Intralesional Triamcinolone for Keloid Scars
Yes, intralesional triamcinolone acetonide is strongly recommended as first-line treatment for keloid scars, with a standard concentration of 40 mg/mL injected just beneath the dermis in the upper subcutis. 1
Primary Treatment Recommendation
Intralesional triamcinolone acetonide is indicated as first-line therapy for both keloids and hypertrophic scars, with specific dosing protocols that differ from acne treatment. 1 For keloid scars specifically, use triamcinolone acetonide 40 mg/mL as the standard concentration, though alternative concentrations of 5-10 mg/mL may be considered depending on lesion characteristics. 1
The injection should be placed just beneath the dermis in the upper subcutis—this is deeper than the intradermal placement used for acne nodules. 1
Expected Outcomes and Efficacy
Response to corticosteroid injection alone is variable, with 50-100% regression reported, though recurrence rates are 33% at 1 year and 50% at 5 years. 2 This highlights an important limitation: monotherapy for keloids yields poor long-term results. 1
Combination Therapy for Superior Outcomes
Combination therapy shows better outcomes with fewer side effects than triamcinolone alone. 1 The evidence supports two specific combinations:
Triamcinolone combined with 5-fluorouracil (5-FU) is more effective and shows fewer undesirable effects compared to triamcinolone alone, with lower mean scar height, better erythema scores, and superior observer and patient assessments. 3 The overall complication rate is also lower with combination therapy. 3
Triamcinolone combined with verapamil achieves statistically significant overall improvements with long-term stable results. 2
When comparing triamcinolone to verapamil alone, triamcinolone shows a faster and more effective response, though with a higher complication rate. 2
Adverse Effects and Risk Mitigation
Local atrophy occurs in 44% of patients treated with triamcinolone alone, making this the most consistent side effect. 1 Other local complications include:
To minimize adverse events, decrease concentration from 40 mg/mL to 10 mg/mL or dilute to 5 mg/mL, which significantly reduces atrophy risk. 1 Using lower concentration and volume of corticosteroid is the key mitigation strategy. 1
Systemic complications with repeated injections include hypothalamic-pituitary-adrenal axis suppression, though this is rare. 1
Critical Technical Considerations
Injecting too superficially increases the risk of atrophy and pigmentary changes, while using excessive concentration or volume dramatically increases adverse effect risk. 1 The proper depth is just beneath the dermis in the upper subcutis, which is distinctly different from the intradermal placement used for acne nodules. 1
Common Pitfalls to Avoid
- Do not use triamcinolone monotherapy as definitive treatment—combination therapy is superior for long-term outcomes. 1
- Do not inject too superficially—this is the most common technical error leading to atrophy. 1
- Do not use excessive concentration or volume—start with lower concentrations to minimize adverse effects. 1