What are the treatment options for a violaceous tender keloid?

Differential Diagnosis and Treatment of Violaceous Tender Keloid

Critical First Step: Rule Out Infection and Malignancy

A violaceous, tender keloid requires immediate evaluation to exclude infection (particularly bacterial superinfection), inflammatory conditions, or malignant transformation before proceeding with standard keloid treatment. The violaceous color and tenderness are atypical features that warrant heightened clinical suspicion.

Key Differential Considerations:

• Infected keloid: Look for warmth, purulent drainage, expanding erythema, and systemic signs of infection 1
• Inflammatory keloid: Active proliferative phase with increased vascularity causing violaceous appearance
• Dermatofibrosarcoma protuberans: Can mimic keloid but shows progressive growth and violaceous nodules
• Kaposi sarcoma: Violaceous plaques/nodules, particularly in immunocompromised patients
• Angiosarcoma: Rare but aggressive, presents with violaceous lesions

Immediate Management if Infection Suspected:

• Treat with standard topical or systemic antibiotics if signs of infection are present 1
• Culture any drainage before initiating antibiotics
• Do not proceed with intralesional injections or surgery until infection is cleared

First-Line Treatment for Confirmed Keloid

Once infection and malignancy are excluded, intralesional triamcinolone acetonide at 40 mg/mL is the first-line treatment for keloids, as recommended by the American Academy of Dermatology 1.

Corticosteroid Injection Protocol:

• Concentration: 40 mg/mL triamcinolone acetonide for keloids (higher than the 10-20 mg/mL used for hypertrophic scars) 1
• Frequency: Typically every 4-6 weeks
• Duration: Continue until flattening achieved, usually 12-24 weeks 2
• Monitor for adverse effects: atrophy, pigmentary changes, telangiectasias, hypertrichosis, and systemic absorption with repeated injections 1

Adjunctive Therapy for Symptom Relief:

Silicone gel sheets should be applied continuously to address pain and pruritus while corticosteroid therapy takes effect:

• Pain and itching typically decrease after 4 weeks and disappear by 12 weeks 3
• Sheets reduce mast cell infiltration, which may be responsible for the tenderness 3
• Replace sheets every 4 weeks 4
• Safe, easy to use, and do not aggravate symptoms 4

Second-Line and Combination Therapies

If corticosteroid monotherapy fails after 3-6 months:

Surgical Excision Plus Adjuvant Therapy:

Trepanation (core excision) combined with superficial radiotherapy has shown excellent results with no recurrence at 3-year follow-up in cases resistant to standard treatment 5. This approach is particularly valuable when:

• Previous intralesional corticosteroids have failed 5
• Laser therapy has been ineffective 5
• The keloid is causing significant functional or aesthetic concerns 5

Alternative Combination Approaches:

• 5-fluorouracil with corticosteroids: Intralesional injection for resistant cases 2, 6
• Laser therapy: Carbon dioxide ablative fractional resurfacing, though this failed in one reported case before trepanation was successful 5
• Pressure therapy: Elastic bandages or compression garments as adjunct 2

Prevention Counseling

Patients with keloid history should be cautioned about any procedures causing skin trauma, as prevention is the best strategy for those with known keloid tendency 1. This includes:

• Elective cosmetic procedures
• Piercings
• Tattoos
• Unnecessary biopsies

Treatment Algorithm Summary:

1. Exclude infection/malignancy → Treat infection if present 1
2. Start intralesional triamcinolone 40 mg/mL every 4-6 weeks 1
3. Add silicone gel sheets for symptom control 3, 4
4. Reassess at 12-24 weeks 2
5. If inadequate response: Consider trepanation + radiotherapy 5 or 5-FU combination 2, 6

Common Pitfall to Avoid:

Do not perform surgical excision alone without adjuvant therapy (radiotherapy, corticosteroids, or other modalities), as recurrence rates approach 50-100% with surgery alone 6.