What is the recommended treatment for injecting keloid scars?

Intralesional Triamcinolone Acetonide is the First-Line Treatment for Injecting Keloid Scars

For keloid scar injection, triamcinolone acetonide (TAC) at 10-40 mg/mL is recommended as first-line treatment, with dosage determined by keloid size and location. 1

Recommended Injection Protocol

Concentration and Dosing

• Small keloids (<2 cm): TAC 10-20 mg/mL
• Larger keloids (>2 cm): TAC 40 mg/mL
• Facial keloids: Use lower concentrations (10-20 mg/mL) to minimize side effects
• Trunk/extremity keloids: Higher concentrations (20-40 mg/mL) may be needed

Administration Technique

• Clean the area with antiseptic solution
• Insert 27-30 gauge needle into the keloid at a 10-15° angle
• Multiple punctures throughout the lesion ensure even distribution
• Inject small amounts until blanching occurs (indicates adequate infiltration)
• Repeat treatments every 3-4 weeks until desired response is achieved

Combination Therapies for Enhanced Efficacy

For Resistant Keloids

1. TAC + Cryotherapy:

   • Apply cryotherapy (15-20 seconds freeze time) first
   • Follow with TAC injection
   • Repeat every 3-4 weeks
   • Success rate: 89-91% for smaller keloids (<30 mm) 1

2. TAC + 5-Fluorouracil (5-FU):

   • Recommended formula: 0.1 mL of TAC (40 mg/mL) + 0.9 mL of 5-FU (50 mg/mL)
   • Inject weekly for 8 weeks
   • Provides better long-term results than TAC alone 2, 3

3. TAC + 5-FU + Pulsed-Dye Laser (PDL):

   • Most effective combination with 70-75% good to excellent response
   • Inject TAC+5-FU weekly for 8 weeks
   • Add PDL (585-nm, 5-7.5 J/cm²) at weeks 1,4, and 8
   • Superior for reducing erythema and improving patient satisfaction 3

Monitoring and Managing Side Effects

Common Side Effects

• Pain during injection
• Skin atrophy (23-37% with TAC alone)
• Telangiectasia (37-41% with TAC alone)
• Hypopigmentation (23-35%)

Risk Reduction Strategies

• Use lowest effective concentration
• Avoid injecting too superficially
• Space treatments at least 3-4 weeks apart
• Consider combination therapy with 5-FU (reduces side effect profile) 2
• Avoid cryotherapy on eyelids, lips, nose, and ears due to risk of tissue damage 1

Alternative Approaches for Special Cases

For Patients with Low Pain Threshold or Needle Phobia

• Topical clobetasol propionate 0.05% cream under silicone dressing occlusion
• Apply daily for 12 weeks
• Comparable efficacy to TAC injections with fewer adverse effects 4

For High-Risk Anatomical Areas

• Chest, shoulders, and back keloids are more resistant to treatment
• Consider starting with combination therapy rather than TAC alone
• Individuals with darker skin types and family history of keloids have higher recurrence rates 1

Treatment Expectations and Follow-up

• Realistic outcomes: 50-100% regression with TAC alone
• Recurrence rates: 33% at 1 year and 50% at 5 years with TAC monotherapy 5
• Follow-up: Evaluate response every 3-4 weeks
• Treatment course: Typically 3-8 sessions depending on response
• Consider maintenance therapy for patients with history of recurrence

Intralesional TAC remains the gold standard for keloid treatment, but combination approaches offer superior outcomes for resistant cases. The treatment plan should be adjusted based on keloid size, location, and patient response to initial therapy.