What is the role of Triamcinolone (Kenalog) injection after keloid excision surgery?

From the Guidelines

Triamcinolone injections are recommended after keloid surgery to reduce the risk of keloid recurrence. The provided evidence, although focused on alopecia areata, highlights the effectiveness of intralesional corticosteroids, such as triamcinolone acetonide, in modulating abnormal tissue responses 1. Typically, the first injection of triamcinolone acetonide (10-40 mg/ml, with lower concentrations for facial keloids) should be administered 2-3 weeks after surgery, followed by monthly injections for 3-6 months depending on the response. The medication is injected directly into the surgical site using a 27-30 gauge needle, with the dose varying based on the size of the treated area.

Key Considerations

• Patients should be monitored for side effects including skin atrophy, hypopigmentation, telangiectasia, and pain at the injection site.
• Cold compresses can help manage post-injection discomfort.
• Triamcinolone works by suppressing inflammation and inhibiting fibroblast proliferation, which are key factors in keloid formation.
• This combination approach of surgery followed by steroid injections significantly improves outcomes compared to surgery alone, as keloids have a high recurrence rate (50-80%) when treated with surgery only.
• The injections help modulate the abnormal wound healing response that leads to excessive collagen production in keloid formation.

Administration and Monitoring

• Hydrocortisone acetate (25 mg mL) and triamcinolone acetonide (5–10 mg mL) are commonly used for intralesional injections 1.
• An injection of 0.05–0.1 mL will produce a localized effect, and multiple injections may be given, with the main limitation being patient discomfort.
• Intralesional corticosteroids may also be administered by a needleless device, which should be sterilized between patients to prevent infection.

Given the high recurrence rate of keloids with surgical treatment alone, the use of triamcinolone injections post-surgery is a crucial adjunct therapy to minimize the risk of recurrence and improve patient outcomes in terms of morbidity, mortality, and quality of life. Although the provided studies primarily discuss the treatment of alopecia areata, the principle of using intralesional corticosteroids to modulate tissue responses can be applied to the management of keloids, emphasizing the importance of evidence-based practice in dermatology 1.

From the Research

Triamcinolone Injection after Keloid Surgery

• The use of triamcinolone injections after keloid surgery has been studied as a method to prevent recurrence of keloids 2, 3.
• A study published in 2017 found that the combination of surgery using the "fillet technique" and intra-lesional injections of triamcinolone 10 mg/ml every 4-6 weeks for 6 months resulted in a recurrence rate of 0% in the treated subgroup 2.
• Another study from 1992 used a protocol that employed carbon dioxide laser resection of the keloid and then allowed the open wound bed to heal by secondary intention, with careful follow-up and treatment of early recurrences with injection consisting of 40 mg/mL of triamcinolone acetonide, resulting in a control rate of 84% with compliant patients 3.
• The effectiveness of triamcinolone injections in preventing keloid recurrence is also supported by a systematic review of prospective, clinical, controlled trials, which found that adjuvant treatment methods, including intralesional triamcinolone injection, can be effective in preventing keloid recurrence, but minimizing dosages should be considered to avoid adverse events 4.

Comparison with Other Treatments

• Other treatments for keloids, such as silicone gel sheeting, pressure therapy, and imiquimod 5% cream, have also been studied and found to have some effectiveness in preventing or treating keloids 5, 6.
• A systematic review of silicone gel sheeting for preventing and treating hypertrophic and keloid scars found that it can reduce the incidence of hypertrophic scarring and improve scar thickness and color, but the evidence is weak and susceptible to bias 6.
• Imiquimod 5% cream has been found to reduce keloid recurrences after surgery, but more research is needed to confirm its effectiveness 5.

Key Findings

• The combination of surgery and adjuvant treatment, including triamcinolone injections, can be effective in preventing keloid recurrence 2, 4.
• Minimizing dosages of triamcinolone injections should be considered to avoid adverse events 4.
• Other treatments, such as silicone gel sheeting and imiquimod 5% cream, may also be effective in preventing or treating keloids, but more research is needed to confirm their effectiveness 5, 6.