INTRODUCTION
Although intramuscular triamcinolone acetonide (IMT) for the treatment of numerous dermatologic conditions has been available for more than 60 years, many dermatologists continue to use it routinely while many others use it rarely or not at all, either because they are unaware of its therapeutic benefits or are concerned about its side effects. A recent survey conducted by the University of Utah Department of Dermatology (personal communication) found that of the 844 out of 2000 dermatologists who completed the survey, only 55% felt comfortable using IMT for steroid-responsive dermatoses, while 90% felt more comfortable using oral corticosteroids. If both were indicated, then 59% preferred oral corticosteroids over IMT.
In 2009, one of the co-authors (DNR) published an article describing the positive response of IMT to many chronic steroid-responsive conditions while also using a technique that minimized any significant side effects, especially when compared with a course of oral corticosteroids. We will review these findings and then discuss IMT's value in the treatment of psoriasis.1
Clearly, in the past two decades, there has been a huge paradigm shift with the introduction of many new systemic agents that can effectively and safely treat moderate to severe psoriasis patients. This begs the question of what IMT can do to bring therapeutic value to our patients. Psoriasis is of course a highly variable disease, and in some cases, IMT can serve as an adjunctive agent if there are significant symptomatic issues, such as pruritus and pain, not completely controlled by one of the systemic medications. In other cases, especially when the disease is localized, IMT can treat psoriasis effectively and safely without having to use one of the systemic drugs. This is important for several reasons. First, patients may have comorbidities or personal preferences which preclude the use of one of these systemic medications. Second, the cost differential between the use of one of these newer drugs and IMT is enormous. Whether insurance companies, pharmaceutical assistance programs, or out-of-pocket costs paid by patients, physicians have an ethical obligation to at least consider cost in choosing between two therapeutic options that have similar effectiveness and safety features.
MATERIALS AND METHODS
IMT is indicated in adults with chronic recalcitrant steroid-responsive dermatologic conditions that are not adequately treated with topical medications alone. Common conditions besides psoriasis include pruritus, lichen planus, atopic dermatitis as well as several types of alopecia.
Typical dosing of IMT is 80 mg at least 7 to 8 weeks apart and gradually tapered off depending on clinical response. The injection is given into the upper outer quadrant of the gluteal muscle with a 3-cc syringe and a 1-1/2 inch needle. Leakage of triamcinolone into the subcutaneous tissue must be avoided to prevent localized tissue atrophy or abscess formation.
Clinical Indications for the Treatment of Psoriasis with IMT
1. Localized Psoriasis
Localized psoriasis, especially of the scalp, hands, and feet (hyperkeratotic and pustular types), may only involve a small body surface area but can be extremely symptomatic and disabling and may often be very resistant to topical medications alone. A large percentage of these patients could be adequately treated with 3 or 4 IMT injections over the course of a year which can negate the need for the use of other systemic drugs.
2. Relief of Pruritus and Pain
Pruritus and pain may often accompany moderate to severe psoriasis patients. The pain, which may or may not be due to underlying psoriatic arthritis, as well as the pruritus, will almost always improve significantly with IMT. This can be very important when patients first present or when switching from one systemic agent to another when insurance delays can take weeks or even months to resolve. Even when doing relatively well on a particular systemic medication, pain and pruritus may be present and IMT can be beneficial as adjunctive treatment.
3. Nail Psoriasis
For occasional patients, psoriasis of the nails can be quite disfiguring, and it can be very painful to treat with intralesional steroids and unresponsive to topicals. These patients will usually respond well to IMT.
