What are the treatment options for keloid management?

Keloid Management: Treatment Options

Intralesional corticosteroid injections are the first-line treatment for keloid management due to their efficacy and widespread clinical use. 1

First-Line Treatments

Intralesional Corticosteroid Injections

• Triamcinolone acetonide (10-40 mg/mL) is the most commonly used corticosteroid for keloid treatment 2
• Higher concentrations (40 mg/mL) are recommended for hypertrophic scars and keloids 2
• Most frequently chosen treatment by dermatologists and plastic surgeons for all keloid phenotypes (small, large, and multiple) 1
• Can be used as monotherapy for small keloids or in combination with other treatments for larger or multiple keloids 1

Silicone Gel Sheets

• Effective for treating keloid scars with minimal side effects 3, 4
• Should be placed directly on the keloid scar and maintained continuously 3
• Typically replaced every 4 weeks for a total treatment duration of at least 24 weeks 3
• Relieves pain and pruritus within 4-12 weeks of treatment 4
• Reduces scar redness and elevation after approximately 12 weeks of consistent use 4
• May work by decreasing mast cell numbers and enhancing Fas antigen expression by lesional fibroblasts 4
• Vitamin E-enriched silicone gel sheets may provide superior results compared to standard silicone sheets 5

Second-Line and Combination Treatments

Surgical Excision

• Often combined with other modalities due to high recurrence rates when used alone 1
• Commonly combined with intralesional corticosteroids (10%) or brachytherapy (8.4%) for large keloids 1
• Caution advised for patients with personal or family history of keloid formation 2

Radiation Therapy

• Brachytherapy is used in combination with surgery for large keloids 1
• Particularly useful for recalcitrant keloids that have failed other treatments 6

Pressure Therapy

• Can be used as an adjunctive treatment, particularly for preventing recurrence 6
• Most effective when applied continuously for at least 23 hours per day 6

Novel and Adjunctive Treatments

Chemotherapy Agents

• 5-Fluorouracil and bleomycin can be used intralesionally for resistant keloids 6
• Often combined with corticosteroids for enhanced efficacy 6

Immunotherapy

• Interferon and imiquimod have shown promise in some studies 6
• May help modulate the abnormal immune response in keloid formation 6

Anti-inflammatory Therapies

• Tacrolimus and other immunomodulators are being investigated 6
• Target the inflammatory component of keloid formation 6

Special Considerations

Prevention

• Individuals with personal or family history of keloids should be cautioned about any procedures that cause skin trauma 2
• Prevention is the best strategy for those with known keloid tendency 2

Treatment Selection Algorithm

1. For small, minimally symptomatic keloids:

   • Start with silicone gel sheets (24 weeks) 3, 4
   • If inadequate response, add intralesional corticosteroids (triamcinolone 10-40 mg/mL) 2, 1

2. For large, symptomatic keloids:

   • Begin with combination therapy: intralesional corticosteroids plus silicone gel sheets 1
   • Consider surgical excision followed by adjuvant therapy (corticosteroids or radiation) for resistant cases 1

3. For multiple keloids:

   • Use intralesional corticosteroids for the most symptomatic lesions 1
   • Apply silicone gel sheets to accessible areas 3, 4
   • Consider systemic therapies for widespread involvement 6

Complications and Monitoring

• Monitor for local adverse effects of corticosteroids: atrophy, pigmentary changes, telangiectasias, and hypertrichosis 2
• Assess for systemic absorption with repeated injections, which can suppress the hypothalamic-pituitary-adrenal axis 2
• Watch for infections, which can be treated with standard topical or systemic antibiotics 2

Despite numerous treatment options, keloids remain challenging to treat effectively, and treatment should be tailored based on keloid size, location, and previous treatment response 6, 1.