What is the best and most effective treatment for keloids?

Best Treatment Options for Keloids

The combination of intralesional bleomycin and triamcinolone acetonide is the most effective treatment for keloids, showing superior outcomes with 76% excellent response rate compared to other treatment modalities. 1

Treatment Algorithm Based on Keloid Size and Characteristics

For Small Keloids (<2 cm)

• First-line treatment: Intralesional triamcinolone acetonide (TAC) 10-40 mg/mL every 3-4 weeks 2
  • If inadequate response after 3 sessions, add cryotherapy
• Second-line treatment: Combination therapy
  • TAC + cryotherapy (15-20 seconds freeze time followed by TAC injection) 2
  • TAC + 5-FU or TAC + bleomycin (superior option based on recent evidence) 1

For Larger or Resistant Keloids (>2 cm)

• First-line treatment: Combination therapy with TAC + bleomycin 2, 1
• Alternative options:
  • TAC + 5-FU (less effective than bleomycin combination) 1
  • TAC + cryotherapy 2

Efficacy of Treatment Options

The most recent high-quality evidence shows that the combination of intralesional bleomycin and triamcinolone acetonide provides:

• 76% excellent response rate
• Significant improvements in:
  • Flattening of lesions
  • Vancouver Scar Scale scores
  • Lower recurrence rates
  • Cosmetic appearance
  • Reduction in movement restriction
  • Decreased tenderness 1

This combination therapy is significantly more effective than the combination of 5-FU and triamcinolone acetonide, which showed only 50% excellent response rate 1.

Treatment Considerations and Precautions

• Anatomical location: Keloids on high-tension areas (chest, shoulders, back) are more resistant to treatment 2
• Patient factors: Darker skin types and family history of keloids are associated with higher recurrence rates 2
• Contraindications:
  • Avoid cryotherapy on eyelids, lips, nose, and ears due to risk of tissue damage 2
  • Patients with history of keloids should avoid body modifications that puncture the skin 2

Additional Treatment Options

For cases resistant to first and second-line therapies:

• Surgical excision: Most effective when combined with adjuvant therapy to prevent recurrence 2
• Radiation therapy: For recalcitrant keloids 3
• Silicone sheeting: Can be used as an adjunct therapy 3
• Pulsed-dye laser: Recently shown to be effective for keloids 3

Important Clinical Pearls

• Begin treatment early for best results
• Combination therapy is more effective than monotherapy 3
• Treatment response is typically evident within the first 2 infiltrations 4
• Multiple treatment sessions are usually required due to high recurrence rates 2
• Patients should be counseled about realistic expectations given the challenging nature of keloid treatment 2

Emerging Therapies

While not yet first-line, promising newer treatments include:

• Amniotic membrane application for non-healing keloids 2
• Autologous serum or platelet-rich plasma for persistent cases 2
• Anti-hypertensive pharmaceuticals, calcineurin inhibitors, and mesenchymal stem cell therapy 5

The treatment of keloids remains challenging, but the combination of intralesional bleomycin and triamcinolone acetonide currently offers the best outcomes for reducing keloid size, improving symptoms, and preventing recurrence.