Triamcinolone is an FDA approved synthetic corticosteroid drug used in the treatment of various skin conditions including atopic dermatitis, contact dermatitis (e.g., poison ivy), eczema, bullous dermatitis herpetiformis, psoriasis, lichen planus, lichen sclerosis, subacute cutaneous lupus erythematosus, dermatomyositis, seasonal or allergic rhinitis, and others. Triamcinolone may also be used to provide symptomatic relief in chronic asthma, rheumatoid arthritis, gouty arthritis, and osteoarthritis. Although hydrocortisone is the preferred drug in the treatment of Addison disease and secondary adrenocortical insufficiency, triamcinolone may also serve as a second-line drug. Triamcinolone is given as a prescription by the primary care physician and topically available as an over-the-counter medication. Triamcinolone comes under several brand names.[1][2][3][4]

Triamcinolone falls under the class of corticosteroids—specifically a glucocorticoid. It exhibits anti-inflammatory and immunosuppressant activity via inhibiting the phospholipase A2 enzyme on the cell membrane phospholipid layer, and thereby hinders the breakdown of leukocyte lysosomal membranes and prevents the formation of arachidonic acid. It ultimately decreases the expression of cyclooxygenase (COX) and lipoxygenase (LOX) and thus prevents the biosynthesis of prostaglandins and leukotrienes, respectively. Corticosteroids manifest anti-inflammatory effects via inhibiting macrophage and leukocyte migration to the affected site by reversing vascular dilation and permeability. These actions lead to reduced edema, erythema, and pruritus. An important anti-inflammatory mechanism gets mediated by the inhibition of nuclear factor kappa-B (NF-kappa-B) which leads to decrease protein expression of interleukin-6 (IL-6), interleukin-8 (IL-8), monocyte chemoattractant protein-1 (MCP-1), and COX-2.

Triamcinolone metabolism is primarily hepatic, and elimination is via both renal and fecal pathways. The onset of action and duration of triamcinolone varies because it depends on the route of administration in the body. The medication has a rapid rate of absorption in the body following oral intake. Triamcinolone has a half-life of between 18 to 36 hours, and peak concentrations of triamcinolone occur within 1.5 to 2 hours following oral administration.[5][6][7]

Triamcinolone administration can be orally (e.g., tablets or capsules), topically (e.g., cream and ointment), oral or intranasal inhalation (e.g., spray), intramuscularly, or via intravitreal injection. Triamcinolone, when given orally, should be taken with meals to avoid GI discomfort. When given as a topical form, it is instructed to apply a thin layer to the affected area and rub gently. When administered as an inhalation solution, the patient must learn the proper administration technique for the correct dose.[8]

For chronic asthma:

• IM form:
  • In adults; dose range between 40 to 80 mg IM daily 
  • In pediatrics; dose range 0.11 to 1.6 mg/kg/day divided into 3 or 4 doses 

• Oral inhalation form:
  • In adults; 150 mcg by mouth three times daily or 300 mcg orally twice daily, *Do not exceed 1200 mcg per day
  • In children between ages 6 to 12; dose range 75 to 150 mcg orally three times daily, or 150 to 300 mcg orally twice daily, *Do not exceed 900 mcg per day
  • In children between age 2 to 5; a low dose of 300 mcg orally each day is advised

For seasonal allergies:

• intranasal inhalation form:
  • In adults and children ages 12 and older; 220 mcg daily (two sprays in each nostril)
  • In children between age 2 to 11; 110 mcg daily (1 spray in each nostril), *Do not exceed 110 mcg daily in children under the age of 6 

For the treatment of various skin conditions (atopic dermatitis, contact dermatitis, dermatitis herpetiformis, psoriasis, eczema or lichen planus):

• Topical form:
  • In adults; apply 0.1% triamcinolone paste twice or three times daily to the affected area after meals

For dermatomyositis or symptomatic sarcoidosis:

• IM form:
  • In adults; dose range between 40 to 80 mg IM daily
  • In pediatrics; dose range 0.11 to 1.6 mg/kg/day divided into 3 or 4 doses 

• Topical form:
  • In adults; apply either 0.025% to 0.05% cream/ointment, or 0.1% to 0.5% cream/ointment twice or three times daily to the affected area 

For Addison disease or adrenocortical insufficiency:

• Oral form:
  • In adults; 4-12 mg orally each day
  • In pediatrics; 117 mcg orally each day

For symptomatic relief of rheumatoid arthritis, gouty arthritis, osteoarthritis: 

• Oral form:
  • In adults; 4 to 48 mg orally each day
  • In pediatrics; 416 mcg to 1.7 mg orally each day

• IM form:
  • In adults; dose range between 40 to 80 mg IM, repeat every four weeks 
  • In pediatrics; 40 mg IM, repeat every four weeks

Common adverse effects associated with the initial use of topical triamcinolone involve itchiness, burning, irritation, or drying of the skin. These symptoms resolve on their own within a few days of use. Other adverse effects may include headaches, dizziness, edema of the ankles or feet, or changes in urination or vision. Chronic use of glucocorticoids such as triamcinolone may cause "Cushing syndrome"; hypertension, weight gain, acne, striae, thinning of the dermal skin layer, osteoporosis, hyperglycemia, amenorrhea, immunosuppression, and steroid psychosis (e.g., depression or mania). 

Patients with congestive heart failure or severe hypertension may experience higher incidences of edema and weight gain when taking triamcinolone. Glucocorticoid drugs must be slowly tapered off with chronic use to prevent the occurrence of adrenal insufficiency (high risk if the drug is abruptly discontinued, especially in very ill patients).[9][10][11]

Triamcinolone injections are strongly contraindicated for epidural administration due to serious medical adverse effects, including paralysis, cortical blindness, and death. The inhalation form of triamcinolone is not indicated for use in acute asthma. Additionally, prolonged use of glucocorticoids may lead to hypothalamic-pituitary-adrenal (HPA) suppression. In patients with head trauma, high doses of corticosteroids are not recommended due to the risk of early mortality. Systemic corticosteroids are not indicated for use in fungal or viral infections. Contraindications to triamcinolone include patients with tuberculosis due to the risk of reactivation. 

Patients diagnosed with diabetes mellitus should use caution when taking triamcinolone due to its hyperglycemic adverse effect. A higher incidence of skin atrophy is noted with glucocorticoid use in the elderly population due to aging. Patients diagnosed with psychosis should also use extreme caution as triamcinolone may cause exacerbation of related symptoms.

Corticosteroids are known to exacerbate glaucoma; thus, primary care physician supervision is necessary. Pregnant patients should not use triamcinolone for prolonged use due to potency. Corticosteroid use is contraindicated in children under the age of two.[12][13]