What is the guideline for using intralesional triamcinolone (corticosteroid) injections for keloid and hypertrophic scar management, including dose, frequency, duration, short-term and long-term safety, and risk of systemic toxicity?

From the Guidelines

Intralesional triamcinolone acetonide injections are a recommended treatment for keloids and hypertrophic scars, with a typical dose of 10-40 mg/mL, and should be administered every 3-4 weeks for a total of 3-6 sessions. The dose and frequency of intralesional triamcinolone injections can vary depending on the location and thickness of the scar, as well as the individual patient's response to treatment 1.

Key Considerations

• For keloids, a dose of 40 mg/mL can be used, while for acne keloidalis, a dose of 10 mg/mL is recommended 1.
• Injections should be administered directly into the scar tissue using a 27-30 gauge needle until the scar blanches.
• Typical volumes range from 0.1-0.5 mL per square centimeter of scar tissue.
• The maximum recommended dose per session is 40 mg to minimize systemic absorption.

Safety and Efficacy

• Short-term side effects include pain during injection, temporary skin depression, telangiectasia, and hypopigmentation, which are usually reversible 1.
• Long-term risks with repeated high-dose injections include permanent skin atrophy, stellate pseudoscars, and rarely, systemic effects such as Cushing's syndrome or adrenal suppression.
• The risk of systemic toxicity is minimal with appropriate dosing and spacing between treatments, as the localized nature of the injection limits systemic absorption 1.

Treatment Protocol

• Treatment sessions are typically scheduled every 3-4 weeks for a total of 3-6 sessions.
• Clinical improvement is often visible after 2-3 treatments.
• Treatment efficacy should be reassessed after 3-4 sessions, and maintenance injections may be needed every 6-12 months for recurrent lesions.

Contraindications

• Intralesional triamcinolone injections should not be used in patients with active infections, hypersensitivity to triamcinolone, or certain systemic conditions such as uncontrolled diabetes, heart failure, or severe hypertension 1.

From the FDA Drug Label

5 mg to 100 mg per day depending on the specific disease entity being treated For the purpose of comparison, the following is the equivalent milligram dosage of the various glucocorticoids: LOCAL Intra-articular administration: A single local injection of triamcinolone acetonide is frequently sufficient, but several injections may be needed for adequate relief of symptoms. Initial dose: 2. 5 mg to 5 mg for smaller joints and from 5 mg to 15 mg for larger joints, depending on the specific disease entity being treated. For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient.

The guideline for using intralesional triamcinolone injections for keloid and hypertrophic scar management is not explicitly stated in the provided drug label. However, based on the information provided for intra-articular administration, the dose of triamcinolone acetonide can range from 2.5 mg to 40 mg depending on the size of the area being treated.

• The frequency of injections is not specified, but it is mentioned that a single injection is frequently sufficient, and several injections may be needed for adequate relief of symptoms.
• The duration of treatment is also not specified.
• Short-term and long-term safety and systemic toxicity are not directly addressed in the context of keloid and hypertrophic scar management. 2

From the Research

Guideline for Using Intralesional Triamcinolone Injection

• The guideline for using intralesional triamcinolone injection for keloid and hypertrophic scar management involves the use of corticosteroid injections, which remain the mainstay of therapy for hypertrophic scars and keloids 3.
• The dose of intralesional triamcinolone acetonide can range from 10 mg/mL to 40 mg/mL, with a maximum indicative volume of 1.5 ml per session 4.
• The frequency of injections can be every three weeks until complete flattening of the scar or eight sessions, whichever comes earlier 4.
• The duration of treatment can vary depending on the individual response, with some studies showing significant improvement in scar height, vascularity, and pliability after 12-21 weeks of treatment 4.

Short-Term and Long-Term Safety

• Intralesional triamcinolone injections have been shown to be safe and effective in the short-term treatment of hypertrophic scars and keloids, with significant improvements in vascularity and pliability compared to verapamil 5.
• However, long-term treatment with triamcinolone acetonide may be associated with skin atrophy and telangiectasia, especially at concentrations of 20 mg/ml or 40 mg/ml 5.
• Combination therapy with 5-fluorouracil (5-FU) and triamcinolone acetonide may produce superior results for medium- and long-term treatments, with significant improvements in scar height, pliability, and pigmentation 6, 5.

Systemic Toxicity

• There is limited evidence on the systemic toxicity of intralesional triamcinolone injections, but one study found that bleomycin was detected in the blood circulation in a very small amount after intralesional injection 3.
• Another study found that intralesional triamcinolone injections were not associated with significant systemic side effects, but skin atrophy and telangiectasia were reported as adverse effects 5.

Alternative Therapies

• Other therapies, such as intralesional verapamil, 5-fluorouracil, and botulinum toxin type A, may be effective alternatives to triamcinolone acetonide for the treatment of keloids and hypertrophic scars 4, 5, 7.
• Laser therapies, surgical revisions, and radiation therapy may also be considered for advanced treatment of keloids and hypertrophic scars 7.