What are the treatment options for keloids?

Treatment Options for Keloids

Intralesional corticosteroid injections, particularly triamcinolone acetonide (TAC), are the first-line treatment for keloids due to their efficacy in reducing inflammation, fibroblast proliferation, and collagen synthesis. 1

First-Line Treatment

Intralesional Corticosteroid Injections

• Dosage and Administration:

  • Triamcinolone acetonide (TAC) 10-40 mg/mL depending on keloid size and location 2
  • For hypertrophic scars and keloids, use TAC-40 (40 mg/mL) 2
  • Inject directly into the lesion until blanching occurs
  • Repeat every 3-4 weeks until satisfactory response (typically 3-5 sessions) 3

• Efficacy:

  • Response rate: 50-100% regression 1
  • Recurrence rate: 33% at 1 year and 50% at 5 years 1

• Adverse Effects:

  • Local skin atrophy
  • Hypopigmentation
  • Telangiectasia
  • Pain at injection site 3

Combination Therapies

1. Corticosteroids + Cryotherapy

• Protocol:

  • Apply cryotherapy first (15-20 seconds freeze time)
  • Allow skin to normalize in color
  • Follow immediately with intralesional TAC injection 2
  • Repeat every 3-4 weeks

• Efficacy:

  • Higher success rates (89-91%) compared to either treatment alone 2
  • Most effective for smaller keloids (<30 mm) on face or neck 2

2. Corticosteroids + 5-Fluorouracil (5-FU)

• Protocol:
  • Combination of TAC and 5-FU in same syringe
  • More effective than either agent alone
  • Fewer side effects than TAC monotherapy 1

3. Corticosteroids + Pentoxifylline (PTX)

• Protocol:

  • TAC and PTX combined in 1:1 ratio
  • Injected intralesionally every 3 weeks 3

• Efficacy:

  • Significantly better improvement in keloid height and pliability
  • Reduced number of treatment sessions required
  • Lower incidence of side effects compared to TAC alone 3

Second-Line Treatments

1. Imiquimod

• Effective for preventing keloid recurrence after surgical excision
• Can be used as a topical treatment (5% cream) 2

2. Silicone Gel Sheets

• Apply to keloid for 12-24 hours daily
• Mechanism: occlusion and hydration
• Most effective for prevention or early treatment

3. Pressure Therapy

• Custom-made pressure garments
• Must provide 24-30 mmHg pressure
• Requires 18-24 hours of daily wear for 6-12 months

Advanced Treatment Options

1. Laser Therapy

• Pulsed-dye laser or CO2 laser
• More effective when combined with intralesional TAC
• Better results than laser therapy alone 1

2. Radiation Therapy

• Used as adjuvant therapy after surgical excision
• Most effective when administered within 24-48 hours post-excision
• Contraindicated in children and pregnant women

3. Surgical Excision

• High recurrence rate (45-100%) when used alone
• Should always be combined with adjuvant therapy
• Consider for large, functionally limiting keloids

Treatment Algorithm

1. Small, non-progressive keloids (<2 cm):

   • Start with intralesional TAC (10-40 mg/mL) every 3-4 weeks
   • If inadequate response after 3 sessions, add cryotherapy before injection

2. Larger or resistant keloids (>2 cm):

   • Consider combination therapy with TAC + 5-FU or TAC + PTX
   • Alternative: TAC + cryotherapy

3. Highly symptomatic keloids (pain/pruritus):

   • TAC + PTX combination shows superior symptom relief 3
   • Consider adding botulinum toxin A for additional symptomatic relief 4

4. Recurrent or treatment-resistant keloids:

   • Surgical excision followed by immediate adjuvant therapy (radiation or intralesional injections)
   • Consider multimodal approach with post-excision TAC injections and silicone sheeting

Special Considerations

• Location matters: Keloids on high-tension areas (chest, shoulders, back) are more resistant to treatment
• Patient factors: Individuals with darker skin types and family history of keloids have higher recurrence rates
• Prevention: Advise patients with history of keloids to avoid body modifications that puncture the skin 2
• Caution: Avoid cryotherapy on eyelids, lips, nose, and ears due to risk of tissue damage 2

Monitoring and Follow-up

• Assess response using Vancouver Scar Scale (height, vascularity, pliability, pigmentation) 3
• Monitor for adverse effects, particularly skin atrophy and hypopigmentation
• Continue treatment until keloid flattening or maximum of 5 sessions 3
• Long-term follow-up is essential due to high recurrence rates

Remember that keloids have high recurrence rates regardless of treatment method, and patients should be counseled about realistic expectations and the potential need for multiple treatment modalities.