What is the recommended dose and procedure for injecting Kenalog (triamcinolone acetonide) for localized skin inflammation?

Intralesional Kenalog for Localized Skin Inflammation: Dosing and Procedure

For localized inflammatory skin lesions, inject triamcinolone acetonide at 2.5-10 mg/mL concentration (typically 2.5 mg/mL for most inflammatory dermatoses), using 0.05-0.1 mL per injection site, administered just beneath the dermis in the upper subcutis, with repeat injections every 3-4 weeks as needed. 1, 2

Concentration Selection by Condition

The concentration should be tailored to the specific inflammatory condition:

• For inflammatory dermatoses (psoriasis plaques, lichen simplex chronicus, localized eczema): Use 2.5 mg/mL concentration, which is virtually 100% effective for small plaques and highly effective for localized dermatitis 2
• For nodular acne: Use 10 mg/mL, which may be diluted with sterile normal saline to 5 or 3.3 mg/mL 1
• For hypertrophic scars and keloids: Use 40 mg/mL 1
• For psoriasis (more resistant lesions): Use up to 20 mg/mL every 3-4 weeks 1

The American Academy of Dermatology recommends 5-10 mg/mL for most dermatologic conditions requiring intralesional therapy, with 0.05-0.1 mL per injection site producing localized therapeutic effect 1. A survey of 100 dermatologists found that 52.5% most commonly use 2.5 mg/mL concentration, with 42.3% using 0.05 mL as their standard volume 3.

Injection Technique

Depth and location are critical to avoid complications:

• Inject just beneath the dermis in the upper subcutis to achieve optimal therapeutic effect 1
• For most inflammatory lesions, inject into the center of the lesion (61.6% of surveyed dermatologists use this approach) 3
• Use strict aseptic technique and shake the vial before use to ensure uniform suspension 4
• Inject without delay after withdrawal to prevent settling in the syringe 4

The European Respiratory Society guidelines note that intralesional injections of triamcinolone acetonide may be more effective than topical preparations for limited skin lesions 5.

Maximum Safe Dosing

Total dose limits per treatment session:

• Maximum 150 mg per injection site 1
• For adults, doses up to 10 mg for smaller areas and up to 40 mg for larger areas have usually been sufficient 4
• Single injections into several sites, up to a total of 80 mg, have been safely administered 4
• Clinical studies indicate safe escalation from the usual 7.5 mg to 15 mg or even 20 mg for patients over 50 kg every 3-4 weeks 2

Treatment Frequency

Repeat injections every 3-4 weeks as needed until clinical resolution is achieved 1, 2. The American Academy of Dermatology recommends this interval for most conditions requiring intralesional corticosteroid therapy 1.

Critical Pitfalls and Contraindications

Absolute contraindications:

• Active infection at injection site (impetigo, herpes) 1
• Previous hypersensitivity to triamcinolone 1
• Active tuberculosis or systemic fungal infections (for large injections) 1

High-risk scenarios requiring caution:

• Facial and intertriginous areas are at higher risk for adverse effects including atrophy, telangiectasias, and pigmentary changes 1, 6
• Avoid injecting into surrounding tissues (particularly in the deltoid region) as this may lead to tissue atrophy 4
• Uncontrolled diabetes, heart failure, or severe hypertension warrant careful consideration 1

Monitoring for adverse effects:

• Local adverse effects include skin atrophy, pigmentary changes, telangiectasias, and hypertrichosis, which are dose-dependent and occur with repeated injections 1, 6
• Repeated injections can suppress the hypothalamic-pituitary-adrenal axis 1
• Atrophy, when it occurs, is long-lasting (over 6 months in 48.4% of cases), though the overall incidence is extremely low (less than 1% of patients in 88.8% of surveyed practices) 3
• Serum cortisol can be performed if concerns about adrenal suppression exist 2

Rare but serious complications:

• Granulomatous foreign body reactions to triamcinolone have been reported, though rarely 7
• Blindness from central artery occlusion has been reported with periorbital injections using older products and with intranasal use, but never with low-pressure injections at 2.5 mg/mL around the eyes 2

Patient Counseling

50.5% of dermatologists counsel patients on potential adverse effects of hypopigmentation and atrophy before every injection 3. This practice should be standard, particularly when treating facial or intertriginous areas where adverse effects are more common 1.