Making Steroid Injections Less Painful for Hair Loss Patients: Should we be using Lidocaine ?

New Study Suggests Use of Lidocaine Makes Steroid Injections More Painful

I perform a lot of steroid injections in my practice for various types of hair loss. I’ve always wondered if I should add a bit of numbing medication (like lidocaine) to my syringes when I perform steroid injections. Would this make the procedure less painful for my patients? 

I’ve gone through periods of time in the past where I use a bit of lidocaine for a few weeks and then long stretches of time when I don’t.  For many years now, I haven’t used lidocaine in the syringes when I perform steroid injections. I suppose I was never really convinced using lidocaine makes my patient’s experience better. But every time a patient asks me “are you going to use freezing?” I start in again thinking about the role of lidocaine.

A new study suggests that lidocaine does not make steroid injection procedures less painful. In fact, it increases pain.

New Study Suggests to Leave Lidocaine Out.

A new study, presented at the American Academy of Dermatology virtual meeting puts an end to the wondering. The study informs us all that adding lidocaine to steroid injections only makes the pain worse. The authors performed a double blind randomized study of 31 patients. Some received steroid injections with saline (the typical way we do injections) and some received steroid injections with lidocaine at 1:100,000. In addition to alopecia patients, patients in the study had patients receiving injections for a range of dermatological issues like psoriasis and keloids. Patients who received injections with lidocaine reported more pain than those who received steroid injections with only saline.

I enjoyed reading this news. It puts to rest a question that has plagued me for a long time. I will keep my lidocaine back on the shelves and keep doing steroid injections with saline dilutions.

Reference 

Helio.com. Intralesional corticosteroid injections with lidocaine more painful. Accessed Sep 11, 2020.

Steroid Injections for Hair Loss - A Look at Triamcinolone Acetonide

Steroid Injections with Triamcinolone Acetonide

Steroid injections are extremely helpful for many hair loss conditions - particularly some forms of localized alopecia areata (AA) some patients with lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), central centrifugal cicatricial alopecia (CCCA) and folliculitis decalvans. I sometimes even use in the early stages of traction alopecia when I feel the condition is in its earliest stages.

Triacminolone acetonide is a common medication used for steroid injections for inflammatory related causes of hair loss. Kenalog is a popular brand name and available in 10 mg and 40 mg bottles. The final dose the physician uses is typically 2.5 to 5 mg per mL.

There are two common doses of triamcinolone acetonide that one orders from the manufacturer - 10 mg per mL and 40 mg per mL. Either is fine to order provided one keeps in mind that when using the 40 mg per mL dose one is going to need to use 4 times less than if using the 10 mg per mL dose. Every few months I get calls from physicians who call me in a panic because they have prepared their injections using a 40 mg per mL bottle but they thought it was a 10 mg per mL bottle. (the correct way to deal with this is to 1) admit one’s error to the patient, and then 2) flood the scalp generously with saline injections to dilute out the steroid and see the patient back in 4 weeks and 8 weeks to see if any atrophy developed). There are many brands of triamcinolone acetonide one can order. Kenalog is one brand (shown here) but there are others. I have used many over the years and find some do get clogged up when using tiny 30 gauge needles. I don’t find this happens with Kenalog.

As reviewed in other posts, I believe in starting steroid injections at 2.5 mg per mL and only going to 5 mg per mL if needed. The low dose can be helpful and allows more injections to be performed as the maximum dose is 4 mL if one uses a 5 mg/mL concentration or 8 mL if one uses a 2.5 mg per mL concentration.

Steroid Injections in Alopecia Areata: Advice for the Primary Care Practitioner and Other Physicians who Treat Alopecia

How do we inject steroids in alopecia areata?

It’s always a great privilege when I have the chance to speak with primary care physicians about the treatment of alopecia areata. Alopecia areata is common in the world - and many patients who first notice the typical patches of alopecia related hair loss are going to make an appointment with their family doctor for advice on the diagnosis and treatment. The family doctor who accepts the challenge to help the patient with alopecia areata can dramatically affect their quality of life - let alone potentially help them get their hair growing back again. It’s a privilege to have the chance to speak to family practitioners about how to perform steroid injections.

There are over 25 treatment options for alopecia areata. However, there are really three treatment options that every family physician should know about. These include 1) topical class I steroids like clobetasol propionate 2) topical minoxidil (ie. Rogaine and generics) and 3) steroid injections with triamcinolone acetonide (ie ‘Kenalog injections’). Many patients with alopecia areata will do extremely well with use of topical steroids and minoxidil. However, if patients don’t regrowth hair with these treatments, steroid injections are often a very good option. Steroid injections are among the most effective options for patients with localized alopecia areata. By localized, I am referring to the type of alopecia areata with one or more discrete patches of hair loss.

Today, I’d like to review the basics of the procedure involved with administering ‘steroid injections.’ I’ll begin with discussing what steroid injections are, what side effects we need to counsel patients, what supplies are actually needed, how these steroid injections are performed and how often they are performed.

What are steroid injections?

Steroid injections for scalp alopecia areata is a short office-based procedure that involves administering a medication known as triamcinolone acetonide into the scalp. Triamcinolone acetonide is a type of corticosteroid which is different than anabolic steroids ( a common source of confusion and fear for the patient). There are many companies that manufacture triamcinolone - and many patients will come to the physician speaking in different terms and different language. Some patients will enquire about ‘steroid injections’, others will ask about “Kenalog injections” (a popular brand name). Other patients will ask if they are going to be getting ‘needles.’ All patents in these cases are referring to the same thing - the use of medications known as corticosteroids to stop the immune reaction that is at the heart of what is causing the alopecia areata.

Although the focus of this article is on the treatment of alopecia areata, steroid injections are useful for treating many hair loss conditions. These include scarring alopecia like lichen planopilaris, pseudopelade of Brocq, discoid lupus of the scalp, frontal fibrosing alopecia and sometimes even early forms of traction alopecia. The medication in all cases is the same - triamcinolone acetonide. Doses that can be used range from 2.5 mg per mL to up to 10 mg per mL. However, as I will mention in the sections below, I strongly believe that use of 2.5 mg per mL concentrations will reduce the chance of side effects and this concentration is definitely the starting point for dermatologists and non dermatologists alike.

Steroid injections are performed a medication known as “triamcinolone acetonide.” Kenalog is a popular brand and many patients enter the clinic asking their physicians if they will be performing “Kenalog injections.”

Side effects of Steroid Injections: What side effects do we need to counsel patients?

Before one begins steroid injections, it’s important to review possible short term and long term steroid-related side effects with the patient and get their permission (consent) to do the injections. I won’t go into all the possible side effects but the main message here is that side effects are actually not common with appropriate technique.

Short term steroid injections: What do we need to counsel patients?

The main side effects of a single session of steroid injections include:

1. Minor Pain and Bleeding with injections. Steroid injections are not extremely painful but they can be uncomfortable. They are usually more uncomfortable for patients the first time they receive injections than in subsequent visits. This is likely because the effect of stress heightens pain for many patents. Many patients will say that the pain is a 3 out of 10 (with 10 being maximum). The pain is highest in the frontal hairline and especially above and around the ears compared to the middle of the scalp. The crown area is a bit more painful than the middle of the scalp. In general though pain is mild. Use of a vibration device and chatting with patients and taking many breaks during the procedure can reduce pain and discomfort a lot. Steroid injections can be performed in children over 12 using these types of basic principles. Small amounts of bleeding are possible with injections but these are easily stopped with light pressure form a gauze. Patients using blood thinners and patients who are very nervous (and have higher heart rates), may bleed a bit more - but this is seldom ever an issue that can’t be stopped with pressure from a gauze.

2. Minor soreness in the scalp after injections. In the first 24-48 hours the scalp can be a bit sore. it is usually extremely minor and relieved partially or completely with use of acetominophen or ibuprofen if necessary. Most patients, however, do not require these supplementary pain medications.

3. Headaches after the procedure (rare). Some patients can develop a minor headache after the procedure. It is not common.

4. Indentations in the area where the steroids were injected (atrophy). Indentations or depressions in the scalp can occur following injections but are much less common when low concentrations are used than when high concentrations are used. Indentations don’t occur in the first day or even in the first week. They develop over 2-4 weeks following the injections. Provided another set of injections is not performed into the area of scalp depressions (i.e. the atrophic area), the skin goes back to normal again in 2-4 months, and sometimes much sooner. If injections are performed into an area that is already atrophic, the recovery may take longer and in some cases be persistent (i.e. very long lasting or even forever).

5. Irregular periods (missed periods). Steroid injections performed in premenopausal and perimenopausal female patients can sometimes result in missed periods, irregular periods or changes in the length of the period or amount of bleeding. This too is not common but some women who receive many steroid injections for alopecia areata will note that their periods are irregular. some patents may even miss their period altogether - prompting some to wondering if they are pregnant or wondering if there is some issue for concern. Advising patients of this side effect before the steroid injections are performed can be very helpful.

Long term steroid injections: What do we need to counsel patients?

Steroid related side effects are still quite uncommon even in patients who receive many many steroid injections (i.e. such as monthly injections for 4-6 months). However, patients who are receiving steroid injections over the long term should be aware the steroid injections can be associated with a range of relatively uncommon side effects. These include acne, increased blood pressure, stretch marks (striae), bone thinning (osteopenia, osteoporosis), cataracts, blood sugar issues. and adrenal suppression and Cushing syndrome. Steroid injections in the eyebrow (i.e. for eyebrow alopecia areata) over many years may also increase the risk of cataracts. Side effects with long term steroid injections are still relatively uncommon - especially when the patient has many months of drug free holidays. The use of 2.5 mg per mL concentrations of triamcinolone acetonide (rather than 5 mg per mL of 10 mg per mL) may reduce absorption and therefore systemic side effects as well.

Setting up for steroid injections: What 9 supplies are needed?

Steroid injections are easy to perform in the office setting and don’t require a great deal of supplies. The basic supplies are shown in the diagram below and include:

1) triamcinolone acetonide 10 mg per mL bottle 2) saline used for dilution 3) 3 mL syringes 4) alcohol swabs to wipe the top of the bottles of bacteriostatic injection grade saline and triamcinolone 5) 18 gauge needle to draw up the steroid and saline 6) 30 gauge needle to administer the triamcinolone into the scalp 7) vibration device to make the injections less painful and 8) gauze and 9) gloves.

Basic supplies for steroid injections. When performing the actual injections, gauze can also be used to stop tiny amounts of bleeding.

Performing Steroid injections: What are the actual steps?

STEP 1. Clean the top of the bottle of triamcinolone with alcohol and draw up 0.75 mL the triamcinolone into a 3 cc syringe with an 18 G needle.

Once the supplies are laid out on a tray, the first step starts with cleaning the top of the bottle of 10 mg per mL bottle of triamcinolone acetonide with alcohol pads. This is to ensure that there is no bacterial contamination. While waiting the 30 seconds for the triamcinolone bottle to dry, an 18 gauge needle can be removed from its packaging can be attached to a sterile 3 mL syringe that was also removed from its own sterile packaging. The 18 G needie is then used to puncture the triamcinolone rubber top and draw up 0.75 mL of steroid.

STEP 2. With the 0.75 mL of triamcinolone already in the syringe, the 18 G needle is used again to puncture the saline bottle and an additional 2.25 mL is draw up into the syringe.

Drawing up the saline in this manner effectively reduces the triamcinolone concentration from 10 mg per mL to 2.5 mg per mL which is the concentration recommended for injections in most cases.

STEP 3. A sterile 30 gauge needle is then attached to the syringe

Once the sterile 30 gauge needle is attached to the syringe, the syringe can be labelled as “2.5 mg per mL” with either marker or tape and set aside. Additional syringes can be then made up - up to a maximum of three syringes per session. Generally speaking no more than approximately 20 mg of triamcinolone acetonide should be injected monthly - which equates to around 3 of these 2.5 mg per mL syringes. Safety is increased by performing the injections every 6 weeks, and that would be a solid recommendation for physicians new to treating alopecia with steroid injections.

STEP 4. Steroid injections are performed with 0.1 to 0.2 mL of solution injected about 1 cm apart.

With a 30 gauge (thin) 1/2 needle attached to the syringe, the physician can begin injecting. A 1/2 needle is appropriate as longer needles are much too flimsy and make it difficult to precisely control the injections. Injections are done every 1 cm and with each injection about 0.1 to 0.2 mL of the steroid is administered. This typically works out to about 15-20 injections at first. A piece of gauze can be held in the non-dominant hand to help stop any inevitable little bits of bleeding that occur during the injections. Over time, as one becomes more proficient with the injections, it’s possible to inject up to 30 individuals times with each syringe. As one injects into the scalp, the physician can help reduce pain by using one or more distraction techniques. I often ‘scratch’ the surrounding scalp with my finger as I inject. A number of battery operated vibration and massaging devices are available which help a great deal as well to distract the patient and his or her nerves.

Injections are performed every 1 cm using a total of 0.1 to 0.2 mL with each injection.

STEP 5. Inject an appropriate number of times into each affected area.

The number of injections is often too few. This is often because physicians are trying to limit side effects. The use of 2.5 mg per mL rather than 5 mg per mL greatly enhances the margin of safety and gives physicians the opportunity to inject appropriate amounts of medicine. A golf ball sided area should be injected with 4-5 injections and a grapefruit sized area should be injected with 20-23 injections.

Too often when treating alopecia areata, the patient receives too few injections. The result is poor regrowth and a conclusion (eventually) by the patient and doctor that “steroid injections didn’t work.” The patient then often moves on to strong and stronger medications with more and more potential side effects. Rather than setting oneself up for failure from the beginning, my recommendation in treating limiting alopecia areata is to make sure the area is appropriately treated. One must not exceed three syringes total in a single 4-6 week interval, but if a small number of patches are being treated one should ensure the patch receives adequate medication.

The number of steroid injections is often too few. If a patient has only limited number of alopecia patches, the number of injections can be performed according to this figure.

STEP 6. The process can be repeated in 4-6 weeks, with a preference for 6 weeks to enhance safety.

Steroid injections can be repeated in 4-6 weeks. My advice for physicians who are newer to performing injections is to space these injections out every 6 weeks rather than every 4 weeks. This enhances safety, limits atrophy and allows one to feel more comfortable using three FULL 2.5 mg/mL syringes with each visit. Steroid injections are among the most effective treatments for localized alopecia areata. I’ll repeat that again just in case it was missed: Steroid injections are among the most effective treatments for ‘localized’ alopecia areata. By using appropriate amounts of medicine, and performing the injections every 6 weeks, one can achieve regrowth in a large proportion of patients with “localized” alopecia areata. Some patients may also elect to also use minoxidil on the patches at home on a daily basis. That is dealt with on a case by case basis and is not always necessary.

Steroid injections can be repeated in 4-6 weeks. For localized patches of alopecia, regrowth is expected to start in 1 month in 80 % to 90 % of patients. It may take several months to achieve full regrowth in the area Not all patients achieve full regrowth but certainly a very large proportion of patients do - especially those with smaller patches of hair loss to begin with.

Conclusion

Steroid injections can be very helpful for patients with localized patches of alopecia areata. Family physicians can safely take on the task of performing these injections into areas fo the scalp affected by alopecia areata. Patients can be counselled about potential side effects but given the appropriate perspective as well that these side effects are rare. Using 2.5 mg per mL rather than 5 mg per mL is highly advised as it enhances safety a great deal. Injections should be performed every 4-6 weeks (if they are needed) and my advice is to space these injections out to every 6 weeks at first. This is to again enhance safety. Patients with localized patches of presumed alopecia areata who fail to respond to steroid injections after 4 visits may benefit from referral to a dermatologist.

To learn more about the diagnosis and treatment of alopecia areata from the perspective of the family physician, consider watching the following video