What is the recommended dose of Kenalog (triamcinolone) for treating cystic acne?

Recommended Dose of Kenalog (Triamcinolone) for Cystic Acne

For treating cystic acne, triamcinolone acetonide should be used at a concentration of 2.5-5 mg/mL, with 10 mg/mL being diluted with sterile normal saline to achieve these lower concentrations. 1

Dosing Guidelines

Concentration

• Standard concentration: 2.5 mg/mL (most commonly used by dermatologists) 2
• Range: 2.5-5 mg/mL (diluted from 10 mg/mL stock) 1
• Higher concentration (10 mg/mL) is recommended for acne keloidalis 1

Volume

• Recommended injection volume: 0.05 mL per lesion 2
• Inject into the center of the lesion 2

Efficacy and Response

• Flattens most acne nodules within 48-72 hours 1
• Highly effective for occasional or particularly stubborn cystic lesions 1
• Not recommended as a treatment strategy for patients with multiple lesions 1

Contraindications

Intralesional triamcinolone should not be used in patients with:

• Active infections at the injection site (impetigo, herpes) 1
• Previous hypersensitivity to triamcinolone 1
• Active tuberculosis or systemic fungal infection (avoid large injections) 1
• Extensive plaque psoriasis, pustular psoriasis, or erythrodermic psoriasis 1
• Active peptic ulcer disease 1
• Uncontrolled diabetes, heart failure, or severe hypertension 1
• Severe depression or psychosis 1

Potential Adverse Effects

• Local overdose can result in:
  • Skin atrophy
  • Pigmentary changes
  • Telangiectasias
  • Hypertrichosis 1
• Other potential complications:
  • Infections
  • Impaired wound healing
  • Contact allergic dermatitis (from benzyl alcohol preservative)
  • Sterile abscess
  • Steroid acne 1
  • Granulomatous reactions (rare) 3
• When atrophy occurs, it may last over six months 2

Clinical Pearls

1. Counsel patients about potential adverse effects (hypopigmentation and atrophy) before injection 2
2. Most dermatologists report that less than 1% of patients return with adverse events 2
3. Consider combination therapy with intralesional antibiotics for enhanced efficacy:
   • A study showed that combining intralesional triamcinolone with lincomycin provided 100% improvement versus 66% improvement with triamcinolone alone 4
4. For severe nodulocystic acne with multiple lesions, consider systemic treatments instead:
   • Oral isotretinoin (0.5-1 mg/kg/day) 1, 5
   • Oral antibiotics (doxycycline, minocycline) with topical therapy 5

Treatment Algorithm

1. For isolated cystic acne lesions:

   • Use triamcinolone 2.5 mg/mL, 0.05 mL per lesion
   • Inject into the center of the lesion
   • Expect improvement within 48-72 hours

2. For multiple cystic lesions or recurrent disease:

   • Consider systemic therapy instead of multiple intralesional injections
   • Oral isotretinoin or antibiotics with topical therapy would be more appropriate

Remember that intralesional triamcinolone is best suited for occasional stubborn cystic lesions rather than widespread disease 1.