Management of Long-Standing Painful Keloids
For a keloid that has been present for years and has become painful, initiate intralesional triamcinolone acetonide injections at 40 mg/mL as first-line therapy, with repeat injections every 4-6 weeks until symptom resolution or flattening occurs. 1, 2, 3
Initial Assessment and Treatment Planning
When evaluating a chronic painful keloid, confirm the diagnosis clinically by identifying a raised, firm scar extending beyond the original wound margins with associated pain or pruritus. 4 The pain in long-standing keloids typically indicates active inflammation and ongoing collagen proliferation, making these lesions particularly responsive to corticosteroid therapy. 3
First-Line Treatment: Intralesional Corticosteroids
Triamcinolone Acetonide Protocol
Inject triamcinolone acetonide at 40 mg/mL concentration directly into the keloid using strict aseptic technique. 1, 2 Higher concentrations (40 mg/mL) are specifically recommended for keloids rather than lower concentrations used for hypertrophic scars. 1
Administer injections every 4-6 weeks, continuing until the keloid flattens or symptoms resolve. 3 Response rates range from 50-100% regression, though this is variable. 3
Expect pain relief within days to weeks after the first injection, as corticosteroids rapidly reduce inflammation and inhibit collagen synthesis. 3
Monitoring for Adverse Effects
Watch for local complications at each follow-up visit, including:
- Skin atrophy (thinning at injection site) 1
- Pigmentary changes (hypopigmentation or hyperpigmentation) 1
- Telangiectasias (visible small blood vessels) 1
- Hypertrichosis (excessive hair growth) 1
With repeated injections, assess for systemic corticosteroid absorption, particularly if treating large or multiple keloids. 1
Second-Line and Combination Therapies
If Inadequate Response to Triamcinolone Alone
Combine triamcinolone acetonide with 5-fluorouracil (5-FU) intralesional injections. 3 This combination is more effective than either agent alone and shows fewer side effects compared to monotherapy. 3 The synergistic effect addresses both inflammation and abnormal fibroblast proliferation. 5
Alternative: Triamcinolone Plus Verapamil
Consider combining triamcinolone with verapamil for patients who fail monotherapy. 3 This combination achieves statistically significant improvements with long-term stable results, though triamcinolone alone shows faster initial response. 3
Surgical Considerations for Refractory Cases
When to Consider Excision
Reserve surgical excision for keloids that fail medical management after 6-12 months of intralesional therapy. 6, 7 Surgery alone carries high recurrence rates (27% overall, 74% in those followed >1 year). 6
Excision Plus Adjuvant Therapy
If surgery is necessary:
Perform complete excision followed immediately by adjuvant radiation therapy to reduce recurrence risk. 6, 5 However, evidence remains equivocal, with recurrence rates still substantial even with this aggressive approach. 6
Alternatively, use CO2 laser resection allowing healing by secondary intention, followed by early detection and treatment of recurrence with triamcinolone 40 mg/mL via dermajet injection. 7 This protocol achieved 84% control rates in compliant patients. 7
Critical Pitfalls to Avoid
Never perform surgical excision without planning for adjuvant therapy, as surgery alone has unacceptably high recurrence rates. 6, 5 Most recurrences occur more than 1 year after treatment, necessitating long-term follow-up. 6
Do not inject triamcinolone subcutaneously or superficially—the injection must be intralesional (directly into the keloid tissue) to be effective. 2 Subcutaneous injection causes fat atrophy without treating the keloid. 2
Warn patients with keloid history to avoid elective procedures causing skin trauma, as prevention is the most effective strategy. 1 Any future injury may trigger new keloid formation. 1
Treatment Algorithm for Painful Chronic Keloids
- Start with intralesional triamcinolone acetonide 40 mg/mL every 4-6 weeks 1, 2, 3
- If partial response after 3 injections, add 5-FU to the triamcinolone regimen 3
- If no response after 6 months of combination therapy, consider surgical excision with adjuvant radiation 6, 5
- Monitor all patients for at least 2 years post-treatment, as late recurrences are common 6, 7
Managing Infection Risk
If the keloid surface is broken or shows signs of secondary infection, add topical or systemic antibiotics before initiating corticosteroid therapy. 1 Corticosteroids can mask infection and impair healing if infection is present. 1