Keloid Management: Treatment Options
Intralesional triamcinolone acetonide (10-40 mg/mL) is the first-line treatment for keloids, with higher concentrations (40 mg/mL) recommended for established lesions, and this can be combined with silicone gel or sheeting for optimal outcomes. 1, 2, 3
First-Line Treatment Approach
Intralesional Corticosteroids
- Triamcinolone acetonide is FDA-approved for intralesional keloid treatment and represents the most commonly used first-line therapy 2
- Use concentrations of 10-40 mg/mL, with 40 mg/mL specifically recommended for hypertrophic scars and keloids 1
- Monthly injections are the standard administration schedule 4
- Monitor for local adverse effects including atrophy, pigmentary changes, telangiectasias, and hypertrichosis, as well as systemic absorption with repeated injections 1
- Post-operative steroid injections reduce keloid recurrence to less than 50% 5
Adjunctive Silicone Therapy
- Silicone gel or sheeting should be used in combination with corticosteroid injections as first-line therapy 3
- The therapeutic effect results from occlusion and hydration rather than the silicone material itself 5
- Silicone sheeting has evidence for reducing keloid recurrence 3
Alternative First-Line Option for Needle-Phobic Patients
- Topical clobetasol propionate 0.05% cream under occlusion with silicone dressing (applied daily) is equally effective to intralesional triamcinolone with significantly fewer adverse effects 4
- This approach causes less pain, erythema (17.6% vs 41.2%), hypopigmentation (23.5% vs 35.3%), telangiectasia (17.6% vs 41.2%), and skin atrophy (5.9% vs 23.5%) compared to intralesional injections 4
Second-Line Adjunctive Intralesional Agents
When corticosteroids alone are insufficient, consider adding:
- 5-fluorouracil (5-FU): Can be used as adjunctive intralesional therapy, though results are mixed 3
- Bleomycin: Another intralesional option with variable efficacy 3
- Verapamil: Can be considered as adjunctive intralesional treatment 3
Cryotherapy
- Cryosurgery with liquid nitrogen is effective for small keloids 6
- Apply for 15-20 seconds until 1-2 mm of surrounding skin appears frozen, followed by 20-60 second thawing, then repeat the cycle 6
- Combined cryotherapy immediately followed by intralesional corticosteroid injection achieves superior success rates of 89-91% 6
Laser Therapy
- Laser therapy should be used in combination with intralesional corticosteroids or topical steroids with occlusion to improve drug penetration 3
- The pulsed-dye laser offers symptomatic improvement and reduces erythema associated with keloids 5
- CO2 ablative fractional resurfacing laser has been used, though it may fail as monotherapy 7
Surgical Excision with Radiation
- Excision combined with immediate post-excision radiation therapy is the most effective option for recalcitrant lesions 3
- Excision alone results in 45-100% recurrence rates and should be avoided 5
- A combined approach of trepanation and superficial radiotherapy has shown success with no recurrence at 3-year follow-up 7
Emerging Therapies
- Interferon alpha-2b applied to post-surgical excised keloids shows 18% recurrence rate 8
- Imiquimod 5% can lower recurrence rates on post-shaved keloids to 37.5% at 6 months and 0% at 12 months 8
- Imiquimod upregulates interferons that inhibit collagen production by fibroblasts 9
Prevention Strategies
- Individuals with personal or family history of keloids must be counseled about the risk of any procedure causing skin trauma, as prevention is the best strategy 1, 6
- UV protection is fundamental, as sun exposure worsens keloid scars 6
- Pressure therapy has evidence for reducing keloid recurrence 3
Infection Management
- Treat infections with standard topical or systemic antibiotics as you would other skin and soft tissue infections 1, 6