There are several cases and occasions wherein the administration of intralesional steroid injections is necessary. This particular steroid is known for its anti-inflammatory effect. The most common reasons for intralesional steroid injections are: Nail bed fungus, erythema and scaling of the toe nails, or onychomycosis. In this article, we will be talking about everything there is to know about intralesional steroid injections.
What is an intralesional steroid injection?
A corticosteroid, such as triamcinolone acetonide, is injected directly into a lesion on or immediately beneath the skin during an intralesional steroid injection.
In New Zealand, triamcinolone injection is marketed as Kenacort-A and comes in two strengths: 10 mg per ml (Kenacort-A 10) and 40 mg per ml (Kenacort-A 40). (Kenacort-A 40). In the United States, triamcinolone acetonide is sold as Kenalog. Celestone Chronodose (1 mL) betamethasone injectable is not available in New Zealand.
Short-acting corticosteroid formulations, such as dexamethasone or betamethasone acetate, are occasionally used in conjunction with triamcinolone.
What are intralesional steroids used for?
The following skin problems may benefit from an intralesional steroid injection:
- Alopecia areata (hair loss)
- Lupus erythematosus discoid
- Scar keloid/hypertrophic
- Annulare Granuloma
- Other granulomatous conditions include cutaneous sarcoidosis and granuloma faciale.
- Lichen planus hypertrophic
- Chronic Lichen Simplex (neurodermatitis)
- Psoriasis of the scalp
- Lipoidica necrobiosis
- Acne cysts (also known as nodulocystic acne) and inflammatory epidermoid cysts are two types of acne cysts.
- Small infantile hemorrhages
- Other inflammatory skin disorders that are localized.
What are the benefits of intralesional steroids?
Corticosteroids used intralesionally directly treat a cutaneous inflammatory condition. Unlike topical steroids, intralesional steroids:
- Bypass a thicker stratum corneum barrier
- Reduce the likelihood of epidermal atrophy (surface skin thinning)
- Deliver higher concentrations to the pathological site.
Other uses for triamcinolone acetonide injection
Triamcinolone injection is sometimes used systemically intramuscularly (rather than intralesionally) as an alternative to oral corticosteroids, for example, to treat seasonal hay fever or a persistent skin disorder such as atopic dermatitis or lichen planus.
Intramuscular dosages of 0.5-1 mg/kg body weight (40-80 mg for an average adult) are normal and can be repeated every 30 days for 3-6 months.
Injections of triamcinolone can also be used to treat tendonitis, arthritis, and synovitis.
What are the contraindications to intralesional steroid injection?
Intralesional steroids should not be administered at the location of an active skin infection (for example, impetigo or herpes simplex).
If there is a known triamcinolone allergy, they should not be utilized.
Systemic steroids are utilized when substantial doses of triamcinolone acetonide are administered as an alternative to oral steroids such as prednisone. These should be avoided in patients suffering from the following conditions:
- Tuberculosis active or systemic fungal infection
- Systemic steroids may destabilize psoriasis in patients with extensive plaque psoriasis, pustular psoriasis, or erythrodermic psoriasis.
- Peptic ulcer illness that is active
- Diabetes that is uncontrolled, heart failure, or severe hypertension
- Psychosis or severe depression
How are intralesional steroids administered to people?
After washing the injection site with alcohol or an antiseptic solution, intralesional triamcinolone is injected directly into the skin lesion using a small needle. To avoid leaving a dent in the skin, the injection should be intradermal rather than subcutaneous.
Depending on the lesion being treated, the initial dose per injection location will vary. In general, 0.1-0.2 mL per square centimetre of affected skin is injected. Normally, the total dose should not exceed 1-2 mL each dose. It should be done every 4-8 weeks.
The corticosteroid can be administered at full dose (for example, triamcinolone 10 mg/mL or 40 mg/mL) or diluted with normal saline or local anaesthesia. Typical triamcinolone intralesional injection regimens include:
- For a thick keloid scar, use 40 mg/mL.
- 10 mg/mL for a hypertrophic scar of moderate thickness
- 10 mg/ml into granuloma annulare or discoid lupus erythematosus
- 5 mg/ml into normal-thickness skin affected by alopecia areata.
While the lesions are active, the injections may be repeated monthly for a few months.
What are some intralesional steroid injection side effects that people should keep in mind?
The dangers and side effects of intralesional triamcinolone can be divided into two categories: immediate and delayed effects.
Early effects are typically self-limiting. They are as follows:
- Pain, bruising, and bleeding
- Contact dermatitis caused by the preservative benzyl alcohol
- Wound healing is hampered.
- Sterile abscess that may necessitate surgical draining.
Among the delayed negative effects are:
- Cutaneous and subcutaneous lipoatrophy (most common) – skin indentations or dimples surrounding injection sites many weeks after treatment; these may be permanent.
- White (leukoderma) or brown (postinflammatory pigmentation) marks at the injection site or spreading from the injection site; these may disappear or persist in the long term.
- Telangiectasia at the injection site, which can be treated with a laser or powerful pulsed light if necessary (IPL).
- Localized hypertrichosis; this gradually resolves.
- Steroid acne, whether localized or distant: steroids boost growth hormone, causing the sebaceous glands to produce more sebum. Steroid acne usually clears up once the steroid has been discontinued.
Systemic side effects of triamcinolone injections
Allergic responses are extremely uncommon and dose-independent. Local or generalized urticaria (wheal and flare) and, in more severe situations, anaphylaxis may occur.
Because the intralesional injection of localised skin illness is so modest, other systemic adverse effects of intralesional steroids are unlikely.
The following potentially dangerous problems have been recorded after receiving large dosages of triamcinolone acetonide intramuscularly.
- Heart: in susceptible patients, congestive heart failure, fluid retention, hypertension, and cardiac arrhythmias.
- Hormonal consequences include impaired glucose tolerance, Cushing syndrome, hirsutism, hypertrichosis, type 2 diabetes, menstrual abnormalities, adrenocortical and pituitary inactivity, and growth suppression in children.
- Aseptic necrosis of the hip or shoulder bones, calcinosis, osteoporosis and pathological fractures, muscular weakness, and tendon rupture are all examples of musculoskeletal disorders.
- Convulsions, despair, euphoria, brain swelling, sleeplessness, and mood changes are some of the neurologic/psychiatric symptoms.
- Glaucoma, cataracts, and rare cases of blindness associated with periocular injections affect the eyes.
Final Thoughts and Conclusion
Intralesional injections indeed have a lot of uses, and it can also be used as a treatment for various health issues that involve inflammation, including chronic pain and severe nerve damage. These injections can be done on any part of the body, with the most popular use being inside the knee.
While this particular steroid has quite a lot of benefits, it would be irresponsible to think that it has no side effects whatsoever. As a matter of fact, there are several negative side effects that people should keep an eye out for. But don’t worry, as long as you are responsible enough to know what you’re in for, and as long as your intralesional steroid injections are administered by the right people, then you have nothing to worry about.