What are the management options for keloid pain incisional?

Management of Keloid Pain Incisional

Topical lidocaine application prior to intralesional injections is the most effective method for managing keloid incisional pain, significantly reducing pain scores from 82.6mm to 18.9mm on the visual analog scale. 1

Pain Management Options for Keloids

Topical Anesthetics

• Pretreatment with 60% lidocaine tape placed on keloids for at least 120 minutes before intralesional triamcinolone acetonide (TA) injections significantly reduces pain and improves treatment tolerability 1
• Application of topical anesthetics significantly relieves needle-stick pain, especially for sternum and auricular keloids 2
• This approach increases patient comfort and enables patients to continue with necessary treatment that they might otherwise discontinue due to pain 1

Intralesional Corticosteroid Injections

• Intralesional injection of triamcinolone acetonide (TA) is widely used for keloid treatment but is associated with significant pain 1, 2
• A 1:1 mixture of 1% lidocaine and TA has not shown significant benefit in reducing injection pain compared to TA alone 2
• Corticosteroid injections should be combined with proper anesthetic techniques to improve patient compliance 1

Anti-inflammatory Medications

• Paracetamol in combination with NSAIDs or COX-2-selective inhibitors is recommended for pain management unless contraindicated 3
• Regular administration of NSAIDs has shown analgesic benefit in postoperative settings and may be applicable to keloid pain management 3
• Dexamethasone (8-10 mg IV) can be considered for its anti-inflammatory and analgesic properties in cases of significant inflammation 3

Comprehensive Management Approach

For Mild to Moderate Pain

1. Apply topical 60% lidocaine tape for at least 120 minutes before any intralesional injection procedure 1
2. Administer oral paracetamol and NSAIDs for baseline pain control 3
3. Consider topical corticosteroids for superficial inflammation 3

For Severe Pain

1. Apply topical anesthetics before any procedure 1, 2
2. Consider systemic corticosteroids for short-term use in cases with significant inflammation 3
3. Evaluate for signs of infection that may be contributing to pain, as incisional SSIs require prompt opening of the surgical incision 3
4. If systemic inflammatory response syndrome (SIRS) criteria are present, antibiotic therapy should be initiated 3, 4

Surgical Considerations

• For recalcitrant painful keloids not responding to conservative management, consider excision with primary closure combined with superficial radiation therapy (SRT) 5
• This approach has shown good outcomes with no recurrence in selected cases 5
• Surgical excision alone has high recurrence rates and should be combined with adjuvant therapy 6, 5

Special Considerations

Infection Management

• Always evaluate for potential surgical site infection as a cause of keloid pain 3, 4
• If infection is suspected, the primary treatment is prompt and wide opening of the surgical incision 3, 4
• Antibiotics should be added only when SIRS criteria, signs of organ failure, or immunocompromise are present 3, 4

Prevention Strategies

• Prophylactic glucocorticoids should be applied after surgery with regular follow-up 3
• Differentiate between inflammation and infection before initiating treatment 3
• For severe inflammatory symptoms, combined medications or interlamellar steroid rinsing may be considered 3

Common Pitfalls to Avoid

• Failing to provide adequate anesthesia before intralesional injections, leading to treatment discontinuation 1
• Misdiagnosing keloid pain as infection without proper evaluation 3
• Using antibiotics for incisional pain without evidence of systemic infection 3, 4
• Relying on single modality treatment for keloids, which often leads to recurrence 6, 7