Intralesional Triamcinolone for Hidradenitis Suppurativa
Intralesional triamcinolone (10 mg/mL) is recommended as an effective adjunctive therapy for acutely inflamed nodules in hidradenitis suppurativa, providing rapid symptom relief within 1 day, though it should not be considered a primary treatment modality. 1
Role in Treatment Algorithm
Intralesional triamcinolone serves as an adjunctive intervention rather than standalone therapy:
- For mild disease (Hurley Stage I), use intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for individual inflamed nodules while maintaining topical clindamycin 1% twice daily as the primary treatment 1, 2
- The injection provides significant reduction in erythema, edema, suppuration, and pain within 24 hours according to the American Academy of Dermatology 1, 2
- This approach is most appropriate for patients experiencing acute flares with painful inflammatory nodules requiring rapid symptomatic relief 1
Evidence Quality and Dosing
The evidence base reveals important nuances about efficacy:
- A 2016 prospective case series demonstrated significant improvements in physician-assessed inflammation (erythema, edema, suppuration, size all improved from median score 2-3 down to 1) and patient-reported pain (VAS decreased from 5.5 to 2.3 after 1 day) 3
- However, a 2020 double-blind RCT found no significant difference between triamcinolone 10 mg/mL, triamcinolone 40 mg/mL, and normal saline placebo for days to clearance, pain reduction at day 5, or patient satisfaction 4
- Despite this conflicting evidence, a 2021 retrospective study of high-dose triamcinolone (20-40 mg/mL) showed 92.6% of patients demonstrated disease improvement and 75.9% experienced enhanced quality of life, with 76.9% reporting satisfaction 5
Clinical Application Strategy
Given the mixed evidence, use intralesional triamcinolone strategically:
- Inject 10 mg/mL concentration (0.2-2.0 mL per lesion) into acutely inflamed nodules for rapid symptomatic relief while awaiting systemic therapy effects 1, 2
- Do not use as monotherapy or primary treatment—always combine with appropriate systemic therapy based on Hurley stage (topical clindamycin for Stage I, oral antibiotics for Stage II, biologics for Stage III) 1, 2
- Reserve for acute flares requiring immediate pain control, not for chronic management or prevention 1, 3
- Consider higher concentrations (20-40 mg/mL) for particularly severe inflammatory lesions based on the 2021 retrospective data showing improved outcomes 5
Critical Limitations
Be aware of important caveats:
- Intralesional corticosteroids have no effect on deep abscesses, sinus tracts, or scarring—these require systemic therapy or surgical intervention 6, 7
- The 2020 RCT suggests the perceived benefit may partially reflect natural disease fluctuation or placebo effect 4
- No evidence supports routine prophylactic injections—use only for active inflammatory lesions 1, 7
- A 2022 systematic review concluded that while corticosteroid injections appear effective for acute inflammatory lesions, the overall quality of evidence remains limited 7
Integration with Comprehensive Management
Position intralesional triamcinolone within the broader treatment framework:
- For Hurley Stage I: Topical clindamycin 1% twice daily for 12 weeks remains first-line; add intralesional triamcinolone for individual inflamed nodules 1, 2
- For Hurley Stage II: Clindamycin 300 mg + rifampicin 300-600 mg daily for 10-12 weeks is primary therapy; intralesional triamcinolone provides adjunctive acute relief 1, 2
- For Hurley Stage III: Adalimumab (160 mg → 80 mg → 40 mg weekly) is first-line; intralesional triamcinolone may help bridge to biologic effect 1, 2
The American Academy of Dermatology explicitly recommends intralesional triamcinolone 10 mg/mL for acutely inflamed nodules to provide rapid symptom relief within 1 day, making it a valuable tool for acute management despite the mixed research evidence 1