Mechanism of action
Steroids act on the inflammatory cascade to reduce prostaglandin synthesis by up to 50% and to increase Interleukin-1 secretion by the synovial membranes. Steroids decrease immune cell migration and reduce vasodilatation and vessel permeability. This action increases the concentration of hyaluronic acid and the viscosity of the synovial fluid. All of this decreases inflammation and swelling, but it takes from 3 to 5 days to take effect.
Preparations
Less soluble
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Triamcinolone acetonide (Kenalog)
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Triamcinolone hexacetonide (Aristospan)
More soluble
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Hydrocortisone
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Methylprednisolone acetate (Depo-Medrone)
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Dexamethasone sodium phosphate (Decadron)
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Betamethasone sodium phosphate (Celestone)
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Betamethasone acetate (Soluspan)
Complications
Flare of active infection
Active infection is a contraindication.
Skin depigmentation and atrophy
Skin depigmentation and atrophy are said to occur in less than 1% of patients receiving steroid injections. The symptoms can take from 6 to 30 months to resolve. Patients with darker skin are more at risk. It is said to occur more often with less soluble steroids, but this is debated.
Prevention
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When you are performing injections near the skin surface—either in soft tissue or a joint—do not use triamcinolone. Take care to avoid subdermal steroid placement.
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Apply pressure with gauze and agitate the subcutaneous tissue to break up the needle tract and prevent leakage into the subcutaneous fat.
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In some areas of the body, you can flush the needle with normal saline before withdrawing the needle.
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