Treatment of Keloids

• Keloid scars are firm, smooth, hard growths due to spontaneous scar formation. They can arise soon after an injury, or develop months later.
• It may be uncomfortable or itchy, and may be much larger than the original wound
• It is harmless to general health and do not change into skin cancers.

Goals of therapy:

• Relief of symptoms (pain, pruritis), reduction of scar volume, functional & cosmetic improvement

*Data on efficacy of these treatments are limited

Pharmacological options:

• Emollients (creams and oils)
• Intralesional corticosteroid injection, repeated every few weeks.             Availability: IV triamcinolone acetonide

Non-pharmacological options:

• Silicone scar reduction patches/shee or silicone gel
• Pressure dressings
• Surgical excision (but in keloids, excision may result in a new keloid even larger than the original one)
• Cryotherapy
• Superficial X-ray treatment soon after surgery.
• Pulsed dye laser

Scar dressings should be worn for 12 to 24 hours per day, for at least 8 to 12 weeks, and perhaps for much longer.

Minor keloids (<0.5cm)

First line: Intralesional triamcinolone acetonide 10-40mg/ml. Injections can be repeated at four-week intervals

MoA: To control pruritus and pain, increase scar pliability and reduce volume

Adjunctive treatment: silicone gel sheeting, compression

Second line:

Intralesional 5-FU in combination with intralesional corticosteroid, contact/intralesional cryotherapy or laser therapy  

Small-based keloids may be treated with surgical excision and postoperative adjuvant therapy (intralesional corticosteroid, cryotherapy or pressure therapy)

Major keloids

First line: Intralesional triamcinolone acetonide 40mg/ml at intervals of 3 to 4 weeks for 4 to 6 months.

Adjunctive treatment intralesional 5-FU and contact or intralesional cryotherapy

For large earlobe keloids: surgical excision +postoperative intralesional corticosteroid, cryotherapy, compression or radiation therapy.

Administration of intralesional steroid

Intralesional triamcinolone is injected directly into the skin lesion using a fine needle after cleaning the site of injection with alcohol or antiseptic solution. The injection should be intradermal, not subcutaneous, to avoid causing a dent in the skin.

The initial dose per injection site will vary depending on the lesion being treated. Generally, 0.1–0.2 mL is injected per square centimetre of involved skin (until skin blanching is noted). The total dose should not normally exceed 1 or 2 mL per dose. It can be repeated every 4 to 8 weeks.

The corticosteroid can be full strength (eg triamcinolone 10 mg/mL or 40 mg/mL) or diluted with normal saline or local anaesthetic. Typical regimes for triamcinolone intralesional injections include:

• 40 mg/mL for a thick keloid scar
• 10 mg/mL for a moderate thickness hypertrophic scar

The injections may be repeated monthly for a few months while the lesions are active.

References:

1. http://www.dermnetnz.org/dermal-infiltrative/keloids.html
2. UpToDate Keloids and hypertrophic scars