What are the treatment options for keloid scars?

Keloid Scar Treatment

Intralesional triamcinolone acetonide (10-40 mg/mL) is the first-line treatment for keloid scars, with higher concentrations (40 mg/mL) recommended for optimal results. 1

First-Line Treatment: Intralesional Corticosteroids

• Triamcinolone acetonide (TAC) remains the gold standard, achieving 50-100% regression rates, though recurrence occurs in 33% at 1 year and 50% at 5 years. 2

• Use concentrations of 10-40 mg/mL, with 40 mg/mL specifically recommended for keloids and hypertrophic scars. 1

• Inject at 3-week intervals until adequate response is achieved. 3

• Monitor for local adverse effects including skin atrophy (44% incidence), telangiectasias (50% incidence), pigmentary changes, and hypertrichosis. 1, 4

• Assess for systemic absorption with repeated injections, particularly with extensive treatment areas. 1

Combination Therapies (Superior to Monotherapy)

TAC + Cryotherapy (Highest Success Rate)

• This combination achieves 89-91% success rates, superior to either treatment alone. 5

• Apply liquid nitrogen cryotherapy for 15-20 seconds until 1-2 mm of surrounding skin appears frozen, allow 20-60 seconds thawing, then repeat the cycle. 5

• Immediately follow with intralesional corticosteroid injection while tissue is still edematous. 5

TAC + 5-Fluorouracil (Fewer Side Effects)

• The combination of TAC and 5-FU is more effective than either agent alone and produces fewer adverse effects compared to TAC monotherapy. 2

• 5-FU alone achieves comparable efficacy to TAC (46% vs 60% remission at 6 months, not statistically significant), but with significantly lower rates of skin atrophy (8% vs 44%) and telangiectasia (21% vs 50%). 4

• Consider 5-FU for cosmetically sensitive areas such as the face and neck where atrophy and telangiectasia are particularly problematic. 4

TAC + Laser Therapy

• Pulsed dye laser (PDL) pretreatment facilitates steroid injection by making the scar edematous and softer. 6

• Combined PDL and TAC improved raised scars by 60%, erythema by 40%, and pain/itching by 75% in recalcitrant keloids. 6

• CO2, pulsed-dye, or Nd:YAG lasers combined with TAC show better results than laser therapy alone, which has high recurrence rates. 2

• Note: Presternal keloids showed no benefit from PDL + TAC combination in one study. 6

Alternative Monotherapy

5-Fluorouracil Alone

• Use when TAC is contraindicated or in steroid-resistant keloids (approximately 50% of keloids are steroid-resistant). 4

• Expect similar clinical outcomes to TAC but with increased fibroblast proliferation on histology and no effect on vascular density. 4

Cryotherapy Alone

• Effective for small keloids when used as monotherapy. 5

• Use the same freeze-thaw-freeze protocol described above. 5

Essential Prevention Counseling

• Warn patients with personal or family history of keloids that any skin trauma (including elective procedures, piercings, tattoos) carries significant keloid risk. 5, 1

• Prevention is the best strategy for those with known keloid tendency. 1

• Mandate UV protection, as sun exposure worsens keloid appearance. 5

Special Considerations

• Ear keloids require heightened vigilance due to higher recurrence risk. 5

• Treat infections with standard topical or systemic antibiotics as you would for other skin and soft tissue infections. 5, 1

• Emerging therapies include imiquimod, which upregulates interferons that inhibit fibroblast collagen production, though more data are needed. 1

Common Pitfalls to Avoid

• Do not use laser therapy alone due to high recurrence rates; always combine with intralesional steroids. 2

• Do not underestimate systemic absorption risk with repeated high-dose TAC injections over large areas. 1

• Do not ignore the 50% steroid resistance rate; if no response after 2-3 injections, switch to 5-FU or combination therapy. 4

• Do not use TAC monotherapy on cosmetically sensitive facial areas without considering 5-FU as a first-line alternative due to lower atrophy risk. 4