What are the treatment options for a non-healing keloid after revision?

Treatment Options for Non-Healing Keloid After Revision

The most effective treatment for a non-healing keloid after revision is a combination of cryotherapy followed by intralesional triamcinolone acetonide (TAC) injection, repeated every 3-4 weeks, which has shown success rates of 89-91% for smaller keloids. 1

First-Line Treatment Approach

Combination Therapy

1. Cryotherapy + Intralesional TAC
   • Apply cryotherapy first (15-20 seconds freeze time)
   • Follow with intralesional TAC injection (10-40 mg/mL depending on keloid size)
   • Repeat every 3-4 weeks
   • Most effective for smaller keloids (<30 mm) on the face or neck 1

For Persistent Non-Healing Keloids

• If inadequate response after 3 sessions of TAC + cryotherapy, consider:
  • TAC + 5-FU combination for larger or resistant keloids (>2 cm) 1
  • Topical silicone gel sheeting under occlusion with corticosteroid cream 2

Alternative Treatment Options

Occlusive Therapy

• Clobetasol propionate 0.05% cream under silicone dressing occlusion
  • Equally effective as intralesional triamcinolone
  • Fewer adverse effects (less erythema, hypopigmentation, telangiectasia, and skin atrophy)
  • Better option for patients with low pain threshold or needle phobia 2

Advanced Interventions for Resistant Cases

• Trepanation combined with superficial radiotherapy
  • Case reports show success with no recurrence during 3-year follow-up 3
  • Consider for keloids that have failed conventional treatments

Adjunctive Therapies

• Amniotic membrane application

  • Promotes healing through anti-inflammatory and anti-angiogenic mediators 4
  • Can be used as an onlay protective flap or inlay tissue substitute

• Autologous serum or platelet-rich plasma

  • Demonstrated beneficial effects for persistent epithelial defects 4
  • May help with wound healing in non-healing keloids

Treatment Considerations

Location-Specific Factors

• Keloids on high-tension areas (chest, shoulders, back) are more resistant to treatment 1
• Avoid cryotherapy on eyelids, lips, nose, and ears due to risk of tissue damage 1

Risk Factors for Poor Response

• Darker skin types
• Family history of keloids
• Previous keloid recurrence
• Keloid size >2 cm 1

Prevention of Recurrence

• Prophylactic use of silicone gel sheets following surgical revision reduces recurrence rates from 71% to 39% in high-risk patients 5

• Tissue adhesive application for small areas of marked thinning may provide structural support and prevent further complications 4

Monitoring and Follow-Up

• Regular assessment of keloid dimensions and symptoms
• Evaluate for adverse effects such as skin atrophy, hypopigmentation, or telangiectasia
• Consider alternative treatment if no improvement after 3 months of consistent therapy

By following this algorithmic approach to non-healing keloids after revision, clinicians can maximize the chances of successful treatment while minimizing adverse effects and recurrence rates.