What are the treatment options for keloid removal in an adult patient with no significant medical history?

Keloid Treatment Recommendations

Intralesional triamcinolone acetonide (10-40 mg/mL) is the first-line treatment for keloid removal, with higher concentrations (40 mg/mL) recommended for established keloids, and surgical excision should be reserved for refractory cases but must be combined with postoperative radiation therapy to prevent recurrence. 1

First-Line Conservative Management

Intralesional Corticosteroid Therapy

• Triamcinolone acetonide is the most commonly used and effective corticosteroid for keloid treatment, with concentrations of 10-40 mg/mL depending on lesion characteristics 1
• Higher concentrations (40 mg/mL) are specifically recommended for hypertrophic scars and keloids 1
• Response rates show 50-100% regression, though recurrence occurs in 33% at 1 year and 50% at 5 years 2
• Triamcinolone demonstrates faster and more effective response compared to verapamil, though with higher complication rates 2

Pain Management During Injection

• Use a 1:1 mixture of 1% lidocaine with epinephrine rather than topical EMLA cream, as this provides significantly better pain relief during and after corticosteroid injection 3
• Inject with a 26G needle to minimize discomfort 3

Monitoring for Adverse Effects

• Watch for local adverse effects including atrophy, pigmentary changes, telangiectasias, and hypertrichosis 1
• Assess for systemic absorption with repeated injections 1

Adjunctive First-Line Therapies

Silicone Sheeting and Pressure Therapy

• Silicone elastomer sheeting, taping to reduce skin tension, and pressure dressings are evidence-supported first-line treatments 4
• These can be used immediately after trauma in high-risk patients to prevent keloid formation 4

Combination Therapy for Enhanced Results

Triamcinolone Plus 5-Fluorouracil

• The combination of 5-FU and triamcinolone is more effective than either agent alone and shows fewer undesirable effects 2
• While 5-FU alone achieves comparable outcomes to triamcinolone alone, it causes more frequent side effects 2

Triamcinolone Plus Verapamil

• This combination proves effective with statistically significant overall improvements and long-term stable results 2

Surgical Excision: High-Risk Without Adjuvant Therapy

Critical Caveat About Surgery Alone

• Surgical removal of keloids poses a high recurrence risk unless combined with postoperative radiation and/or standard therapies 4
• Surgery alone should never be performed due to the high recurrence rate 4

Surgery Plus Radiation Protocol

• When surgery is necessary for refractory keloids, combine surgical excision with postoperative irradiation followed by immediate intralesional triamcinolone if any signs of recurrence appear 5
• This combination achieved complete cure in 56% of keloids without additional treatment, and 89% showed good results with additional conservative treatment 5
• This represents the most effective approach for forcing keloids into remission 5

Alternative Therapies for Refractory Cases

Laser Therapy

• Laser therapy alone carries a high recurrence rate and should not be used as monotherapy 2
• Better results occur when combining CO2, pulsed-dye, or Nd:YAG lasers with triamcinolone intralesional injections 2

Cryotherapy

• Reserve cryotherapy for smaller lesions only 4

Emerging Options

• Intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections appear beneficial for established keloids 4
• Imiquimod upregulates interferons that inhibit collagen production by fibroblasts 1
• Pulsed dye laser and imiquimod cream are alternative postsurgical options for refractory scars 4

Prevention in High-Risk Patients

Risk Factor Identification

• Patients younger than 30 years with darker skin are at highest risk 4
• Sternal skin, shoulders, upper arms, earlobes, and cheeks are most susceptible sites 4
• Body piercings trigger keloid formation in approximately 2.5% of ear piercings 6
• Strong genetic predisposition exists, with patients having personal or family history facing significantly elevated risk with any skin trauma 6

Preventive Strategies

• Individuals with personal or family history of keloids should be cautioned about any procedures causing skin trauma, as prevention is the best strategy 1
• Implement immediate silicone elastomer sheeting, taping to reduce skin tension, or corticosteroid injections when trauma is anticipated 4
• Watch for infections, which can be treated with standard topical or systemic antibiotics 1

Common Pitfalls to Avoid

• Never perform surgical excision without planning for postoperative radiation therapy and close monitoring for early recurrence 5
• Do not rely on over-the-counter herb-based creams, as evidence is mixed, and there is little evidence that vitamin E is helpful 4
• Avoid laser therapy as monotherapy due to high recurrence rates 2