How to administer Kenalog (triamcinolone) with lidocaine for cystic acne treatment?

Intralesional Kenalog with Lidocaine for Cystic Acne Treatment

For cystic acne treatment, use triamcinolone acetonide (Kenalog) at a concentration of 2.5 mg/mL mixed with lidocaine 1% to reduce injection pain, injecting 0.05 mL directly into the center of each cystic lesion. 1

Preparation and Administration

Concentration and Dilution

• Start with Kenalog-40 (triamcinolone acetonide 40 mg/mL) 2
• Dilute to 2.5 mg/mL (most commonly used concentration for acne) 1
• Dilution method:
  • Mix 0.5 mL of Kenalog-40 with 7.5 mL of 1% lidocaine
  • This creates an 8 mL solution of 2.5 mg/mL triamcinolone with lidocaine

Injection Technique

• Clean the area with alcohol swab
• Use a 30-gauge needle (smallest possible) to minimize pain
• Inject directly into the center of the cystic lesion 1
• Standard volume: 0.05 mL per lesion (most common reported volume) 1
• Maximum volume: Do not exceed 0.1 mL per lesion to avoid atrophy

Treatment Protocol

Patient Selection

• Best for isolated inflammatory nodulocystic acne lesions 3
• Not an effective strategy for patients with multiple lesions 3
• Particularly useful for stubborn cystic lesions that have not responded to conventional therapy

Expected Results

• Flattening of most acne nodules within 48-72 hours 3
• Reduction in inflammation and pain

Treatment Frequency

• Use for occasional stubborn cystic lesions only
• Limit to 3-4 injections per session
• Allow at least 3-4 weeks between treatments to the same area

Precautions and Adverse Effects

Common Side Effects

• Local atrophy (most common long-term complication)
  • Occurs in less than 1% of patients 1
  • Can last over 6 months when it occurs 1
• Hypopigmentation
• Telangiectasias

Risk Minimization

• Always counsel patients about potential adverse effects before injection 1
• Use the lowest effective concentration (2.5 mg/mL)
• Inject small volumes (0.05 mL)
• Avoid repeated injections in the same site
• Use caution on facial areas or thin skin

Contraindications

• Active skin infections at injection site 3
• Previous hypersensitivity to triamcinolone 3
• Widespread acne (not practical for multiple lesions)

Advanced Considerations

Enhanced Efficacy Option

• Some evidence suggests adding lincomycin (75 mg/mL) to the triamcinolone injection may improve efficacy 4
• In one study, combination therapy showed 100% improvement at one week versus 66% with triamcinolone alone 4

Alternative Approaches

• For patients with multiple cystic lesions, consider systemic therapy instead:
  • Oral isotretinoin (0.5-1 mg/kg/day) for severe cases 3
  • Oral antibiotics with topical retinoids for moderate cases

Remember that intralesional triamcinolone is an effective targeted therapy for isolated cystic acne lesions but is not practical as a primary treatment strategy for widespread acne vulgaris.