Treatment of Keloid Scars
Primary Recommendation
The best strategy for keloid scars is prevention—patients with a personal or family history of keloids should be counseled to avoid any procedures that puncture or traumatize the skin, as the outcome of keloid formation is uncertain whenever there is skin trauma. 1
Prevention Strategy (First-Line Approach)
- Patients with darker skin tones are at higher risk for keloid formation and should be specifically counseled about avoiding elective procedures that traumatize the skin (including tattooing, piercing, and scarification). 2
- The American Academy of Dermatology recommends considering keloid risk when using aggressive treatments like cryotherapy or surgical excision in high-risk patients. 2
- Family history of keloids is a critical risk factor—anyone with affected family members should be informed that scarification and other body modifications carry uncertain outcomes. 1
Treatment Options for Established Keloids
Non-Invasive First-Line Treatment
Silicone gel sheeting (SGS) is the primary non-invasive treatment option, applied at least 4 hours per day for optimal results. 3
- SGS significantly improves keloid color, thickness, and elasticity regardless of scar maturity. 3
- Pain and itching clearly decrease after 4 weeks of SGS application and typically disappear after 12 weeks. 4
- Reduction in scar redness and elevation requires 12 weeks of continuous treatment. 4
- SGS works by decreasing mast cell numbers and enhancing Fas antigen expression in lesional fibroblasts. 4
Important caveat: The evidence quality for SGS is very low due to small sample sizes and methodological limitations, though clinical experience supports its use as a safe, easily applied first-line option. 5, 6
Invasive Treatment Options
Intralesional corticosteroid injections (triamcinolone acetonide) represent the primary invasive treatment modality. 7, 5
- This is typically combined with other modalities rather than used as monotherapy. 7
- Surgery alone carries high recurrence risk and should generally be avoided as monotherapy. 7
- Radiotherapy may be considered as adjunctive treatment post-surgery. 7
Emerging Therapies
Novel treatments include chemotherapy, immunotherapy, and anti-inflammatory therapies, though these remain investigational. 7
Special Considerations for Bleeding Disorders
- Patients on anticoagulants or with bleeding disorders should avoid invasive treatments (intralesional injections, surgery, cryotherapy) until bleeding risk is adequately managed.
- Non-invasive options like silicone gel sheeting become the preferred approach in these patients. 3, 4
Treatment Algorithm
- Prevention counseling for high-risk patients (darker skin, family history) to avoid elective skin trauma 1, 2
- Silicone gel sheeting as first-line treatment for established keloids (≥4 hours daily for minimum 12-24 weeks) 3, 4
- Intralesional corticosteroids for keloids not responding to SGS, unless contraindicated by bleeding risk 7, 5
- Combination therapy (surgery + radiotherapy or surgery + corticosteroids) for refractory cases 7
Critical Pitfalls to Avoid
- Never perform surgical excision alone—keloids have extremely high recurrence rates without adjunctive therapy. 7
- Avoid aggressive treatments (cryotherapy, surgery) in darker-skinned individuals without thorough counseling about keloid risk. 2
- Do not discontinue silicone gel sheeting prematurely—minimum 12 weeks needed for structural improvement, though symptomatic relief occurs earlier. 4
- Keloids continue to pose significant treatment challenges due to lack of highly efficacious options, so realistic expectations must be set with patients. 7