Retinol for Keloid Scars: Limited Evidence with Modest Efficacy
Topical tretinoin (0.05%) can be used for keloid treatment, but it is not a first-line therapy and shows only modest results compared to intralesional corticosteroids or combination treatments. 1
Evidence for Retinoid Use in Keloids
The only direct evidence for topical retinoids in keloid treatment comes from a small 1988 study where 0.05% tretinoin applied topically for 12 weeks showed statistically significant decreases in keloid weight (p < 0.04) and size (p < 0.01) in 9 patients who completed the study. 1 However, 2 of 11 patients discontinued treatment due to irritant contact dermatitis, highlighting the tolerability concerns. 1
The theoretical mechanism involves retinoids affecting collagen metabolism, which could potentially reduce the excessive collagen deposition characteristic of keloids. 1
Current Standard Treatment Approaches
Intralesional corticosteroid injection remains the first-line treatment for keloids, with intralesional treatments showing 64.1% mean reduction in scarring compared to only 34% for topical treatments. 2
For intralesional therapy specifically:
- Combination 5-fluorouracil and triamcinolone (9:1 dilution) appears superior among intralesional options for keloids 2
- Intralesional vitamin D (0.2 ml or 200,000 IU per 1 cm lesion) weekly for 3-4 sessions has shown highly significant improvement in recent studies 3
Protocol If Using Tretinoin for Keloids
Based on the available evidence, if tretinoin is chosen despite limited data:
Application method:
- Use 0.05% tretinoin cream applied topically to the keloid 1
- Apply once daily, preferably at bedtime 4
- Treatment duration of at least 12 weeks is needed to assess response 1
Monitoring and management:
- Watch for irritant contact dermatitis, which occurred in 18% of patients in the available study 1
- If excessive irritation develops, reduce frequency to every other day until tolerance develops 4
- Counsel patients about photosensitivity and need for sun protection 4
- Avoid in pregnancy (Category C) 5
Critical Limitations and Caveats
The evidence for tretinoin in keloids is extremely limited - only one small study from 1988 with 11 patients total. 1 This is in stark contrast to the robust evidence for intralesional corticosteroids and combination therapies. 2
Treatment of keloids requires individualization based on lesion distribution, size, thickness, and inflammation, with combination approaches generally being most effective. 6 Topical tretinoin alone would be considered a weak option compared to established therapies. 2
Retinoids are more established for treating post-inflammatory hyperpigmentation from acne rather than keloid scars themselves. 7 The American Academy of Dermatology specifically recommends azelaic acid for post-inflammatory dyspigmentation, not keloids. 7
Recommended Alternative Approach
Rather than tretinoin monotherapy, consider:
- First-line: Intralesional triamcinolone with or without 5-fluorouracil 2
- Alternative intralesional: Vitamin D 200,000 IU per cm weekly for 3-4 sessions 3
- Adjunctive: Silicone gel sheeting, compression therapy 8
- For recalcitrant cases: Pulsed-dye laser, cryotherapy, or surgical excision with adjunctive radiation 6, 2