Is a corticosteroid injection appropriate for a 17‑year‑old adolescent?

Can Corticosteroid Injections Be Used in a 17-Year-Old?

Yes, corticosteroid injections are appropriate for a 17-year-old adolescent, with specific considerations based on the anatomic site and clinical indication.

General Safety and Efficacy in Adolescents

• Intra-articular corticosteroid injections are conditionally recommended for adolescents with juvenile idiopathic arthritis (JIA) as part of initial therapy for oligoarticular disease. 1

• Triamcinolone hexacetonide is strongly recommended as the preferred agent for intra-articular injections over other corticosteroid formulations (e.g., triamcinolone acetonide) due to superior efficacy in achieving and maintaining remission. 1

• The efficacy and safety of corticosteroids in the pediatric population are well-established and similar to adult populations, with published evidence supporting use in patients >2 years of age for various inflammatory conditions. 2

Site-Specific Considerations

For Peripheral Joints (Knee, Shoulder, Elbow, Hip, Ankle, Wrist)

• Intra-articular glucocorticoid injections are conditionally recommended as adjunct therapy for active arthritis in adolescents. 1, 3

• Recommended doses: 20-40 mg triamcinolone (or methylprednisolone equivalent) depending on joint size, with evidence showing 20 mg is as effective as 40 mg for shoulder injections and 40 mg as effective as 80 mg for knee injections. 4

• Ultrasound guidance increases injection accuracy and reduces procedural pain. 4

For Temporomandibular Joint (TMJ)

• In skeletally mature adolescents (typically ≥17 years), intra-articular corticosteroid injection may be indicated for active TMJ arthritis with orofacial symptoms. 1, 5

• In skeletally immature patients, intra-articular glucocorticoids are NOT recommended as first-line management due to unique TMJ-specific adverse events including potential growth disturbances and mandibular asymmetry. 1, 5

• At age 17, most patients are approaching skeletal maturity, making the risk-benefit profile more favorable than in younger children. 1

• Repeated glucocorticoid injections in the TMJ are not recommended regardless of skeletal maturity. 1

For Hidradenitis Suppurativa (HS)

• Intralesional steroids are suggested for acute, localized flares in pediatric patients with HS, taking into consideration the patient's age and procedural tolerance. 1

• Appropriate pain management and distraction techniques should be used. 1

For Infantile Hemangiomas

• Intralesional corticosteroid injection (triamcinolone and/or betamethasone) may be recommended for focal, bulky hemangiomas during proliferation or in critical anatomic locations. 1

Critical Safety Considerations and Adverse Events

Systemic Effects

• A single intra-articular corticosteroid injection can cause adrenal suppression lasting up to 14 days, with 9 of 10 young athletes developing adrenal insufficiency within 2 days of injection. 6

• Blood glucose elevation may occur, particularly relevant in patients with diabetes or insulin resistance. 4

• Reduction in bone mineral density with repeated injections. 4

Local Effects

• Postinjection flare, facial flushing, and skin/fat atrophy are the most common side effects. 7

• Local complications may include dermal atrophy and pigmentary changes, particularly with superficial injections. 1

• Risk of postoperative joint infection if surgery occurs within months of injection. 4

Monitoring Requirements

• Pediatric patients should be carefully observed with frequent measurements of blood pressure, weight, height, intraocular pressure, and clinical evaluation for infection, psychosocial disturbances, thromboembolism, peptic ulcers, cataracts, and osteoporosis. 2

• Growth velocity should be monitored as it may be a more sensitive indicator of systemic corticosteroid exposure than HPA axis function tests. 2

Practical Administration Guidelines

• Appropriate pain management and distraction techniques should be used for adolescent patients undergoing injection procedures. 1

• Injections should be performed with proper technique, ideally with ultrasound guidance for improved accuracy. 4

• Patients should be informed about the risk of adrenal insufficiency and instructed to report any symptoms (fatigue, weakness, dizziness) to their physician, especially if exposed to physical stress or trauma. 6

When NOT to Use Corticosteroid Injections

• Strongly recommend against chronic low-dose oral glucocorticoids irrespective of disease activity in adolescents with JIA. 1

• Oral glucocorticoids should only be used as short-term bridging therapy (<3 months) during initiation or escalation of disease-modifying therapy. 1, 3

• Repeated intra-articular injections should be limited; evidence supports safety for repeated use every 3 months for up to 2 years in peripheral joints, but TMJ injections should not be repeated. 1, 7

Common Pitfalls to Avoid

• Do not use corticosteroid injections as monotherapy; they should be adjunctive to disease-modifying treatment in inflammatory conditions. 1, 3

• Do not inject the TMJ in skeletally immature patients as first-line therapy due to growth disturbance risk. 1, 5

• Do not dismiss the risk of adrenal suppression even after a single injection, particularly if the patient may face physical stress. 6

• Do not use doses higher than necessary; lower doses (20 mg vs 40 mg triamcinolone for shoulder) are equally effective with potentially fewer adverse effects. 4