What is the recommended protocol for administering intralesional steroids (corticosteroids) for treating keloids in a patient at a clinic?

Intralesional Steroid Administration Protocol for Keloids

Use triamcinolone acetonide at 10-20 mg/mL concentration, injecting 0.05-0.1 mL per site just beneath the dermis in the upper subcutis, with treatment repeated every 4 weeks for up to 6 sessions, though combination therapy with 5-fluorouracil demonstrates superior efficacy and fewer side effects. 1, 2

Patient Selection Criteria

Ideal keloid characteristics:

• Small, well-localized lesions are best suited for intralesional steroid therapy 3
• Focal, bulky keloids respond well to this approach 3
• Avoid flat or superficial lesions due to significantly increased risk of local complications including atrophy and pigmentary changes 3, 1
• Never inject periocular keloids due to risk of central retinal artery embolism, even with proper technique 3

Injection Technique and Dosing

Standard protocol:

• Use triamcinolone acetonide concentration of 10-20 mg/mL 1
• Inject 0.05-0.1 mL per injection site 1
• Place injection just beneath the dermis in the upper subcutis of the affected area 1
• Repeat injections every 4 weeks 4
• Most lesions respond within 3 months; change treatment if no substantial improvement occurs after a complete course 1

Advanced tunneling technique:

• A tunneling method of steroid delivery shows significantly higher effectiveness scores at 1 and 6 months compared to conventional injection 5
• This technique allows longer intervals between treatments and reduces side effect occurrence 5

Anesthesia Considerations

• Local anesthetics may be used for patient comfort, particularly with larger lesions or multiple injections 3

Combination Therapy (Preferred Approach)

Triamcinolone acetonide 40 mg/mL combined with 5-fluorouracil 50 mg/mL demonstrates superior outcomes:

• 95% of patients achieve good to excellent response versus 70% with triamcinolone alone 2
• Faster response rate compared to monotherapy 2
• Significantly fewer side effects: atrophy occurs in only 3% versus 9.1% with triamcinolone alone, and telangiectasia in 3% versus 6.1% 2
• This combination is more effective than either agent used individually 6, 2

Critical Safety Considerations

Dose limitations:

• Keep total dose below 4 mg/kg to prevent systemic adrenal suppression 3, 1
• Avoid high injection pressures and volumes to prevent vascular complications 1

Common adverse effects to monitor:

• Skin atrophy at injection sites is the most consistent side effect 1
• Local complications include fat/dermal atrophy, pigmentary changes, and telangiectasia 1, 4, 2
• Telangiectasia occurs more frequently with standard triamcinolone concentrations 3

Contraindications:

• Active infections at the injection site 7
• Known hypersensitivity to triamcinolone 7
• Use with caution in patients with diabetes, heart failure, or severe hypertension 7

Expected Outcomes

• Volume reduction of 79-83% can be expected with intralesional steroid therapy 4
• Significant improvement in hardness, elevation, and redness occurs with treatment 4
• Subjective symptoms (itching, pain, tenderness) improve significantly 4
• Recurrence rates are 33% at 1 year and 50% at 5 years with steroid monotherapy 6

Alternative Adjunctive Therapies

• Radiofrequency followed by intralesional steroid achieves 95.4% mean volume reduction with less recurrence 8
• Laser therapy (CO2, pulsed-dye, or Nd:YAG) combined with triamcinolone shows better results than laser alone 6
• Intralesional botulinum toxin type A 5 IU/cm³ every 8 weeks provides comparable efficacy with better tolerability, though more expensive 4