What are the management options for keloid pruritus?

Management of Keloid Pruritus

For keloid-associated pruritus, initiate treatment with intralesional corticosteroid injections as first-line therapy, which addresses both the keloid pathology and the pruritus simultaneously. 1, 2

First-Line Treatment Approach

Intralesional Corticosteroids

• Inject triamcinolone acetonide directly into the keloid tissue, as this addresses both the underlying keloid pathology and provides relief from pruritus 1, 3
• Typical dosing involves intralesional injections repeated at 4-6 week intervals until symptomatic improvement is achieved 1
• This approach is superior to topical therapies alone because keloids require direct tissue-level intervention 3

Adjunctive Topical Therapy

• Apply moderate-to-high potency topical corticosteroids (mometasone furoate 0.1% ointment or betamethasone valerate 0.1% ointment) to the keloid surface between intralesional treatments 4, 5
• Avoid prolonged use beyond 2-4 weeks continuously due to risk of skin atrophy 5
• Menthol 0.5% preparations can provide additional symptomatic relief for pruritus 6, 4

Second-Line Systemic Options

Oral Antihistamines

• Start with non-sedating antihistamines: fexofenadine 180 mg daily or loratadine 10 mg daily for daytime management 6, 4
• For nighttime pruritus interfering with sleep, consider hydroxyzine 25-50 mg at bedtime 6, 4
• Use sedating antihistamines cautiously in elderly patients due to cognitive impairment risk 4

Neuropathic Agents for Refractory Pruritus

• If antihistamines fail after 2-4 weeks, escalate to gabapentin 900-3600 mg daily or pregabalin 25-150 mg daily 6, 4
• These agents target the neurogenic component of keloid-associated pruritus, which is frequently reported 2, 7

Alternative Intralesional Therapies

Bleomycin Injections

• Intralesional bleomycin (3-5 infiltrations at 1-month intervals) achieved 86% good results with significant reduction in keloid volume and functional impairment 8
• This treatment showed effectiveness within the first 2 infiltrations with reduction in pruritus in most patients 8
• Well-tolerated without significant pain during infiltration 8

5-Fluorouracil

• Intralesional 5-fluorouracil can be used as an alternative to corticosteroids, particularly for recalcitrant cases 1, 3

Physical Modalities

Pressure Therapy

• Silicone sheets or elastic compression garments applied continuously can reduce keloid symptoms including pruritus 1
• Requires consistent use for several months to achieve benefit 1

Laser Therapy

• Laser irradiation may provide symptomatic relief for pruritus while also addressing keloid appearance 1

Important Clinical Caveats

Do not use topical capsaicin for keloid pruritus - despite promotion for other pruritic conditions, systematic reviews do not support its use except in uremic pruritus, and it is not indicated for keloid-associated itch 6, 9

Avoid calamine lotion - there is no evidence supporting its use for keloid pruritus 6

Monitor for recurrence - keloid disease commonly recurs regardless of treatment modality, requiring long-term follow-up and potentially combination therapy 1, 7

Address the psychological impact - keloid disease significantly affects quality of life due to disfigurement, intense pruritus, and pain; consider referral for psychological support in distressed patients 6, 2

Treatment Algorithm Summary

1. Start with intralesional corticosteroids (triamcinolone acetonide) as primary therapy 1, 3
2. Add topical corticosteroids (moderate-to-high potency) between injections 4, 5
3. Layer in non-sedating antihistamines if pruritus persists 6, 4
4. Escalate to gabapentin/pregabalin for refractory neurogenic pruritus 6, 4
5. Consider intralesional bleomycin if corticosteroids fail or are contraindicated 8
6. Add pressure therapy with silicone sheets for comprehensive management 1