Topical
	Corticosteroids
	Retinoids
	Imiquimod
	Mederma
	Vitamin E
Injectable
	Corticosteroids
	Interferons
	5-Fluorouracil
	Verapamil
	Bleomycin
Surgical
	Surgical debulking or excision
	Laser debulking or excision
	Radio-frequency electrosurgery planing
Physical
	Laser therapy
	Radiation therapy
	Compression therapy
	Silicone sheeting
	Cryotherapy
	Fractional laser ablation

Source: Adapted from Baldwin H. Keloid management (Chap 44). In: Robinson JK, et al., eds., Surgery of the Skin: Procedural Dermatology. Philadelphia: Elsevier; 2005.

Steroid Strength

Once the appropriate-strength steroid for the injection has been chosen, the standard-strength preparations may need to be diluted to produce the desired strength. Recommendations for steroid strength and needle size are listed in Table 16-2. Triamcinolone acetonide suspension is available in two strengths: 10 and 40 mg/mL. It is essential to dilute the steroid, especially for injections of cystic acne of the face. Dilution may be done for each patient just before giving the injection or may be done in a sterile vial of saline and saved for the injection of multiple patients over time. Unless giving intralesional injections frequently, it is probably better to perform the dilution for each patient. Diluted vials can lose their potency and have a higher theoretical risk of contamination.

TABLE 16-2 Recommended Steroid Strength and Needle Size for Intralesional Injections

Lesions	Triamcinolone (mg/mL)^a	Needle size (gauge)
Acne cysts (face and neck)	1–2	30
Acne cysts (trunk)	2–3.3	27–30
Acne keloidalis nuchae	5–10	25–27
Alopecia areata	5 for scalp and 3.3 for face	27
Discoid lupus	2.5–5	27
Granuloma annulare	5	27
Hidradenitis suppurativa	3.3–5	27
Hypertrophic scars	10–20	25–27
Keloids	10–40	25–27
Lichen simplex chronicus	2.5–5	27
Prurigo nodularis	5	27
Psoriasis	2.5–5	27
Sarcoidosis	2.5 on face and 5 on body	27–30

^a For lesions on the face, always start with lower concentrations.

Triamcinolone is most often diluted with sterile normal saline for injection. Alternatives include sterile water or 1 or 2% lidocaine (without epinephrine). The isotonicity and neutral pH of sterile saline makes it the preferred solution for dilution.

A 1-mL Luer-Lok or tuberculin syringe is useful for making a single dilution before injection. To create a 2 mg/mL concentration, draw 0.4 mL of sterile saline into a 1-mL syringe and add 0.1 mL of 10 mg/mL triamcinolone. Other dilutions are listed in Table 16-3. Turn the syringe upside down a number of times to mix the new suspension. It is recommended that the saline be drawn up first because it is more acceptable to get a little saline into the triamcinolone than vice versa. Recommended needle sizes by lesion are listed in Table 16-2.

TABLE 16-3 Common Triamcinolone Dilutions in a 1-mL Syringe

Concentration (mg/mL)	mL of Triamcinolone 10 mg/mL	mL of Sterile Saline for Injection
1	0.1	0.8
2	0.1	0.4
2.5	0.2	0.6
3.3	0.2	0.4
5	0.3	0.3

A disadvantage of using the MadaJet is that approximately 1 mL of liquid is needed to prime it. Steroid is relatively inexpensive so this is a minor problem.

Treating Specific Lesions

Acne Nodules and Cysts

Patients with tender large nodulocystic lesions can expect to get symptomatic relief within 24 hours of an intralesional injection. The lesion will flatten within 2 to 3 days with an effective injection.¹ Although this should not be the primary treatment of acne, it can provide short-term relief while employing more long-term treatment regimens.

One small study evaluated the effectiveness of intralesional injections of steroids in the therapy of nodulocystic acne.¹ They found that 0.63 mg/mL of triamcinolone was as effective as 2.5 mg/mL.¹ Betamethasone injections were no better than saline controls.¹ One review article states that concentrations of 3.3 and 5 mg/mL of triamcinolone are standard dilutions for intralesional acne injections.²

We recommend using 1 to 3.3 mg/mL of triamcinolone for nodulocystic acne depending on the location of the lesions and the experience of the clinician and patient. Triamcinolone can be injected with minimal pain using a 30-gauge needle on a 1-mL syringe at a 45- to 90-degree angle with the skin (Figure 16-3).

FIGURE 16-3 Nodulocystic acne being injected with dilute triamcinolone.

(Copyright Richard P. Usatine, MD.)

For acne cysts on the face, it is safer to use 1 to 2 mg/mL to make sure that atrophy does not occur. On the trunk consider using 2 to 3.3 mg/mL of triamcinolone. Enough suspension should be injected to see and feel the cyst become distended, but no more than 0.1 mL is needed for any one cyst. One injection site per acne cyst should be adequate. If the cyst is large and soft, do not inject more volume because that can lead to atrophy. If there is a lot of purulent material inside the cyst, a quick incision and drainage (with lidocaine and a No. 11 scalpel) before injecting the steroid may be helpful.

Acne Keloidalis Nuchae

Acne keloidalis (Figure 16-4) occurs on the posterior neck most commonly in men with highly pigmented skin. It is an inflammatory condition that is exacerbated by shaving the back of the neck. It has features of acne and folliculitis. Over time keloidal-type scars occur and can become very large. Treatment and prevention include not cutting the hair too short and using topical steroids and topical retinoids. Tender and painful keloidal nodules can be injected with triamcinolone for some relief. Concentrations of 5 to 10 mg/mL can be used. The heavier the fibrosis and scarring, the larger the needle needed to inject the lesion.

FIGURE 16-4 Acne keloidalis nuchae being treated with intralesional steroids.

(Copyright Richard P. Usatine, MD.)

Alopecia Areata (Figure 16-5)

Although a recent Cochrane review on the treatment of alopecia areata (Figure 16-5) found no RCTs on the use of intralesional steroids (and many other treatments), they did acknowledge that this is a commonly used treatment for alopecia areata.³ Considering the possibility of spontaneous remission in the early stages of the disease, it is reasonable to reassure the patient and recommend tincture of time. However, many patients are seeking an active treatment. Intralesional steroid for alopecia areata is a well-accepted standard treatment and often gives patients hope that they will regain their hair. Recommended concentrations of triamcinolone range from 5 to 10 mg/mL for the scalp, but the higher concentrations often cause scalp atrophy. Therefore we recommend using 5 mg/mL of triamcinolone for the scalp. Alopecia areata can affect the eyebrows and the beard. For those regions it is safer to stick with a lower concentration of triamcinolone such as 3.3 mg/mL. A long 27-gauge needle (1.25 to 1.5 inches) will allow for treatment of larger areas with fewer injections per site.