Treatment of Keloid Scarring with Kenalog (Triamcinolone Acetonide)
For keloid scarring, inject triamcinolone acetonide (Kenalog) intralesionally at a concentration of 40 mg/mL directly into the keloid tissue, repeating injections every 3-4 weeks until the lesion flattens. 1
Dosing and Concentration
- Use triamcinolone acetonide 40 mg/mL concentration specifically for keloids and hypertrophic scars 1, which is higher than the 10 mg/mL used for inflammatory acne lesions 1
- Inject 0.05-0.1 mL per injection site to achieve localized therapeutic effect 2
- Maximum safe dose is 150 mg per injection site 2
- The injection should be administered just beneath the dermis in the upper subcutis of the keloid 3
Treatment Schedule and Frequency
- Administer injections every 2-4 weeks 1, 2, 4
- Treatment typically requires 20-30 injections over 3-5 years for complete resolution 4
- Most keloids will show flattening and cessation of itching within the first several treatment sessions 5
Expected Outcomes and Recurrence
The evidence shows variable but generally favorable short-term results with significant long-term recurrence:
- Immediate response: 50-100% regression of keloid tissue with complete flattening in the majority of cases 6, 5
- Recurrence rates are substantial: 33% at 1 year and 50% at 5 years 6, 5
- Objective improvement (fair or better results) occurs in approximately 63% of patients, with good or excellent results in 39% 4
- Subjective symptom improvement (itching, pain) occurs in 82% of patients 4
Combination Therapy Considerations
While monotherapy with triamcinolone is the standard approach, combination treatments show enhanced efficacy:
- Triamcinolone combined with 5-fluorouracil (5-FU) is more effective than either agent alone and shows fewer side effects compared to monotherapy 6
- Triamcinolone combined with verapamil produces statistically significant improvements with long-term stable results 6
- Laser therapy (CO2, pulsed-dye, or Nd:YAG) combined with triamcinolone injections reduces recurrence rates compared to laser alone 6
- Intralesional cryotherapy followed by triamcinolone and onabotulinumtoxinA injections has shown success in case reports with high patient satisfaction 7
Adverse Effects and Monitoring
Common local adverse effects are dose-dependent and include:
- Skin atrophy, pigmentary changes, telangiectasias, and hypertrichosis 1, 3, 2
- Mild pain and inflammation at injection site 8
- Risk of sterile abscess formation 1
- Repeated injections can suppress the hypothalamic-pituitary-adrenal axis 1, 2
Critical Contraindications
- Active infection at the injection site 1, 2
- Previous hypersensitivity to triamcinolone 1, 2
- Active tuberculosis or systemic fungal infection (for large injections) 1, 2
- Uncontrolled diabetes, heart failure, or severe hypertension require careful consideration 1, 2
Common Pitfalls to Avoid
- Using too low a concentration: The 10 mg/mL concentration used for acne nodules is insufficient for keloids; 40 mg/mL is required 1
- Inadequate treatment duration: Patients often discontinue treatment prematurely due to pain or lack of immediate improvement, but 20-30 injections over years may be necessary 4
- Injecting too superficially or too deeply: The injection must be placed just beneath the dermis in the upper subcutis for optimal effect 3, 2
- Failing to warn patients about recurrence: With 50% recurrence at 5 years, patients need realistic expectations about long-term outcomes 6, 5
Alternative Approach for Treatment-Resistant Cases
For keloids that have failed corticosteroid monotherapy, consider adding intralesional interferon-alpha2b (twice weekly) to the triamcinolone regimen (every 2 weeks), which produces statistically significant decreases in depth (81.6%) and volume (86.6%) 8. This combination is particularly valuable for patients with a history of failed corticosteroid injections alone 8.