Intralesional Triamcinolone Acetonide for Keloid Management

Dosage and Concentration

• The American Academy of Dermatology recommends using triamcinolone acetonide 40 mg/mL (TAC‑40) injected intralesionally into keloid tissue. 1
• TAC‑40 (40 mg/mL) is the standard concentration for both keloids and hypertrophic scars. 1
• For smaller or thinner lesions, lower concentrations of 5–10 mg/mL may be employed to lessen the risk of skin atrophy. 2
• In cases of localized non‑responding or very thick lesions, concentrations up to 20 mg/mL can be considered. 3

Injection Technique

• Inject 0.05–0.1 mL per site; this volume treats approximately a 0.5 cm diameter area of the lesion. 2
• The needle should be placed just beneath the dermis, within the upper subcutis, to maximize local effect and limit systemic absorption. 2
• Using lower concentrations (5–10 mg/mL) together with the small‑volume technique (0.05–0.1 mL per site) reduces the incidence of steroid‑induced atrophy. 4

Schedule and Duration

• Injections are administered every 3–4 weeks. 3
• An alternative regimen of monthly injections may be used until an adequate clinical response is achieved. 2
• Treatment should continue until the maximum therapeutic response is observed. 2
• The beneficial effect of a single treatment course typically persists for about 9 months. 2

Efficacy and Response

• Clinical improvement is generally seen after repeated sessions; multiple injections are usually required for optimal flattening of keloids. 2

Safety and Adverse Effects

• Skin atrophy is the most consistent adverse effect, especially when higher steroid concentrations are used. 2
• Pigmentary alterations and hypertrichosis may occur following injection. 1
• Pain at the injection site is common and often limits the number of injections that can be given in one session. 2
• Injecting just beneath the dermis (rather than deeper) helps to optimize efficacy while minimizing systemic absorption and related complications. 2

Contraindications

• Active infection at the injection site (e.g., impetigo, herpes). 1
• Known hypersensitivity to triamcinolone. 1
• Active tuberculosis or systemic fungal infection when large‑volume injections are planned. 1
• Uncontrolled systemic conditions such as diabetes, heart failure, or severe hypertension. 1

Practical Administration

• Multiple injection sites may be treated in a single visit; patient discomfort is the primary limiting factor. 2
• Needle‑free delivery systems (e.g., Dermajet) are acceptable alternatives to conventional syringes. 2
• The total injection volume should be adjusted according to the size of the keloid and the area involved. 3
• For best outcomes, ensure an even distribution of the steroid throughout the entire keloid tissue. 5

Practical Administration of Intralesional Triamcinolone Acetonide for Keloid Treatment

Needle Selection

• Use 25–27 gauge needles for intralesional injections to achieve adequate tissue penetration while minimizing patient discomfort 6.

Pain Mitigation

• Apply a topical anesthetic (e.g., EMLA cream) before injection to reduce injection‑related pain and improve patient tolerance 6.

Systemic Adverse Effects of Intralesional Triamcinolone Acetonide

Systemic Absorption and Transient Cushingoid Features

• In patients receiving intralesional triamcinolone acetonide, especially when larger total doses or multiple injection sites are used, systemic absorption can occur and may lead to transient Cushingoid‑type skin changes. 7

Adrenal Suppression with High‑Dose Therapy

• Adrenal axis suppression has been reported, albeit infrequently, in individuals treated with high cumulative doses of intralesional triamcinolone acetonide exceeding 4 mg per kilogram of body weight. 7

Intralesional Triamcinolone for Periauricular Keloids – Evidence‑Based Recommendations

Pain Management

• In patients undergoing extensive intralesional triamcinolone therapy for periauricular keloids, the use of procedural sedation or general anesthesia can be considered to improve tolerability and allow completion of the treatment course. 8

Safety Precautions

• When intralesional triamcinolone is combined with adjunctive modalities such as heat therapy, injections should not be placed over delicate anatomical structures—including the eyelids, tip of the nose, lips, mucous membranes, cartilaginous areas, or superficial nerves—to avoid local tissue injury. 8

Efficacy Outcomes

• Repeated intralesional triamcinolone sessions in patients with periauricular keloids lead to clinically meaningful improvements, demonstrated by reductions in physician‑assessed erythema, edema, suppuration, and overall lesion size. 9
• Patients experience a rapid decrease in pain, with visual analogue scale (VAS) scores showing significant improvement as early as one day after each injection. 9