Mastering Steroid Therapy: Maximizing Benefits and Minimizing Risks of Triamcinolone and Dexamethasone Combinations

By Dr. Taghogho Von Apochi

Triamcinolone is a corticosteroid often used to reduce inflammation and treat various skin conditions, including hypertrophic scars and keloids. While it is effective in reducing the mass of hypertrophic scars, the systemic side effects of corticosteroids like triamcinolone can be more complex.

Corticosteroids, when used systemically (taken orally or injected into the bloodstream), can have a range of side effects on internal organs. However, localized injections of triamcinolone into scars typically do not have the same systemic effects. What happens to internal organs of the human body when we use these medications?

I asked a clinical question to myself, "Hoe does triamcinolone and dexamethasone affect the mass of internal organs?" I did some findings from well-established clinical research done on the effect on organs mass. why organ mass? The combination of Triamcinolone and Dexamethasone is evidently known (I am a recipient of the result) to reduce the sizes of hypertrophic scars like keloids. let me share a brief overview of potential systemic effects on internal organs with prolonged or high-dose corticosteroid use:

1. Brain: Long-term use of systemic corticosteroids can potentially cause mood swings, memory issues, and other psychiatric effects, but they are not known to directly reduce brain mass.

2. Heart: Chronic corticosteroid use can lead to cardiovascular issues, such as hypertension and increased risk of heart disease, but it does not directly reduce heart mass.

3. Liver: While corticosteroids can affect liver function tests and potentially lead to liver enzyme elevations, they do not typically reduce liver mass. They may, however, exacerbate conditions in those with pre-existing liver disease.

4. Kidney: Corticosteroids can affect electrolyte balance and blood pressure, potentially leading to kidney issues over time. However, they do not directly reduce kidney mass.

Triamcinolone injections for hypertrophic scars like keloids are generally localized and do not typically cause the systemic side effects associated with oral or intravenous corticosteroid use. Therefore, reducing the mass of internal organs such as the brain, heart, liver, or kidneys is not a common side effect of localized triamcinolone injections. However, systemic side effects can occur with higher doses or prolonged use, so disclaimer would be to follow prescribed guidelines and discuss any concerns with a qualified healthcare provider.

Now, let us examine the prolonged use of corticosteroids:

Prolonged use of corticosteroids, including triamcinolone, varies depending on the specific medication, dosage, and the condition being treated. However, in general medical practice, prolonged usage is often considered to be treatment that extends beyond a few weeks to several months or longer. See some well-established guidelines below:

• Short-term Use: Typically, this refers to corticosteroid use for a duration of less than two weeks. Short-term use is often associated with fewer side effects and is usually sufficient for treating acute conditions. 
• Medium-term Use: This can range from a few weeks to a few months. During this period, monitoring for side effects becomes important, and some patients may start to experience more significant side effects.
• Long-term or Prolonged Use: This usually refers to treatment extending beyond three months. Long-term use of corticosteroids increases the risk of systemic side effects and requires careful monitoring by qualified healthcare providers.

Let us contextualize this discussion of triamcinolone:

Topical or Injectable for Skin Conditions: Localized injections for hypertrophic scars or keloids are generally given at intervals and authoritatively this should be every 4-6 weeks and nothing less than this. Let me make it clear, every dose should be given once every 4-6 weeks and are not typically classified as prolonged use unless treatments extend for many months or years. Even then, the localized nature reduces the risk of systemic side effects. I can confidently say this because i worked with one doctor Adekunle of the Lagoon hospital in Nigeria for years and later with one Dr. Alakija for few weeks on localized administration. I was the subject.

Systemic Use: When taken orally or intravenously for systemic conditions, prolonged use is more likely to result in significant side effects. Whilst I do not have a direct experience in a systemic use, I have researched materials to verify these facts.

To minimize the risk of adverse effects during prolonged use, medical practices often include:

• Tapering Doses: Gradually reducing the dosage to the minimum effective amount.
• Regular Monitoring: Conducting regular check-ups and tests to monitor for side effects, including blood pressure, blood glucose levels, bone density, and eye health.
• Alternative Therapies: Using non-steroidal treatments when possible or combining corticosteroids with other medications to reduce the required dose.

Like I would always disclaim, each patient's situation is unique, so it's important to follow the specific guidance of a healthcare provider when using corticosteroids.

Combining Triamcinolone and Dexamethasone:

Whilst working with Dr. Adekunle, we started administering locally, triamcinolone on my keloidal scars. We got results but I noticed that the keloids resurfaced over time. We then devised a new way to increase the potency of triamcinolone. The result was phenomenon however, as a point of note, when corticosteroids like triamcinolone are mixed with another corticosteroid such as dexamethasone, the potential for systemic effects and side effects can increase. Just like I emphasized in my case, the combination might be used in certain clinical situations to leverage the properties of both drugs, but it also warrants careful consideration and monitoring.

Let me give a brief overview of what is important to consider when you are combining triamcinolone with dexamethasone:

Potency and Duration:

1. Dexamethasone: A potent corticosteroid with a long duration of action. It has strong anti-inflammatory and immunosuppressive effects.
2. Triamcinolone: Also potent, with a duration of action that varies depending on the specific formulation used (example: acetonide, hexacetonide).

Potential Increased Risks:

Combining these medications can potentially amplify the following risks and side effects:

1. Systemic Effects: Even if injected locally, combining two potent corticosteroids increases the potential for systemic absorption and systemic side effects.
2. Adrenal Suppression: The body’s natural corticosteroid production can be suppressed more significantly, leading to adrenal insufficiency, especially with prolonged use.
3. Immunosuppression: Increased risk of infections due to a more pronounced immunosuppressive effect.
4. Metabolic Effects: Greater potential for hyperglycemia (high blood sugar), dyslipidemia (abnormal lipid levels), and weight gain.
5. Bone Health: Increased risk of osteoporosis and fractures with long-term use.
6. Cardiovascular Effects: Elevated blood pressure and increased risk of cardiovascular diseases.
7. Psychiatric Effects: Higher likelihood of mood swings, anxiety, and other psychiatric symptoms.

Prolonged Use Considerations:

Duration: Use beyond a few weeks to a few months is generally considered prolonged, and careful monitoring becomes crucial.

Dosage: Higher doses and the combination of two corticosteroids require a tailored approach to minimize side effects.

Clinical Monitoring

To manage the risks associated with prolonged use and combination therapy, the following practices are recommended:

1. Regular Medical Check-ups: Frequent visits to monitor for side effects and adjust dosages as needed.
2. Laboratory Tests: Periodic blood tests to check blood glucose, lipid profiles, and other relevant markers.
3. Bone Density Scans: To monitor for osteoporosis, especially if therapy extends beyond a few months.
4. Adrenal Function Tests: To check for adrenal insufficiency.
5. Infection Precautions: Increased vigilance for signs of infection due to immunosuppression.

Tapering and Alternative Therapies

Effective management of corticosteroid therapy includes considering tapering and alternative treatments:

1. Gradual Tapering: If stopping the treatment, doses should be gradually tapered to allow the body’s natural corticosteroid production to resume.
2. Use of Adjunctive Therapies: Non-steroidal anti-inflammatory drugs (NSAIDs), immunosuppressants, or other treatments might be employed to reduce the reliance on corticosteroids.

Conclusively, combining triamcinolone with dexamethasone can be effective but increases the risk of systemic side effects, particularly with prolonged use. Close medical supervision and regular monitoring are essential to manage these risks effectively. Health professionals must tailor the treatment plan to each patient's specific needs and conditions, ensuring a balance between therapeutic benefits and minimizing potential harms. By understanding and applying these principles, we can master steroid therapy and provide optimal care for our patients.

For more detailed information, refer to clinical guidelines and peer-reviewed studies on corticosteroid therapy, such as the "Principles and Practice of Endocrinology and Metabolism" (Becker, K. L., 2001) and the "Journal of Clinical Endocrinology & Metabolism."

© Dr. Taghogho Von Apochi - Geneticist and Clinical Scientist, 2024. All rights reserved.