Triamcinolone: Proper Usage and Dosage
Overview
Triamcinolone is a versatile corticosteroid with distinct dosing regimens depending on route of administration and indication, ranging from topical 0.1% cream applied 2-3 times daily for inflammatory dermatoses to intravitreal 1 mg injections for retinal vein occlusions, with careful attention to side effects including skin atrophy, elevated intraocular pressure, and HPA axis suppression. 1, 2, 3
Topical Formulations
Standard Dermatologic Use
Triamcinolone acetonide 0.1% cream is FDA-approved for inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses, applied 2-3 times daily to affected areas with gentle rubbing. 1
For mild to moderate psoriasis, the American Academy of Dermatology recommends triamcinolone acetonide 0.1% as a medium-potency topical corticosteroid for daily application. 3
Apply the minimum effective amount to control symptoms, with consideration for periodic breaks or maintenance regimens (e.g., twice weekly application) once control is achieved. 3
Occlusive Dressing Technique
For psoriasis or recalcitrant conditions, apply a small amount until it disappears, reapply leaving a thin coating, then cover with pliable nonporous film and seal edges. 1
The 12-hour occlusion regimen involves applying cream under occlusive dressing in the evening and removing in the morning, with additional non-occluded application during the day. 1
Discontinue occlusive dressings immediately if infection develops and institute appropriate antimicrobial therapy. 1
Special Considerations for Topical Use
Facial skin is thinner and more prone to steroid-induced atrophy than other body sites, requiring careful monitoring with long-term use. 3
Apply sparingly to skin folds and intertriginous areas to minimize risk of atrophy, with close monitoring for adverse effects in these sensitive areas. 3
Consider topical calcineurin inhibitors (tacrolimus, pimecrolimus) as steroid-sparing agents, particularly useful for facial application. 3
Intralesional Injections
Dermatologic Applications
For alopecia areata, inject triamcinolone acetonide 5-10 mg/mL into affected areas. 3, 4
For lichen sclerosus with topical steroid-resistant areas, use intralesional triamcinolone 10-20 mg after excluding malignancy. 3, 4
For inflammatory nodulocystic acne, intralesional treatment flattens most acne nodules within 48 to 72 hours, though this is not recommended for patients with multiple acne lesions. 5
For nail psoriasis affecting the nail matrix and recurrent, severe, or treatment-refractory paronychia, the American Academy of Dermatology recommends intralesional triamcinolone acetonide. 3
Musculoskeletal Applications
For pes anserine bursa injections, use triamcinolone acetonide 5-10 mg/mL with total dose typically 20-40 mg, depending on the size of the affected area. 3
A volume of 0.05-0.1 mL per injection site is sufficient, administered just beneath the dermis in the upper subcutis. 3
Critical Safety Warning for Intralesional Use
- Intradermal triamcinolone acetonide for keloid scars in children should be used with extreme caution, as it can cause Cushing's syndrome and adrenal insufficiency requiring up to 12 months for recovery of intrinsic cortisol production. 6
Intravitreal Injections
Retinal Vein Occlusions
For central retinal vein occlusion (CRVO), the SCORE trial demonstrated that intravitreal triamcinolone 1 mg is preferred over 4 mg due to similar efficacy (27% vs 26% gained ≥3 lines of visual acuity at 1 year) but lower rates of cataract formation, cataract surgery, and elevated IOP. 2
Patients in the 1 mg corticosteroid group were significantly more likely to have substantial visual gain compared to observation (27% vs 7%), with results persisting up to 2 years. 2
For branch retinal vein occlusion (BRVO), approximately one-third of eyes in both the triamcinolone 1 mg and 4 mg groups gained ≥15 letters at 1 year, with mean gain of 4-5 letters in all groups including laser treatment. 2
The SCORE recommendations for BRVO favor considering macular grid laser treatment due to similar efficacy to triamcinolone but lower risk of cataract and elevated IOP. 2
Other Intraocular Conditions
Intravitreal triamcinolone shows best response in terms of visual acuity gain for intraretinal edematous diseases including diffuse diabetic macular edema, branch retinal vein occlusion, central retinal vein occlusion, and pseudophakic cystoid macular edema. 7
Visual acuity increased and intraocular inflammation decreased in eyes with various types of non-infectious uveitis including acute or chronic sympathetic ophthalmia and Adamantiadis-Behcet's disease. 7
Given in a dosage of approximately 20 mg to non-vitrectomized eyes, the duration of effect and side-effects is 6-9 months. 7
Intranasal Formulations
Allergic Rhinitis Dosing
For allergic rhinitis, intranasal triamcinolone dosing is age-stratified: 1 spray per nostril daily for ages 2-5 years, 2 sprays per nostril daily for ages 6-11 years, and 2 sprays per nostril 1-2 times daily for ages ≥12 years. 4
Once-daily triamcinolone acetonide 110-220 mcg reduces symptoms within the first day of administration, with dosage reduction from 220 to 110 mcg/day possible once symptoms are controlled without loss of effect. 8
Triamcinolone acetonide 220 mcg/day was significantly more effective at reducing nasal symptoms than oral antihistamines loratadine and astemizole (both 10 mg daily), with equal effectiveness for associated ocular symptoms. 8
Safety Profile for Intranasal Use
Nasally administered triamcinolone acetonide is not significantly absorbed into systemic circulation and does not suppress HPA axis function at therapeutic dosages. 8
Headache and epistaxis were the only adverse events considered possibly or probably related to aerosol therapy in a 1-year study (110-440 mcg/day). 8
Systemic/Intramuscular Use
Atopic Dermatitis
- For atopic dermatitis, the American Academy of Dermatology advises against chronic use due to risk of rebound flares, recommending a dosage range of 0.5-1.0 mg/kg with a tapering schedule to prevent adrenal suppression if used as transitional therapy in severe cases. 4
Current Practice Patterns
- Only 55% of US dermatologists report feeling comfortable using intramuscular triamcinolone for steroid-responsive dermatoses, compared to 90.4% for oral corticosteroids, with 59.2% not preferring intramuscular over oral routes when both are indicated. 9
Monitoring and Adverse Effects
Common Adverse Effects by Route
Topical:
- Local skin adverse effects include skin atrophy, striae, folliculitis, telangiectasia, purpura, and pigmentary changes. 3, 5
- May exacerbate acne, rosacea, perioral dermatitis, or tinea infections, with risk of rebound flares upon abrupt withdrawal. 3, 5
Intravitreal:
- Secondary ocular hypertension occurs in approximately 40% of eyes injected, along with cataractogenesis, and risk of infectious and non-infectious endophthalmitis. 7
Systemic/Prolonged Use:
- HPA axis suppression, growth suppression in children, hypertension, glucose intolerance, and decreased bone density. 4
Monitoring Recommendations
For long-term administration, monitor blood pressure, consider ophthalmologic examination, evaluate for HPA axis suppression, and track growth velocity in children. 4
Regular follow-up to assess for potential adverse effects of long-term topical use, including skin atrophy, telangiectasia, and pigmentary changes. 3
Contraindications and Precautions
Contraindicated in patients with hypersensitivity to triamcinolone acetonide or any components of the formulation. 4, 5
Use with caution in patients with diabetes, heart failure, or severe hypertension. 5
Caution in patients with HIV who may absorb steroids at a higher rate. 4
Avoid use at sites of active infections such as impetigo or herpes. 5
Not recommended for extensive plaque psoriasis, pustular psoriasis, or erythrodermic psoriasis. 5