What is the proper usage and dosage of Kenalog (triamcinolone)?

Proper Usage and Dosage of Kenalog (Triamcinolone)

Kenalog (triamcinolone acetonide) is indicated for specific conditions with different dosages based on administration route, with intralesional injection using 2.5-10 mg/mL concentration for inflammatory skin conditions and 40 mg/mL for intramuscular administration for systemic effects. 1, 2

Intralesional Administration for Dermatologic Conditions

Dosing for Acne

• Concentration: 10 mg/mL (may be diluted to 5 or 3.3 mg/mL with sterile normal saline) 1
• Volume: 0.05 mL per lesion is most commonly used 3
• Technique: Inject into the center of the lesion 3
• Indication: Inflammatory nodulocystic acne (for occasional stubborn cystic lesions, not for multiple lesions) 1
• Response time: Flattens most acne nodules within 48-72 hours 1

Dosing for Other Dermatologic Conditions

• Acne keloidalis: Triamcinolone acetonide 10 mg/mL for inflammatory follicular lesions 1
• Hypertrophic scars/keloids: Triamcinolone acetonide 40 mg/mL 1
• Alopecia areata: Triamcinolone acetonide 5-10 mg/mL 1
• Psoriasis/Lichen planus affecting nails: Triamcinolone acetonide 5-10 mg/mL 1
• Gout (intra-articular): Triamcinolone acetonide 10 mg per affected joint 1

Intramuscular Administration

Dosing for Systemic Effects

• Concentration: Available as Kenalog-40 (40 mg/mL) and Kenalog-80 (80 mg/mL) 2
• Severe asthma: 360 mg as a single intramuscular injection (high-dose protocol for elderly patients with steroid-dependent asthma) 4, 5
• Atopic dermatitis (when necessary): 0.5-1.0 mg/kg 1

Contraindications

1. Should not be injected at sites of active infections (impetigo, herpes) 1
2. Previous hypersensitivity to triamcinolone 1
3. Large injections should be avoided in patients with:
   • Active tuberculosis or systemic fungal infection
   • Extensive plaque psoriasis, pustular psoriasis, or erythrodermic psoriasis
   • Active peptic ulcer disease
   • Uncontrolled diabetes, heart failure, or severe hypertension
   • Severe depression or psychosis 1

Adverse Effects

Local Effects (Intralesional)

• Skin atrophy, pigmentary changes, telangiectasias, hypertrichosis 1, 3
• Impaired wound healing 1
• Contact allergic dermatitis (from benzyl alcohol preservative) 1
• Sterile abscess, steroid acne 1

Systemic Effects

• Hypothalamic-pituitary-adrenal axis suppression with repeated injections 1
• Anaphylaxis, angioedema, urticaria (rare) 1
• Postinjection flares mimicking septic arthritis (rare but severe) 6
• Weight gain, menstrual disturbances, increased blood pressure, edema 5

Important Considerations

1. Duration of effect: Triamcinolone acetonide has a uniquely long duration of action compared to other corticosteroids 7
2. Atrophy risk: While observed skin atrophy rates are extremely low with proper technique, when it occurs, it can last over six months 3
3. Patient counseling: 50.5% of dermatologists counsel patients about potential hypopigmentation and atrophy before every injection 3
4. Systemic absorption: Even with local injections, some systemic absorption occurs, which may affect conditions like diabetes 1
5. Rebound effects: Systemic steroids may cause rebound flares upon discontinuation, especially in atopic dermatitis 1

Monitoring

• For patients receiving repeated or high-dose injections, monitor for signs of systemic absorption
• For intralesional injections, follow up to assess response and potential adverse effects
• For children receiving long-term systemic steroids, monitor growth velocity 1

Remember that while triamcinolone is effective for many conditions, it should be used judiciously due to its potential for significant adverse effects, especially with repeated use.