Intralesional Steroid Treatment for Keloids
Direct Recommendation
Intralesional triamcinolone acetonide (TAC) is an effective first-line treatment for keloids, but combination therapy with 5-fluorouracil (5-FU) is superior due to comparable efficacy with significantly fewer adverse effects, particularly avoiding skin atrophy and telangiectasia. 1
Treatment Algorithm
Initial Assessment and Patient Selection
- Document medical necessity by identifying qualifying symptoms (pain, pruritus, functional impairment) to distinguish from purely cosmetic intervention 2
- Keloid characteristics best suited for intralesional steroids:
First-Line Treatment Protocol
Recommend TAC + 5-FU combination over TAC alone for superior efficacy and safety profile 2, 1
Monotherapy Option (if combination unavailable):
- Triamcinolone acetonide concentration: 10-40 mg/mL 4, 5
- Dosing: 1-20 mg per cm² (maximum 40-80 mg per session) 6, 4
- Injection technique: Deep intralesional injection until blanching occurs 6
- Treatment interval: Every 4 weeks (most common evidence-based interval) 6
- Expected response: 50-100% regression with TAC alone 5
Combination Therapy (Preferred):
- TAC + 5-FU combination achieves comparable clinical outcomes (46% vs 60% remission rates, not statistically significant) but with markedly fewer adverse effects 1
- 5-FU alone shows comparable efficacy to TAC but with higher side effect rates when used as monotherapy 5
Critical Safety Considerations
Major Adverse Effects with TAC Monotherapy
- Skin atrophy: 44% incidence with TAC vs 8% with 5-FU (p < 0.05) 1
- Telangiectasia: 50% incidence with TAC vs 21% with 5-FU (p < 0.05) 1, 2
- Subcutaneous fat atrophy if injection not properly administered 4
- Systemic effects: Adrenal suppression can occur with doses >4 mg/kg 3
Special Anatomic Considerations
Avoid intralesional steroids in periocular keloids due to risk of central retinal artery embolism, even with large-capacity syringes and small-bore cannulas 3
Enhanced Treatment Strategies
Combination with Other Modalities
Radiofrequency + intralesional steroid:
- Achieves 95.4% mean volume reduction over 3-4 sessions 7
- Significant reduction in pliability, height, and erythema (p < 0.001) 7
- Lower recurrence rates compared to steroid alone 7
Pulsed dye laser + intralesional steroid:
- 60% improvement in raised scar appearance, 40% improvement in erythema, 75% improvement in pain/itching 8
- PDL pretreatment makes scar edematous and facilitates steroid injection 8
- Benefits appear summative, not just adjunctive 8
Expected Outcomes and Recurrence
- Recurrence rates with TAC monotherapy: 33% at 1 year, 50% at 5 years 5
- TAC + verapamil combination: More effective with long-term stable results compared to TAC alone 5
- Follow-up duration: Minimum 6 months required to assess recurrence, though most studies have inadequate follow-up 6
Technical Injection Details
Equipment and Technique
- Needle gauge: 26-30 gauge (when reported) 6
- Syringe size: 1 mL (when specified) 6
- Injection endpoint: Continue until blanching occurs 6
- Strict aseptic technique mandatory 4
- Shake vial before use to ensure uniform suspension; discard if agglomerated 4
Anesthesia Considerations
- Local anesthetics used in only 20% of RCTs 6
- Consider for patient comfort, particularly with larger lesions or multiple injections
Common Pitfalls to Avoid
- Using TAC monotherapy in cosmetically sensitive areas when 5-FU or combination therapy would reduce atrophy/telangiectasia risk 1
- Treating large or diffuse keloids with intralesional steroids due to difficulty achieving even distribution and increased systemic absorption 3
- Inadequate follow-up duration (<6 months) missing late recurrences 6
- Injecting periocular keloids without considering safer alternatives due to embolism risk 3
- Failing to document medical necessity (pain, pruritus, functional impairment) leading to denial as cosmetic 2