What are the treatment options for keloids?

Treatment Options for Keloids

For keloid management, intralesional corticosteroid injections (triamcinolone acetonide 40 mg/mL) represent the current standard of care and should be the first-line treatment for most keloids. 1

First-Line Treatment: Intralesional Corticosteroids

• Triamcinolone acetonide at 40 mg/mL is the mainstay monotherapy, administered via intralesional injection directly into the keloid tissue 1, 2
• The injection can be delivered using a dermajet system for optimal distribution 2
• Treatment typically requires multiple sessions spaced 3-4 weeks apart to achieve optimal results 1
• This approach has demonstrated an 84% control rate in compliant patients when used for early recurrence detection and treatment 2

Combination Therapy for Enhanced Efficacy

When monotherapy proves insufficient, combination approaches significantly improve outcomes:

Corticosteroid + 5-Fluorouracil

• Intralesional injections combining triamcinolone (40 mg/mL) and 5-fluorouracil (50 mg/mL) in a 1:1 ratio administered monthly have shown complete resolution in recurrent cases 3
• This combination addresses both the inflammatory and proliferative components of keloid formation 3

Cryotherapy-Based Combinations

• Cryotherapy with liquid nitrogen followed immediately by intralesional corticosteroids achieves superior success rates of 89-91% 4
• Apply liquid nitrogen for 15-20 seconds until 1-2 mm of circumferential skin appears frozen, thaw for 20-60 seconds, then repeat the freeze cycle 5, 4
• The whitened skin should normalize in color before injecting the corticosteroid 5
• Avoid application over eyelids, nose tip, lips, ears, and cartilaginous structures due to risk of tissue damage 5, 4

Physical and Adjunctive Therapies

Pressure Therapy and Silicone

• Silicone sheets and elastic compression bandages provide non-invasive options, particularly useful for prevention and early lesions 6, 7
• Pressure therapy works best when applied consistently over extended periods 6

Laser Therapy

• CO₂ laser and other laser modalities can be used as adjunctive treatments, though recurrence remains common with laser monotherapy 6, 3
• Laser therapy may be combined with intralesional injections for improved outcomes 6

Radiation Therapy

• Post-surgical radiation can reduce recurrence rates but should be reserved for refractory cases due to long-term risks 6, 7
• Both superficial radiation and brachytherapy applicators are utilized 6

Surgical Approach for Large or Refractory Keloids

When keloids are large, symptomatic, or resistant to conservative management:

• Surgical excision should be combined with adjunctive therapy (never performed as monotherapy due to high recurrence rates) 6, 3
• Use tension-adapted layered closure with sutures selected based on anatomical tension zones to minimize mechanical stress 3
• Immediately initiate postoperative intralesional corticosteroid injections to prevent recurrence 2, 3
• Consider adding polarized light therapy (400-3400 nm) sessions following each injection to promote tissue regeneration 3

Emerging and Alternative Agents

For cases resistant to standard therapy, consider:

• Bleomycin, verapamil, botulinum toxin, or collagenase as intralesional injection alternatives 1
• Dupilumab for severe, refractory cases (emerging evidence) 1, 7
• Pentoxifylline as an oral adjunct 1, 7
• Imiquimod topical application, though evidence is limited primarily to adult data 5, 7

Critical Prevention Considerations

• Patients with personal or family history of keloids face significantly elevated risk with any skin trauma and should be counseled accordingly 8, 4
• UV protection is essential as sun exposure worsens keloid appearance 4
• Body piercings carry approximately 2.5% keloid occurrence risk in ears, with higher rates in other locations 8

Treatment Algorithm

1. Small, recent keloids: Start with intralesional triamcinolone 40 mg/mL monthly
2. Moderate keloids or partial response: Add cryotherapy immediately before corticosteroid injection
3. Large or resistant keloids: Combine triamcinolone with 5-fluorouracil (1:1 ratio) monthly
4. Refractory cases: Surgical excision with layered closure + immediate postoperative intralesional therapy + consider radiation or emerging biologics
5. All cases: Emphasize UV protection and monitor for early recurrence requiring prompt re-treatment

The key pitfall is treating keloids with monotherapy alone—combination approaches consistently outperform single modalities, with recurrence remaining the primary challenge regardless of treatment chosen. 6, 1