What are the indications for Kenalog (triamcinolone) shots?

Indications for Kenalog (Triamcinolone) Injections

Kenalog injections are indicated for intra-articular treatment of inflammatory joint conditions (particularly acute monoarticular/oligoarticular arthritis, osteoarthritis flares, and juvenile idiopathic arthritis) and intramuscular administration for severe systemic inflammatory conditions when oral therapy is not feasible. 1

Intra-Articular Indications

Rheumatologic Conditions (Primary Use)

Acute Crystal-Induced Arthritis

• Glucocorticoid injections are particularly useful and safe for acute monoarticular or oligoarticular microcrystalline synovitis (gout and calcium pyrophosphate deposition disease). 2
• For acute gout involving 1-2 large joints, intra-articular corticosteroids are an appropriate first-line option, with dosing based on joint size. 3
• Triamcinolone acetonide 60 mg intramuscularly showed at least 50% clinical improvement in all patients with acute crystal arthritis within 14 days without significant side effects. 2

Juvenile Idiopathic Arthritis (JIA)

• Intra-articular glucocorticoids are strongly recommended as part of initial therapy for active oligoarthritis (≤4 joints involved). 2
• Triamcinolone hexacetonide is strongly recommended as the preferred agent over triamcinolone acetonide due to more durable clinical responses demonstrated in randomized trials. 2, 3
• For polyarticular JIA, use intra-articular glucocorticoids as adjunct therapy when arthritis prevents ambulation or interferes with important daily activities. 3

Osteoarthritis

• Indicated as adjunctive therapy for acute episodes or exacerbations in synovitis of osteoarthritis. 1
• Multiple studies demonstrate efficacy across knee, hip, hand, and foot osteoarthritis, though response varies by disease severity. 2
• Patients with ultrasonographic evidence of synovitis show significantly better response to intra-articular methylprednisolone than those without inflammatory features. 2
• Earlier radiographic stages (Kellgren-Lawrence grades 1-2) demonstrate better initial response compared to advanced disease (grades 3-4). 2

Other Rheumatic Disorders

• Acute gouty arthritis (as adjunctive short-term therapy). 1
• Rheumatoid arthritis, including juvenile rheumatoid arthritis (triamcinolone hexacetonide is most effective for relieving local inflammatory symptoms in early disease). 3, 1
• Acute and subacute bursitis. 1
• Acute nonspecific tenosynovitis. 1
• Epicondylitis. 1
• Psoriatic arthritis and ankylosing spondylitis. 1

Intramuscular Indications (When Oral Therapy Not Feasible)

Systemic Inflammatory Conditions

Allergic States

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

Dermatologic Diseases

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

Rheumatic Disorders

• Acute rheumatic carditis, dermatomyositis, polymyositis, systemic lupus erythematosus. 1
• For acute gout flares when oral medications cannot be used, intramuscular triamcinolone acetonide 60 mg is recommended as initial dose. 4

Endocrine Disorders

• Primary or secondary adrenocortical insufficiency (with mineralocorticoid supplementation), congenital adrenal hyperplasia, hypercalcemia associated with cancer, nonsuppurative thyroiditis. 1

Hematologic Disorders

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

Respiratory Diseases

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

Neurologic Conditions

• Acute exacerbations of multiple sclerosis, cerebral edema associated with primary or metastatic brain tumor or craniotomy, tuberculous meningitis with subarachnoid block. 1

Other Systemic Indications

• Gastrointestinal diseases (regional enteritis, ulcerative colitis during critical periods), ophthalmic diseases (sympathetic ophthalmia, temporal arteritis, uveitis unresponsive to topical corticosteroids), renal diseases (nephrotic syndrome), neoplastic diseases (palliative management of leukemias and lymphomas). 1

Intralesional Indications

Dermatologic Conditions

• Inflammatory nodulocystic acne: 10 mg/mL triamcinolone acetonide (may be diluted to 5 or 3.3 mg/mL) injected directly into nodular lesions, flattening most nodules within 48-72 hours. 3
• Acne keloidalis: inject into inflammatory follicular lesions. 3
• Hypertrophic scars and keloids: triamcinolone acetonide 40 mg/mL. 3
• Note: Intralesional triamcinolone is efficacious for occasional or particularly stubborn cystic lesions but NOT effective for patients with multiple lesions. 3

Critical Contraindications and Precautions

Absolute Contraindications

• Active infections at injection sites (impetigo, herpes). 3
• Previous hypersensitivity to triamcinolone. 3
• Active tuberculosis or systemic fungal infection (for systemic use). 3
• Extensive plaque psoriasis, pustular psoriasis, or erythrodermic psoriasis. 3

Relative Contraindications Requiring Caution

• Active peptic ulcer disease, uncontrolled diabetes, heart failure, severe hypertension, severe depression or psychosis. 3

Important Safety Warnings

• Postinjection flares can occur, ranging from mild effusion to severe disabling pain mimicking septic arthritis, typically presenting within 2 hours of injection. 5
• Local overdose of intralesional triamcinolone causes atrophy, pigmentary changes, telangiectasias, and hypertrichosis. 3
• Repeated corticosteroid administration increases risks of dysphoria, mood disorders, elevated blood glucose, fluid retention, and immunosuppression with increased infection risk. 4
• Long-term continuous use in children risks skin atrophy, growth suppression, and HPA axis suppression. 3

Technical Considerations

Imaging Guidance

• Ultrasound-guided injections demonstrate significantly higher accuracy (95-98%) compared to blind injections (77-78%) for knee triamcinolone administration. 2
• US-guided procedures result in lower pain, decreased reinjection rates, and better clinical outcomes, though at higher cost. 2

Formulation Selection

• For intra-articular use in JIA, triamcinolone hexacetonide provides more complete and longer duration of clinical response than triamcinolone acetonide. 2, 3
• For intralesional use in children with recurrent lesions, consider triamcinolone hexacetonide (5-10 mg/mL) over acetonide. 3