dermatitis was established.
Testosterone-replacement therapy is the principal treatment of male pathologic hypoandrogenism, but off-label prescription frequently occurs for age-related hypogonadism and hypoactive sexual desire disorder.1 Testosterone-replacement therapy also can enhance sexual desire and function and improve mood in premenopausal and postmenopausal women with testosterone deficiency.2 Delivery options include topicals, intramuscular injections, oral formulations, transdermal patches and gels, and subcutaneous placement of testosterone pellets (TPI).
Cutaneous reactions to TPI are rare. Hirsutism, male-pattern hair loss, and acne are possible cutaneous adverse reactions.3 In addition, a localized erythematous pruritic eruption at the implantation site and an immunologic foreign-body reaction to testosterone pellets have been reported.4
Our case of histologically consistent testosterone pellet–induced dermatitis highlights a rare cutaneous adverse reaction that can occur subsequent to TPI and illustrates the efficacy of high-dose oral steroids as a treatment option. With the increased use of TRT, physicians should be cognizant of the potential adverse cutaneous effects related to this treatment and counsel patients appropriately prior to initiating treatment.
A 51-year-old man with hypogonadism presented with an extremely pruritic rash that began on the left buttock 3 days after receiving his fourth TPI. The patient had received subcutaneous insertions of 8 testosterone pellets (75 mg per pellet every 6 months) to the left buttock. He denied any history of a similar rash. His medical history was remarkable for hyperlipidemia, which was controlled with niacin and omega-3 fatty acids (fish oil). Other medications included glucosamine. Before presenting to our clinic, he was given a 40-mg intramuscular injection of triamcinolone acetonide and trimethoprim-sulfamethoxazole twice daily for 7 days, a methylprednisolone dose pack, and triamcinolone ointment 0.1% twice daily by his primary care physician, all without improvement of the rash.
Physical examination revealed multiple well-circumscribed, coalescing clusters of darkly erythematous papules and dermal plaques of varying size on the buttocks with extension to the lower back, abdomen, and thighs (Figure 1). The differential diagnosis included the lichenoid eruption, pseudolymphoma, sarcoidosis, and granuloma annulare.
Histologic examination of a punch biopsy revealed an epidermis with a normal stratum corneum and subtle cell-poor vacuolar interface dermatitis with rare necrotic keratinocytes. There was a mild perivascular lymphocytic infiltrate with slight edema within the dermis without notable eosinophils or findings indicative of a vasculitic process (Figure 2).
Oral prednisone 60 mg daily and betamethasone ointment 0.05% applied twice daily were started, with the notable improvement of the rash in 1 week (Figure 3). Given the temporal relationship of the TPI, histologic findings suggestive of drug eruption, and resolution of symptoms shortly after treatment, a diagnosis of testosterone pellet– induced generalized dermatitis was established.
Testosterone-replacement therapy is the principal treatment of male pathologic hypoandrogenism, but off-label prescription frequently occurs for age-related hypogonadism and hypoactive sexual desire disorder.1 Testosterone-replacement therapy also can enhance sexual desire and function and improve mood in premenopausal and postmenopausal women with testosterone deficiency.2 Delivery options include topicals, intramuscular injections, oral formulations, transdermal patches and gels, and subcutaneous placement of testosterone pellets (TPI).
Cutaneous reactions to TPI are rare. Hirsutism, male-pattern hair loss, and acne are possible cutaneous adverse reactions.3 In addition, a localized erythematous pruritic eruption at the implantation site and an immunologic foreign-body reaction to testosterone pellets have been reported.4
Our case of histologically consistent testosterone pellet–induced dermatitis highlights a rare cutaneous adverse reaction that can occur subsequent to TPI and illustrates the efficacy of high-dose oral steroids as a treatment option. With the increased use of TRT, physicians should be cognizant of the potential adverse cutaneous effects related to this treatment and counsel patients appropriately prior to initiating treatment.
