- Barbara M Mathes, MD, FACP, FAAD
Barbara M Mathes, MD, FACP, FAAD
- Clinical Associate, Dermatology
- University of Pennsylvania
- Secretary Treasurer
- American Academy of Dermatology
- Patrick C Alguire, MD, FACP
Patrick C Alguire, MD, FACP
- Senior Vice President Emeritus for Medical Education
- American College of Physicians
- Section Editor
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — General Dermatology
- Professor of Dermatology and Public Health
- University of Colorado School of Medicine
- Colorado School of Public Health
- Chief, Dermatology Service
- US Department of Veterans Affairs
- Eastern Colorado Health Care System
Intralesional injection, the direct delivery of medication percutaneously into skin lesions, has been an important part of dermatologic therapy since first introduced in 1961 [1,2]. Intralesional injections are effective for a wide range of indications, are easily performed, and are relatively safe.
The rationale for intralesional therapy is simple: to deliver a medication directly into a specific skin lesion to treat local tissues with minimal systemic effects. The skin also serves as a reservoir, allowing medication deposited in the dermis to be delivered over a period of time, resulting in prolonged therapy while avoiding or minimizing the adverse effects of systemic therapy.
The drugs primarily used for intralesional injections are corticosteroids, but in recent years bleomycin, 5-fluorouracil, methotrexate, chloroquine, and interferons also have been dispensed in this manner . This review is limited to the use of intralesional corticosteroids.
Triamcinolone acetonide and triamcinolone diacetate are the most widely used intralesional corticosteroids, although dexamethasone and betamethasone are used by some clinicians. Triamcinolone agents are available as micronized suspensions. Characteristics associated with micronized suspensions that make them desirable as intralesional corticosteroids are the small size of the corticosteroid particles, the persistence of small crystal size for extended periods of time, and that the process of gently shaking resuspends the drug evenly in solution. Small corticosteroid crystals are more efficiently delivered to the treatment site, thereby decreasing the total administered dose of the drug and reducing the risk of systemic side effects and skin atrophy. In addition, because micronized crystals of corticosteroid are in a depot form, the active ingredients are stored in the tissues and released over a period of weeks, making this type of corticosteroid delivery system well suited for the treatment of chronic inflammatory dermatoses . Examples of chronic inflammatory dermatoses that are particularly amenable to this type of extended action include psoriasis, lichen simplex chronicus, cutaneous lupus erythematosus, and prurigo nodularis.
INDICATIONS AND CONTRAINDICATIONS
Indications for intralesional corticosteroid therapy are acute and chronic inflammatory processes , hyperplastic and hypertrophic skin disorders, and conditions that typically have a favorable response to systemic and topical corticosteroids. In addition to anti-inflammatory properties, the atrophogenic side effect of corticosteroids also can be used advantageously when treating hypertrophic types of lesions, including hypertrophic scars and keloids, lichen simplex chronicus, hypertrophic discoid lupus erythematosus, psoriasis, and cutaneous sarcoidosis (ie, lupus pernio).
- Article modified with permission from Atlas of Office Procedures 1999; 2:129.
- HOLLANDER A. Intralesional injections of triamcinolone acetonide; a therapy for dermatoses. Antibiotic Med Clin Ther (New York) 1961; 8:78.
- Madden S, Ho VC. Dermatologic therapy. In: Dermatology, 3rd ed, Moschella S, Hurley HH (Eds), WB Saunders, Philadelphia 1992. p.2200.
- Richards RN. Update on intralesional steroid: focus on dermatoses. J Cutan Med Surg 2010; 14:19.
- Lugo-Janer G, Padial M, Sánchez JL. Less painful alternatives for local anesthesia. J Dermatol Surg Oncol 1993; 19:237.
- Stewart JH, Chinn SE, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia--II. J Dermatol Surg Oncol 1990; 16:842.
- Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med 1998; 16:353.
- Mader TJ, Playe SJ, Garb JL. Reducing the pain of local anesthetic infiltration: warming and buffering have a synergistic effect. Ann Emerg Med 1994; 23:550.
- Yang CH, Hsu HC, Shen SC, et al. Warm and neutral tumescent anesthetic solutions are essential factors for a less painful injection. Dermatol Surg 2006; 32:1119.
- Tosa M, Murakami M, Hyakusoku H. Effect of lidocaine tape on pain during intralesional injection of triamcinolone acetonide for the treatment of keloid. J Nippon Med Sch 2009; 76:9.
- Al-Qarqaz F, Al-Aboosi M, Al-shiyab D, Al Dabbagh Z. Using cold air for reducing needle-injection pain. Int J Dermatol 2012; 51:848.
- Ud-Din S, Bayat A. Strategic management of keloid disease in ethnic skin: a structured approach supported by the emerging literature. Br J Dermatol 2013; 169 Suppl 3:71.
- Fredman R, Tenenhaus M. Cushing's syndrome after intralesional triamcinolone acetonide: a systematic review of the literature and multinational survey. Burns 2013; 39:549.