How to treat old keloid scars?

Treatment of Old Keloid Scars

For old keloid scars, intralesional corticosteroid injections (triamcinolone acetonide) represent the first-line treatment, with combination therapy using cryotherapy followed immediately by corticosteroid injection achieving the highest success rates of 89-91%. 1

Critical Patient Education

• UV protection is essential as sun exposure worsens keloid scars and must be emphasized before starting any treatment 1
• Complete elimination of keloids is rarely achievable; patients must understand that improvement, not disappearance, is the realistic goal 2
• Recurrence rates are high regardless of treatment modality chosen 2

First-Line Treatment: Intralesional Corticosteroids

Triamcinolone acetonide is FDA-approved specifically for keloid treatment and should be your primary approach 3:

• Inject directly into the lesion intradermally or subcutaneously 3
• Use a tuberculin syringe with 23-25 gauge needle for accuracy 3
• Dosing varies by lesion size but typically starts at 2.5-15 mg per injection site 3
• Multiple sites separated by at least 1 cm can be injected 3
• Repeat injections weekly or less frequently as needed 3

Common pitfall: Avoid injecting into surrounding tissue as this causes tissue atrophy; inject only into the keloid itself 3

Optimal Combination Therapy

The most effective approach combines cryotherapy with immediate corticosteroid injection 1:

• Apply liquid nitrogen cryotherapy for 15-20 seconds until 1-2 mm of surrounding skin appears frozen 1
• Allow thawing for 20-60 seconds 1
• Repeat the freeze-thaw cycle 1
• Immediately follow with intralesional corticosteroid injection 1
• This combination achieves 89-91% success rates, superior to either modality alone 1

Additional Treatment Options

For Small Keloids

• Cryotherapy alone with liquid nitrogen is effective for smaller lesions 1

For Recalcitrant Cases

• Multimodal surgical approach: tissue expansion, excision, followed by intralesional triamcinolone and 5-fluorouracil injections 4
• Surgery alone has extremely high recurrence rates and should never be performed without adjunctive therapy 5, 6

Adjunctive Therapies

• Silicone gel sheeting can be used alongside other treatments 6, 2
• Pressure therapy may provide additional benefit 5, 2
• Pulsed-dye laser therapy has shown success in recent studies 7

Special Considerations

Patients with personal or family history of keloids should avoid any elective procedures causing skin trauma, as this will trigger new keloid formation 1

For infected keloids, treat with standard topical or systemic antibiotics as you would other skin and soft tissue infections 1

Keloids on ears require extra caution due to higher recurrence risk in this location 1

Treatment Algorithm

1. Start with intralesional triamcinolone acetonide injections 3
2. For better results, combine cryotherapy immediately before corticosteroid injection 1
3. Repeat treatments weekly or biweekly until maximum improvement 3
4. If inadequate response after 3-4 months, consider adding 5-fluorouracil to the corticosteroid injections 4
5. Reserve surgical excision only for cases failing conservative therapy, and always combine with immediate postoperative adjunctive treatment 4