What are the treatment options for keloids?

Treatment of Keloids

Intralesional triamcinolone acetonide (10-40 mg/mL) is the standard of care and first-line treatment for keloids, with higher concentrations (40 mg/mL) recommended for thicker or more resistant lesions. 1, 2

First-Line Monotherapy: Intralesional Corticosteroids

• Administer triamcinolone acetonide injections every 3-4 weeks until the keloid flattens or symptoms improve 1
• Use 10-40 mg/mL concentration, selecting 40 mg/mL for hypertrophic scars and thicker keloids 1, 2
• Expect 50-100% regression with monotherapy, though recurrence occurs in 33% at 1 year and 50% at 5 years 3, 4
• Monitor for local adverse effects including skin atrophy, pigmentary changes (hypopigmentation/depigmentation), telangiectasias, and hypertrichosis with repeated injections 1, 2, 5
• Assess for systemic absorption with repeated injections 2

Combination Therapies for Enhanced Efficacy

Cryotherapy Plus Intralesional Steroids

• Apply liquid nitrogen with a cotton-tipped applicator for 15-20 seconds until 1-2 mm of circumferential skin around the lesion appears frozen 1
• Allow to thaw for 20-60 seconds, then repeat the freeze step 1
• Repeat the entire process at 3-week intervals until healing occurs 1
• When combining 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 1
• Avoid cryotherapy on eyelids, tip of nose, lips, mucous membranes, cartilaginous structures, or superficial nerves 1
• Use with caution in patients with darker skin as both hypo- and hyperpigmentation can result 1

Triamcinolone Plus 5-Fluorouracil

• The combination of 5-FU and triamcinolone acetonide is more effective and shows fewer undesirable effects compared to either agent alone 3
• This combination achieves better outcomes than monotherapy with either drug 3

Triamcinolone Plus Verapamil

• Triamcinolone combined with verapamil achieves effective results with statistically significant overall improvements and long-term stable results 3
• Triamcinolone alone shows faster and more effective response than verapamil alone, though with a higher complication rate 3

Surgical Excision Plus Perioperative Corticosteroids

• For earlobe keloids specifically, excision combined with perioperative intralesional triamcinolone acetonide can be used as first-line therapy 6
• Administer preoperative intralesional triamcinolone acetonide injection twice at 1-month intervals 6
• Give postoperative intralesional injections every 1 month for several months depending on clinical progress (typically 2-13 times, mean 5.2 times) 6
• This approach achieves good results in 61% of cases with a recurrence rate of 17% 6
• Excision combined with steroid therapy gives no better results than injection therapy alone for non-earlobe keloids 4

Alternative and Emerging Therapies

• Imiquimod has been noted to be effective in treating keloids by upregulating interferons that inhibit collagen production by fibroblasts 1, 2
• Other options include bleomycin, verapamil, hyaluronic acid and hyaluronidase, botulinum toxin, collagenase, laser therapy, radiofrequency ablation, radiation, extracorporeal shockwave therapy, pentoxifylline, and dupilumab 7
• Laser therapy alone (CO2, pulsed-dye, or Nd:YAG) is burdened with high recurrence rates, but better results occur when combined with triamcinolone acetonide intralesional injections 3

Critical Prevention Strategies

• Prevention is the best strategy for individuals with personal or family history of keloids 2, 8
• Caution patients about any procedures that cause skin trauma, as there is a strong genetic component to keloid formation 2, 8
• Consider prophylactic treatment for high-risk patients undergoing surgery 1
• Body piercings trigger keloid formation in approximately 2.5% of ear piercings 8

Management of Complications

• Monitor for secondary infections, which can be treated with standard topical or systemic antibiotics 1, 2
• Hypopigmentation from corticosteroid injections is typically self-limiting and repigments successfully without clinical intervention 5