How to Give Kenalog Injections
Kenalog (triamcinolone acetonide) should be administered using proper technique with concentration and volume tailored to the specific anatomical site and condition being treated, with the 4-mm needle being the safest option for subcutaneous injections and specific concentrations ranging from 2.5-40 mg/mL depending on the indication.
Concentration Selection by Indication
Dermatologic Conditions
- For nodular acne: Use triamcinolone acetonide 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 triamcinolone acetonide 40 mg/mL 1
- For psoriasis plaques: Use triamcinolone acetonide up to 20 mg/mL every 3-4 weeks 1
- For alopecia areata: Use triamcinolone acetonide 5-10 mg/mL injected into affected areas 1, 2
- For nail psoriasis affecting the nail matrix: Use intralesional triamcinolone acetonide 5-10 mg/mL 1
Musculoskeletal Conditions
- For shoulder injections: Administer 40 mg of triamcinolone acetonide into either the glenohumeral joint or subacromial space 1
- For trigger finger: Use 20 mg dose for optimal clinical effectiveness, as this dosage shows significantly higher success rates (79% effective at 6 months) compared to 5 mg (52%) or 10 mg (62%) doses 3
- For juvenile idiopathic arthritis: Strongly prefer triamcinolone hexacetonide over triamcinolone acetonide for intra-articular injections due to more durable clinical responses 4
Other Indications
- For esophageal strictures: Inject 0.5 mL aliquots of triamcinolone 40 mg/mL into four quadrants immediately before bougie dilatation 1
Injection Technique
Needle Selection and Depth
- Use a 4-mm needle for subcutaneous injections as it is the safest option for all patients regardless of age, sex, ethnicity, or BMI, with minimal risk of intramuscular injection 4
- Insert the 4-mm needle perpendicularly to the skin (at 90 degrees), not at an angle 4
- For intralesional dermatologic injections: Inject just beneath the dermis in the upper subcutis 1
- For esophageal strictures: Use a 4 mm-long, 23-gauge needle and leave it in place for at least 1 minute to minimize leakage 1
Volume Guidelines
- For small dermatologic lesions: Use 0.05-0.1 mL per injection site, which produces localized therapeutic effect 1, 5
- For acne lesions: The most commonly used volume is 0.05 mL, with 61.6% of dermatologists injecting into the center of the lesion 5
- Maximum dose per injection site: Should not exceed 150 mg 1
Skinfold Technique
- Very young children (≤6 years) and very thin adults: Lift a skinfold and insert the 4-mm needle perpendicularly into it 4
- Other patients: May inject using the 4-mm needle without lifting a skinfold 4
Site Preparation
Pre-Injection Assessment
- Inspect the injection site before administration: Injections should only be given into clean sites using clean hands 4
- Never inject into sites with: Lipohypertrophy, inflammation, edema, ulceration, infection, active impetigo, or herpes 4, 1
- Disinfection requirements: Usually not required in noninstitutional settings (homes, restaurants, workplaces), but mandatory in hospitals and nursing homes 4
- If alcohol is used for disinfection: Allow it to dry completely before giving the injection 4
Frequency of Administration
- Most dermatologic conditions: Administer every 3-4 weeks as needed 1
- Acute gout: A single injection is often sufficient 1
- Esophageal strictures: Administer as needed based on symptom recurrence (typically lasts up to 1 year) 1
Critical Contraindications and Precautions
Absolute Contraindications
- Previous hypersensitivity to triamcinolone acetonide or any formulation components 1, 2
- Active infection at injection site (impetigo, herpes) 1
- Active tuberculosis or systemic fungal infections (for large injections) 1
Relative Contraindications and Cautions
- Uncontrolled diabetes, heart failure, or severe hypertension: Use with caution 1
- HIV patients: May absorb steroids at a higher rate 2
- Facial and intertriginous areas: Higher risk for developing adverse effects 1
Monitoring for Adverse Effects
Local Adverse Effects
- Monitor for skin atrophy: This is a consistent, dose-dependent side effect that can be long-lasting (over 6 months in 48.4% of cases when it occurs) 1, 5
- Watch for pigmentary changes, telangiectasias, and hypertrichosis: These are common local effects with repeated injections 1
- Facial skin is particularly vulnerable: Thinner facial skin is more prone to steroid-induced atrophy than other body sites 6
Systemic Adverse Effects
- Hypothalamic-pituitary-adrenal axis suppression: Can occur with repeated injections 1, 2
- For long-term administration: Monitor blood pressure, consider ophthalmologic examination, evaluate for HPA axis suppression, and track growth velocity in children 2
Acute Complications
- Postinjection flare: Can occur 2 hours after injection with severe swelling and intense pain mimicking septic arthritis, caused by acute crystal-induced inflammatory response 7
- Incidence of adverse events: Less than 1% of patients return for adverse events in most practices 5
Available Formulations
Kenalog-40
- 40 mg/mL concentration available in 1 mL single-dose vials, 5 mL multiple-dose vials, and 10 mL multiple-dose vials 8
Kenalog-80
- 80 mg/mL concentration available in 1 mL single-dose vials and 5 mL multiple-dose vials 8
Storage Requirements
- Store at controlled room temperature 20°C to 25°C (68°F to 77°F) 8
- Protect from temperatures below 20°C (68°F) and from light 8
- Do not refrigerate 8
- Once opened: Multiple-dose vials may be stored for maximum of 28 days at 15°C to 25°C (59°F to 77°F) 8
Patient Counseling
- Inform patients about potential hypopigmentation and atrophy: 50.5% of dermatologists counsel patients on these adverse effects before every injection 5
- Explain the risk of postinjection flare: Though rare, patients should be aware of this potential acute complication 7
- Discuss duration of effect: Varies by condition and site, typically requiring repeat injections every 3-4 weeks for maintenance 1