What is the procedure for using Kenalog (triamcinolone acetonide) injections to treat acne lesions in adults?

Kenalog (Triamcinolone Acetonide) Intralesional Injection for Acne Lesions in Adults

For inflammatory nodular or cystic acne lesions in adults, inject triamcinolone acetonide at a concentration of 2.5-5 mg/mL (diluted from 10 mg/mL stock with sterile normal saline) using a volume of 0.05 mL or less, injected into the center of the lesion at mid-dermal depth. 1

Indications and Patient Selection

• Use intralesional triamcinolone as an adjuvant therapy for occasional or particularly stubborn inflammatory nodules or cysts, not as a primary treatment strategy for patients with multiple lesions 1
• Consider this intervention for patients at risk of acne scarring or those requiring rapid improvement in inflammation and pain 1
• This treatment flattens most acne nodules within 48-72 hours, making it ideal for urgent cosmetic concerns 1

Preparation and Concentration

• Start with triamcinolone acetonide 10 mg/mL stock solution and dilute with sterile normal saline to 2.5-5 mg/mL 1
• The most commonly used concentration among dermatologists is 2.5 mg/mL (used by 52.5% of practitioners), which minimizes atrophy risk while maintaining efficacy 2
• Lower concentrations (2.5-3.3 mg/mL) minimize the risk of local adverse effects including atrophy, pigmentary changes, and telangiectasias 1

Injection Technique

• Inject 0.05 mL volume per lesion (the most frequently used volume among experienced dermatologists) 2
• Target the center of the lesion at mid-dermal depth, which is the approach used by 61.6% of surveyed dermatologists 2
• Use a small gauge needle (typically 30-gauge) to minimize discomfort and tissue trauma 3
• Inject slowly to avoid blanching of the skin, which indicates excessive volume or superficial placement 3

Contraindications - Screen Before Injection

• Do not inject at sites of active infections such as impetigo or herpes 1
• Avoid in patients with previous hypersensitivity to triamcinolone or benzyl alcohol (the preservative) 1
• Large or extensive injections should be avoided in patients with active tuberculosis or systemic fungal infection 1
• Exercise caution in patients with uncontrolled diabetes, heart failure, or severe hypertension 1

Patient Counseling on Adverse Effects

• Counsel patients before every injection about the potential for hypopigmentation and atrophy (50.5% of dermatologists do this routinely) 2
• Local overdose or superficial injection can result in dermal atrophy, pigmentary changes, telangiectasias, and hypertrichosis 1
• When atrophy occurs, it is long-lasting (over 6 months in 48.4% of cases), though the overall incidence is extremely low (less than 1% of patients) 2
• Rare complications include sterile abscess formation, contact allergic dermatitis from benzyl alcohol, and granulomatous reactions 1, 4

Critical Pitfalls to Avoid

• Never use intralesional corticosteroids as monotherapy for widespread acne - this is only effective for occasional stubborn lesions 1
• Avoid injecting too superficially or using excessive volume, as this dramatically increases atrophy risk 1, 2
• Do not use concentrations higher than 5 mg/mL for facial lesions to minimize cosmetically significant atrophy 1
• Repeated injections at the same site can suppress the hypothalamic-pituitary-adrenal axis, so limit frequency 1

Emerging Evidence on Self-Administration

• Recent data suggests that patient self-administered intralesional triamcinolone using injection assistance devices shows comparable safety and efficacy to provider-administered injections, with no adverse events reported 5
• Higher concentration (0.2% vs 0.1%) may provide improved lesion resolution for more severe inflammatory lesions when self-administered 5