What are the treatment options for keloid scarring on the shoulder caused by acne?

Treatment Options for Keloid Scarring on the Shoulder Due to Acne

For keloid scarring on the shoulder caused by acne, intralesional corticosteroid injections are the first-line treatment, with cryosurgery being particularly effective for early, vascular keloids. Multiple therapeutic options exist with varying degrees of efficacy and should be implemented based on keloid characteristics.

First-Line Treatments

Intralesional Corticosteroid Injections

• Recommended as primary therapy for keloid scars 1
• Typically triamcinolone acetonide (10-40 mg/ml) injected directly into the keloid
• Benefits include flattening of the scar and reduction in symptoms like itching and pain
• May require multiple sessions spaced 4-6 weeks apart

Cryosurgery

• Particularly effective for early, vascular keloid lesions with 85% showing moderate to good response 1
• Single freeze cycle of 5-10 seconds per session
• Can be used alone or in combination with intralesional corticosteroids
• Caution: May cause hypopigmentation, especially in darker skin types

Second-Line Treatments

Silicone-Based Products

• Silicone gel sheets or topical silicone gel
• Shown to improve texture, color, and height of keloid scars 2
• Should be applied for at least 12 hours daily for several months
• Non-invasive option with minimal side effects

Pressure Therapy

• Compression garments or devices that apply continuous pressure to the keloid
• Most effective for shoulder location where consistent pressure can be maintained
• Requires 3-6 months of continuous use (at least 23 hours daily)
• Works best for newer keloids

Advanced Treatment Options

Combination Therapy

• Combining intralesional corticosteroids with cryosurgery shows better results than either treatment alone
• Often used for recalcitrant keloids that don't respond to single modalities

Surgical Excision with Adjuvant Therapy

• Surgery alone has high recurrence rates (45-100%)
• Should always be combined with adjuvant therapy such as:
  • Post-operative corticosteroid injections
  • Radiation therapy for recalcitrant cases
  • Silicone sheeting application

Laser Therapy

• Pulsed-dye laser can reduce redness, thickness, and symptoms
• Multiple sessions typically required
• Works by targeting blood vessels within the keloid

Emerging Treatments

Immunotherapy and Chemotherapy

• 5-fluorouracil (5-FU) injections, often combined with corticosteroids
• Interferon injections to reduce collagen production
• Imiquimod cream as post-surgical adjuvant therapy

Treatment Algorithm

1. For small, early keloids (<2 years old):

   • Start with intralesional corticosteroid injections every 4-6 weeks
   • Consider adding cryotherapy between injection sessions
   • Apply silicone gel/sheets daily

2. For established keloids (>2 years old):

   • Combination of intralesional corticosteroids and cryotherapy
   • Add pressure therapy if location permits
   • Consider more aggressive options if no response after 3-6 months

3. For large, recalcitrant keloids:

   • Surgical excision followed by immediate adjuvant therapy
   • Consider radiation therapy for highly recurrent cases

Important Considerations

• Keloids have high recurrence rates regardless of treatment method

• Treatment should continue for several months even after clinical improvement

• Preventive measures are crucial after any treatment:

  • Sun protection to prevent hyperpigmentation
  • Early treatment of any new acne lesions to prevent additional keloid formation
  • Maintenance therapy with silicone products

• Monitor for side effects of treatments:

  • Skin atrophy from corticosteroids
  • Hypopigmentation from cryotherapy
  • Pain and potential infection from invasive procedures

Remember that keloid treatment is often a long-term process requiring patience and persistence, as complete resolution may not always be achievable, but significant improvement in appearance and symptoms is possible with appropriate therapy.