50 Practical Dermatology December 2008 lucocorticosteroids are a mainstay in the dermatol- side effects. However, menstrual irregularities often occur in ogist’s armamentarium. In fact, almost 90 percent premenopausal women who are not on anovulatory drugs. of dermatologists responding to a survey of the San This has been shown to be a result of suppression of cyclical Francisco Dermatologic Society in 1974 indicated gonadotrophins, leading to decreased estrogen and markedly Gthey used long-acting parenteral corticosteroids in low levels of progesterone.1 their practice, mostly the acetonide salt of triamcinolone Endometrial biopsies from such women show proliferative (TAC-A1). Despite the age of the survey, findings likely still changes, and spotting is believed to be due to low-estrogen reflect practice, as no reliable alternatives to glucocorticos- shedding. These occurrences are unique to TAC-A. Other teroids have emerged for the most common dermatologic injectables, such as betamethasone, methylprednisolone and indications. triamcinolone diacetate, do not have this effect and may be substituted but are less effective with much shorter durations TAC-A in the Clinic of action. Despite its popularity and its general safety and tolerability, Another predictable effect of TAC-A is suppression of the triamcinolone acetonide is associated with potential short- hypophyseal-pituitary-adrenal (HPA) axis. In studies of the comings. TAC-A is a suspension and must be shaken vigor- axis in patients treated with very high doses of TAC-A, there ously prior to injection. “Clumping” renders the product less remains some production of cortisol by the adrenals, and this effective, and irreversible clumping will occur with freezing. is assumed to be the reason that no adverse effects, such as Product information accompanying TAC-A is vague and fails Addisonian crisis, have been observed in patients on long- to outline a specific approach to long-term therapy of any term therapy. Still, suppression of the HPA axis persists for dermatologic disease. months after TAC-A is discontinued,2 and, therefore, the Using an example of chronic hand eczema in an atopic potential for Addisonian crisis exists. individual, 40mg of TAC-A is administered deeply in gluteal Capillary fragility with purpura on the dorsal forearms is muscle to avoid lipoatrophy at the injection site. If such a frequently observed in elderly patients and is accentuated in depression is created, it will take many months—up to 18— people with chronic sun damage or those taking aspirin or to return to normal. In some cases, the lipoatrophy never Coumadin. Posterior, subcapsular cataracts have been found completely resolves. After initial treatment, the patient is then in patients on very high doses of TAC-A on an experimental seen in two to three weeks. Clearing is expected and will last basis but do not occur in patients on the suggested doses of an almost predictable 18-21 days. Early signs of recurrence 40mg or less per month.2 prompt another dose administration of 40mg. The patient is Other infrequent events seen with suggested doses of then seen in about a month. Remission lasts longer with each TAC-A include hirsutism, acneiform eruptions, emotional successive dose, and the intervals are gradually extended to six lability (mood swings, insomnia, hyperirritability), and post- weeks then to three months. Of note, this treatment is only menopausal spotting. Increased blood sugar in diabetics is a effective if patients follow the advice of their dermatologist: potential problem that must be monitored. Suggested doses minimize hand-washing and moisturize each time their hands of TAC-A as outlined above have not been reported to have are wet, use mild soaps, cotton liners and rubber gloves with an effect on intraocular pressure, hypertension, avascular dish-washing, and avoid any specific irritants or allergents necrosis of the femoral head, gastric upset, purple striae, or fat that would potentiate the hand eczema. redistribution (moon facies, buffalo hump, etc.). All of these Note that if divided to represent the average daily dose of problems have been observed, for example, with oral pred- oral triamcinolone, these relatively small doses of TAC-A nisone over long periods. This fact again demonstrates the would be well under 2mg, lessening the risks of undesirable uniqueness and safety of TAC-A in recommended doses. December 2008 Practical Dermatology 51 BMD Testing Table 1. Conditions for Which IM TAC-A Demonstrates Benefit ication for a number of der- matologic disorders. Used judiciously, it is safe, and seri- Atopic Eczema Aquagenic Pruritus ous side effects are rare and Lichen Simplex Chronicus Lichen Sclerosus predictable; however, little is Prurigo Nodularis Balanitis known about the drug’s effect Neurotic Excoriations Erythema Annulare Centrifugum on bone mineral density (BMD). Factitial Dermatitis Stomatitis and Cheilitis Nummular Eczema Pemphigus Investigating Effects Chronic Hand Eczema Papular Urticaria including on BMD Bullous Keratolysis Exfoliativa Insect Bite Reactions Significant bone loss is a pre- dictable event in patients on Infectious Eczematoid Dermatitis Generalized Granuloma oral glucocorticoids and is Seborrheic Dermatitis Annulare most dramatic in the first Inflammatory Keratosis Pilaris Chronic Blepharitis three to six months of thera- 11,12 Bullous Pemphigoid Cholinergic Urticaria py. Baseline DXA scans and concurrent bisphospho- Chronic Urticaria including Dermographism Granuloma Faciale nate treatment are recom- Erythema Multiforme/Erythema Nodosum Essential Pruritus mended for patients in whom Aquagenic Urticaria Sunburn long-term oral glucocorticoid Photosensitivity including Seasonal Adult Mastocytosis therapy is anticipated. In order to assess the Lupus Erythematosus Pityriasis Rosea effects of TAC-A on BMD, Knuckle pads including Fingertip Lichen Amyloidosis data were collected from the Hyperkeratosis Onycholysis medical records of 32 patients Intertrigo Polymorphous Light Eruption (18 women and 14 men), who were on long-term TAC- Pityriasis Alba & Post-Inflammatory Pityriasis Rubra Pilaris A for various dermatologic Hypopigmentation Stasis Dermatitis conditions (Table 2). The Pseudoacanthosis Nigricans Lichen Planus average length of treatment Brachioradial Pruritus was 8.6 years per patient. The average daily dose of TAC-A was calculated at 0.5mg (total milligrams of TAC-A divided Applications of TAC-A by the number of days of treatment). Bone mineral density Table 1 provides a listing of conditions for which TAC-A was ascertained employing dual energy X-ray absorptiometry treatment has been found effective.3 A special note should be (DXA). made regarding aquagenic pruritus. Complete control of this The average age of the 18 women at the time of DXA very annoying problem with periodic TAC-A (40mg every scans was over 65 years (range 53-81). Six had BMD T- two to three months) has been obtained in 15 patients. No scores in the osteoporosis range, and 10 were osteopenic. other corticosteroid has this profound effect, and antihista- One patient (subject #30) had a minor osteoporotic fracture mines are of no value.4 of the wrist. About half of postmenopausal women in the Despite the utility of TAC-A, adjunctive treatment with general population have a bone density T-score at the other medications is commonly necessary. Examples include femoral neck between –1.0 and –2.55 (osteopenia). In the chloroquine with lupus erythematosus, antibiotics with present study, 55 percent of the women were osteopenic. inflammatory rosacea, acyclovir with herpes zoster, azathio- Osteoporosis would be expected in 35 percent of women in prine with pemphigus, antihistamines with chronic urticaria, the general population over 65,6 about the same as that and acitretin with pityriasis rubra pilaris. found in this study group (33 percent). In short, intramuscular triamcinolone is a valuable med- The average age of the 14 men at the time of DXA scans 52 Practical Dermatology December 2008 Table 2. Bone Mineral Density / Treatment Data Subject Age Date of Treatment Lumbar Spine Femur Bisphosphonates 1 No. (Sex) DXA Scan Total Period TAC-A2 (mg) T-Score3 BMD4_ T-Score3 BMD4_ Pre-Scan Post-Scan 1 47 (F) 1/25/99 5yrs.8mos. 1520 0.435 0.3725 0.136 0.8266 _ _ 2 68 (F) 1/30/99 3yrs.6mos. 520 -0.645 0.3185 -2.366 0.6696 _ _ 74 (F) 6/15/05 6yrs.4mos. 680 -1.585 0.2715 -4.076 0.5626 _ + 3 66 (F) 8/29/00 11yrs.11mos. 1120 -3.4 0.361 _ + 70 (F) 11/16/04 4yrs.1mo. 1000 -1.0 0.942 -1.1 0.809 + + 4 81 (F) 11/18/04 17yrs. 1200 -3.37 0.77 -2.41 0.63 _ + 5 76 (F) 3/2/05 3yrs.7mos. 360 -1.7 0.492 -2.1 0.747 _ + 6 62 (F) 4/18/05 11yrs. 1480 -3.55 0.774 -1.54 0.795 _ + 7 78 (M) 4/19/05 4yrs.2mos. 720 1.1 1.209 -0.3 0.982 _ _ 8 77 (F) 3/7/06 5yrs. 880 0.8 1.275 -1.9 0.789 _ + 9 73 (M) 4/12/06 7yrs.2mos. 1920 -3.2 0.85 -1.6 0.885 _ + 10 60 (F) 4/13/06 1yr.3mos. 320 -0.6 1.129 -1.2 0.859 _ _ 11 57 (M) 5/14/06 16yrs.1mo. 2960 0.1 1.24 -1.3 0.90 _ + 12 58 (M) 6/13/06 12yrs.3mos. 4400 -0.8 1.149 -1.3 0.917 _ _ 13 61 (F) 3/21/04 13yrs.1mo. 1360 -2.1 0.947 0.1 1.010 _ + 63 (F) 6/23/06 2yrs.2mos. 160 -2.2 0.932 -0.5 0.945 + + 14 66 (F) 8/30/04 0 0 1.0 1.322 0.1 1.009 _ _ 67 (F) 6/26/06 1yr.10mos. 400 0.7 1.288 -0.7 0.918 _ _ 15 70 (M) 8/16/99 0 0 1.8 1.438 0.2 1.117 _ _ 77 (M) 7/5/06 1yr.7mos.