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Objectives: Inflammatory nodules will usually have the characteristics of pain, tenderness, or redness. I usually advise treating these with antibiotics and steroids in combination. My protocol is as below. I am aware that some physicians may disagree with my more liberal use of steroids, but I have the advantage of having dealt with many hundreds of patients with good effect.

Introduction: 1. Initial treatment should be with an antibiotic, either a macrolide (e.g., clarithromycin 500mg twice daily or doxycycline 100mg twice daily).
2. After two weeks, if there is significant improvement, then dual antibiotic therapy should be prescribed and oral steroids (Dexamethasone 4mg daily x 3/7 considered).
3. If there has been no significant improvement after four weeks and the DON is a result of injection with hyaluronic acid dermal filler, then hyaluronidase should also be considered but its benefit in giant cell granulomas is rather doubtful.

Materials / method: 4. For non-hyaluronic acid fillers, inflammatory DONs can be treated with intralesional steroid injection with good effect.
5. I recommend graduated injections of either DepoMedrone 0.1ml starting with a 20mg/mL or Triamcinolone acetonide 0.1mL starting with a 10mg/mL concentration and then increasing concentration to 20mg/mL and 40mg/mL at four weekly intervals.
6. There is a risk of post-treatment soft tissue atrophy and telangiectasia when administering intralesional steroids and the patient will need counselling to this effect

Results: 7. If there has still not been any significant improvement then an expert in the management of DONs should be consulted to consider punch biopsy and anaerobic and aerobic culture, resurfacing procedures such as spot dermabrasion or laser, intralesional antimitotics (e.g., 5-fluorouracil) and surgical excision.

Conclusion: 8. Throughout the whole process, the patient should be kept fully informed and under regular review with good documentation and photography. It is recommended to speak to your medical defence organisation early on as they will also be able to advise on the correct course of action and by not doing so may invalidate the policy if a claim does arise.

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请注明名称（个人，公司，学会等等）: Bsure Medical

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