What is the best treatment for a keloid (hypertrophic scarring) on the ear after piercing?

Treatment of Ear Keloids After Piercing

For ear keloids following piercing, surgical excision combined with immediate postoperative adjuvant radiotherapy (10 Gy within 24 hours) provides the highest long-term control rate of approximately 79% at 5 years, making it the most effective treatment for definitive management. 1

Initial Assessment and Prevention Counseling

• Keloids occur in approximately 2.5% of ear piercings and represent abnormal scar tissue that proliferates beyond the original injury site 2
• These lesions are aesthetically problematic and may cause itching or pain, warranting treatment in most cases 3
• Prevention is the most cost-effective approach given the difficulty and expense of treating established keloids 4

Treatment Algorithm Based on Evidence Quality

First-Line Definitive Treatment (Highest Quality Evidence)

Surgical excision with immediate postoperative radiotherapy:

• Complete extralesional excision of the keloid with closure using interrupted sutures 1
• Apply 10 Gy of radiation (100 kV photons, 4 mm HVT Al) within 24 hours of surgery 1
• This protocol achieved 91.2% control at 1 year and 79.4% cumulative control at 5 years with no serious toxicity 1
• Cover the operative scar with topical 2% lignocaine-0.25% chlorhexidine gel under transparent adhesive dressing 1

Alternative Surgical Approach (For Patients Declining Radiation)

Excision with loupe magnification plus topical silicone gel:

• Use magnification to identify and remove the keloid tract (present in 73% of cases) and pseudopods for complete clearance 3
• Apply topical liquid silicone gel postoperatively as adjuvant therapy 3
• This approach achieved success in 20 of 22 patients (91%) without requiring painful injections or radiotherapy 3
• The two recurrences were managed with conventional triamcinolone injection 3

Critical surgical principles to minimize recurrence (the "5 As and one B"):

• Asepsis, atraumatic technique, absence of raw surface, avoidance of tension, accurate approximation of wound margins, and complete bleeding control 5
• Consider the "keloid fillet flap" technique: dissect skin over the keloid as a flap, completely remove the keloid mass, then close the flap after trimming 5

Conservative Management (For Patients Refusing Surgery)

Form-pressure therapy:

• Maintain pressure at 24-30 mmHg using a form-pressure device to preserve the natural contours of the pinna 6
• Duration of therapy is approximately 25 weeks 6
• This approach avoids surgery but requires prolonged compliance 6

Intralesional corticosteroid injection:

• Can be used as primary treatment or for managing recurrences after surgery 3, 4
• Less effective as monotherapy compared to surgical approaches 1

Size-Based Treatment Considerations

• Keloids measuring 1-3 cm are ideal candidates for surgical excision with topical silicone gel adjuvant 3
• Lesions less than 0.5 cm or greater than 5 cm may require modified approaches 3

Common Pitfalls to Avoid

• Do not use subcutaneous sutures during closure, as this increases recurrence risk 5
• Avoid primary closure under tension, which compromises healing and increases keloid recurrence 5
• Do not delay adjuvant radiotherapy beyond 24 hours if using the radiation protocol, as timing is critical for efficacy 1
• Recognize that massage, silicone alone, and corticosteroid injection as monotherapy have high failure rates for established keloids 1

Management of Recurrence

• Recurrence is closely related to the coverage method after excision 5
• For recurrences after surgery with silicone gel, use intralesional triamcinolone injection 3
• Consider switching to the surgical excision plus radiotherapy protocol for patients who have failed other approaches 1

Special Population Considerations

• Keloids are more likely to develop when ears are pierced in susceptible age groups (younger patients) 4
• The condition predominantly affects women (6:2 ratio in one series) 5
• Ear piercing accounts for the majority of cases (approximately 79% in one study) 4