What are the indications for Kenalog (triamcinolone)?

Indications for Kenalog (Triamcinolone)

Kenalog (triamcinolone acetonide) is FDA-approved for a broad range of inflammatory and immune-mediated conditions via intramuscular and intra-articular routes, with specific dermatologic and rheumatologic applications supported by major society guidelines. 1

FDA-Approved Indications (Intramuscular Route)

The FDA label provides comprehensive approved uses when oral therapy is not feasible 1:

Allergic Conditions

• Severe or incapacitating allergic conditions intractable to conventional treatment, including asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, serum sickness, and transfusion reactions 1

Dermatologic Diseases

• Bullous dermatitis herpetiformis, exfoliative erythroderma, mycosis fungoides, pemphigus, and severe erythema multiforme (Stevens-Johnson syndrome) 1

Endocrine Disorders

• Primary or secondary adrenocortical insufficiency (as adjunct to hydrocortisone/cortisone with mineralocorticoids), congenital adrenal hyperplasia, hypercalcemia associated with cancer, and nonsuppurative thyroiditis 1

Gastrointestinal Diseases

• Regional enteritis and ulcerative colitis during critical disease periods 1

Hematologic Disorders

• Acquired (autoimmune) hemolytic anemia, Diamond-Blackfan anemia, pure red cell aplasia, and selected cases of secondary thrombocytopenia 1

Rheumatic Disorders

• Acute gouty arthritis, acute rheumatic carditis, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis (including juvenile rheumatoid arthritis), dermatomyositis, polymyositis, and systemic lupus erythematosus 1

Respiratory Diseases

• Berylliosis, fulminating or disseminated pulmonary tuberculosis (with appropriate antituberculous chemotherapy), idiopathic eosinophilic pneumonias, and symptomatic sarcoidosis 1

Neurologic Conditions

• Acute exacerbations of multiple sclerosis and cerebral edema associated with primary or metastatic brain tumor or craniotomy 1

Other Indications

• Trichinosis with neurologic or myocardial involvement, tuberculous meningitis with subarachnoid block (with appropriate antituberculous chemotherapy), palliative management of leukemias and lymphomas, sympathetic ophthalmia, temporal arteritis, uveitis, and nephrotic syndrome 1

FDA-Approved Indications (Intra-Articular/Soft Tissue Route)

For intra-articular or soft tissue administration, Kenalog is indicated as adjunctive therapy for acute episodes or exacerbations of: 1

• Acute gouty arthritis 1
• Acute and subacute bursitis 1
• Acute nonspecific tenosynovitis 1
• Epicondylitis 1
• Rheumatoid arthritis 1
• Synovitis of osteoarthritis 1

Guideline-Supported Dermatologic Indications

Acne Management

The American Academy of Dermatology recommends intralesional triamcinolone acetonide specifically for inflammatory nodulocystic acne and acne keloidalis. 2, 3

• Dosing for nodular acne: 10 mg/mL (may be diluted to 5 or 3.3 mg/mL with sterile normal saline) injected directly into inflammatory nodules 2, 3
• Dosing for acne keloidalis: Inject into inflammatory follicular lesions 2, 3
• Dosing for hypertrophic scars/keloids: Use triamcinolone acetonide-40 formulation 2, 3
• Expected response: Flattens most acne nodules within 48-72 hours 2, 3
• Important limitation: Efficacious for occasional or particularly stubborn cystic lesions but NOT an effective strategy for patients with multiple lesions 2, 3

Guideline-Supported Rheumatologic Indications

Juvenile Idiopathic Arthritis (JIA)

The American College of Rheumatology strongly recommends intra-articular glucocorticoids as part of initial therapy for active oligoarthritis, with triamcinolone hexacetonide being the preferred agent over triamcinolone acetonide. 2, 3

• Triamcinolone hexacetonide provides more durable clinical responses than triamcinolone acetonide based on randomized trials and large observational studies 2, 3
• For polyarticular JIA, use as adjunct therapy when arthritis prevents ambulation or interferes with important daily activities 3
• Note: Triamcinolone hexacetonide was unavailable in the US for several years but the FDA has recently allowed importation specifically for joint injections in JIA patients 2

Acute Gout

For acute gout involving 1-2 large joints, the American College of Rheumatology recommends intra-articular corticosteroids as an appropriate option, with dosing based on joint size. 3

Osteoarthritis

• Intra-articular triamcinolone is used for symptomatic relief in knee, hip, hand, and foot osteoarthritis 2
• Ultrasound guidance improves injection accuracy (95.5% vs 77.2% blind injection) and clinical outcomes, with lower pain and reinjection rates 2
• Presence of synovitis on ultrasound significantly predicts better response to intra-articular methylprednisolone in hip osteoarthritis 2

Critical Contraindications

The American Academy of Dermatology identifies absolute contraindications for intralesional use: 2, 3

• Active infections at injection site (impetigo, herpes) 2, 3
• Previous hypersensitivity to triamcinolone 2, 3
• Active tuberculosis or systemic fungal infection (for large injections) 2, 3
• Extensive plaque psoriasis, pustular psoriasis, or erythrodermic psoriasis 2, 3
• Active peptic ulcer disease 2, 3
• Uncontrolled diabetes, heart failure, or severe hypertension 2, 3
• Severe depression or psychosis 2, 3

Important Safety Considerations

Local Adverse Effects

Local overdose can result in atrophy, pigmentary changes, telangiectasias, and hypertrichosis. 2, 3

• Subcutaneous atrophy is relatively frequent yet underappreciated, occurring more commonly in young women and girls 4
• Although often reversible, long-term disfigurement is well documented 4
• Granulomatous foreign body reactions to intralesional triamcinolone have been reported 5

Systemic Adverse Effects

• Repeated injections can suppress the hypothalamic-pituitary-adrenal axis 2, 3
• Monitor for infections, impaired wound healing, sterile abscess, and steroid acne 2, 3
• Anaphylaxis, angioedema, and urticaria are possible 2

Postinjection Flare

• Acute postinjection flares can occur, ranging from mild joint effusion to disabling pain 6
• Severe reactions can mimic septic arthritis with acute crystal-induced inflammatory response, though this is rare 6
• Patients should be informed of this potential side effect before injection 6

Pediatric Considerations

The American Academy of Pediatrics advises against long-term continuous use in children due to risk of skin atrophy, growth suppression, and HPA axis suppression. 3

• Use the minimum effective amount 3
• Consider periodic breaks in treatment 3

Clinical Pearls

• The unique long-term efficacy of intramuscular triamcinolone acetonide may be attributed to differing binding mechanisms, low solubility in blood, low renal clearance rate, and slow absorption from the injection site 7
• For recurrent dermatologic lesions in children, triamcinolone hexacetonide (5-10 mg/mL) provides more complete and longer duration of clinical response compared to triamcinolone acetonide 3
• Triamcinolone hexacetonide is the most effective intra-articular corticosteroid for relieving local symptoms of inflammation in early rheumatoid arthritis 3