Medications for Hypertrophic Scars
Intralesional triamcinolone acetonide 40 mg/mL is the first-line medication for hypertrophic scars, injected directly into the scar tissue at intervals ranging from weekly to monthly until flattening occurs. 1
Primary Pharmacologic Treatment
Intralesional Corticosteroid Therapy
Triamcinolone acetonide represents the gold standard medication based on the highest quality evidence available:
- Use triamcinolone acetonide 40 mg/mL concentration specifically for hypertrophic scars 1, 2
- Inject directly into the scar tissue intralesionally, avoiding healthy surrounding tissue 1
- Treatment frequency: weekly to monthly depending on scar response 1
- Expected response: most scars flatten within 48-72 hours after injection 1
The combination of triamcinolone with fluorouracil (5-FU) shows superior efficacy compared to triamcinolone alone, with significant improvements in scar height, pliability, and pigmentation 3. This represents the highest level of evidence (Level 1) for intralesional therapy.
Technical Injection Protocol
- Mark scar borders with skin-safe markers before treatment 1
- Use 25-27 gauge needles for injection 1
- Monitor and document scar evolution at each visit, ideally with photography 1
- Continue treatment until satisfactory flattening is achieved 1
Topical Medication Options
Silicone-Based Therapy
Silicone gel or sheeting is the primary topical medication with Level 1 evidence:
- Apply silicone gel twice daily for at least 6 months 4
- Expected reduction: approximately 37% mean scar thickness reduction (range 20-54%) 4
- Silicone gel sheets and topical silicone both show significant improvement in scar height, pliability, and pigmentation 3
- The mechanism involves occlusion and hydration rather than silicone itself 5
Pressure Therapy
- Pressure devices reduce scar height through local tissue hypoxia 5
- Pressure therapy combined with silicone shows Level 1 evidence for efficacy 3
- Apply continuous pressure for optimal results 3
Absolute Contraindications to Intralesional Corticosteroids
Do not inject triamcinolone if any of the following are present:
- Active infection at injection site 1
- Previous hypersensitivity to triamcinolone 1
- Active tuberculosis or systemic fungal infection 1
- Extensive plaque psoriasis, pustular psoriasis, or erythrodermic psoriasis 1
- Active peptic ulcer disease 1
- Uncontrolled diabetes, heart failure, or severe hypertension 1
- Severe depression or psychosis 1
Monitoring for Adverse Effects
Local Complications from Intralesional Steroids
- Skin atrophy 1
- Pigmentary changes (hypo- or hyperpigmentation) 1
- Telangiectasias 1
- Hypertrichosis 1
- Steroid acne 1
- Contact allergic dermatitis from benzyl alcohol preservative 1
- Sterile abscess formation 1
Systemic Concerns
- Repeated injections can suppress the hypothalamic-pituitary-adrenal axis 1
- Rare anaphylaxis, angioedema, and urticaria 1
- Check injection sites at every visit, or at least annually 1
Treatment Algorithm
For localized hypertrophic scars (1-10 lesions):
- Start with intralesional triamcinolone acetonide 40 mg/mL 1, 3
- Consider adding 5-FU to triamcinolone for enhanced efficacy 3
- Inject weekly to monthly until flattening occurs 1
For widespread hypertrophic scars:
- Topical silicone gel applied twice daily is the primary option 4
- Add pressure therapy if anatomically feasible 3, 5
- Continue for minimum 6 months 4
Note: Intralesional therapy is not practical for patients with multiple widespread lesions 1. In these cases, topical silicone-based therapy becomes the primary medication approach.
Important Clinical Caveats
- Simple excision without adjunct medication therapy results in 45-100% recurrence 5
- Post-operative intralesional steroid injections reduce keloid recurrence to less than 50% 5
- Cryosurgery is most effective when combined with intralesional corticosteroids rather than used alone 5
- The evidence base remains limited, with only 9 high-quality studies meeting Level 1 criteria 3