What is the best treatment for keloids?

Best Treatment Options for Keloids

The most effective treatment for keloids is intralesional triamcinolone acetonide (10-40 mg/mL), which is considered the first-line therapy according to current guidelines. 1

First-Line Treatment

• Intralesional triamcinolone acetonide (10-40 mg/mL) is the standard of care for keloid treatment, with higher concentrations (40 mg/mL) recommended for thicker or more resistant keloids 1, 2
• Injections are typically administered every 3-4 weeks until the keloid flattens or symptoms improve 1
• Monitor for local adverse effects including skin atrophy, pigmentary changes, telangiectasias, and hypertrichosis with repeated injections 1, 3

Combination Therapies

• Combination therapy with cryotherapy followed by intralesional triamcinolone shows superior efficacy compared to either treatment alone 4

  • This combination has demonstrated greater than 50% reduction in keloid size compared to triamcinolone monotherapy 4
  • Particularly effective for pubic keloids, which respond remarkably well to this combination approach 4

• For cryotherapy application:

  • Apply liquid nitrogen with a cotton-tipped applicator for 15-20 seconds until 1-2 mm of circumferential skin around the lesion appears frozen 5
  • Allow to thaw for 20-60 seconds, then repeat the freeze step 5
  • Repeat the entire process at 3-week intervals until healing occurs 5
  • When combined with intralesional steroids, use a shorter application of liquid nitrogen (no second freeze step) and inject the steroid after the whitened skin normalizes in color 5

Alternative Treatments

• 5-Fluorouracil (5-FU) injections show comparable efficacy to triamcinolone with fewer adverse effects:

  • Similar remission rates (46% for 5-FU vs 60% for triamcinolone) 3
  • Significantly lower rates of skin atrophy (8% vs 44%) and telangiectasia (21% vs 50%) 3
  • May be preferable for cosmetically sensitive areas due to fewer adverse effects 3

• Multi-modal laser therapy combined with intralesional steroids:

  • Combination of pulsed dye laser, fractional CO2 laser, and intralesional steroids has shown significant improvement in keloid appearance and texture 6
  • Particularly beneficial for patients with darker skin tones, with lower risk of post-inflammatory hyperpigmentation 6
  • Results in significant flattening and decreased redness of keloids 6

Important Considerations and Pitfalls

• Prevention is critical for individuals with personal or family history of keloids 1

  • Caution patients about any procedures that cause skin trauma 1
  • Consider prophylactic treatment for high-risk patients undergoing surgery

• Avoid cryotherapy on:

  • Eyelids, tip of nose, lips, mucous membranes, cartilaginous structures, or superficial nerves 5
  • Use with caution in patients with darker skin as both hypo- and hyperpigmentation can result 5

• Monitor for secondary infections, which can be treated with standard topical or systemic antibiotics 1

• Botulinum toxin A alone or in combination with triamcinolone is ineffective for formed keloid scars, though it may help with symptomatic relief of pain and pruritus 7

• Imiquimod (a treatment option for actinic keratoses) has been noted to be effective in treating keloids in some cases 5

Treatment Algorithm

1. For small, uncomplicated keloids:

   • Start with intralesional triamcinolone acetonide (10-40 mg/mL) every 3-4 weeks
   • Consider 5-FU for cosmetically sensitive areas

2. For resistant or recurrent keloids:

   • Implement combination therapy with cryotherapy followed by intralesional triamcinolone
   • Consider multi-modal laser therapy with intralesional steroids, especially for patients with darker skin tones

3. For keloids causing significant symptoms (pain, pruritus):

   • Focus on symptomatic relief alongside size reduction strategies
   • Consider adding botulinum toxin A for symptomatic relief if pain and pruritus are severe 7