Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

small/single keloid

1st line – individualized local therapy: corticosteroid

Back
ACUTE
|
small/single keloid
1st line – 

individualized local therapy: corticosteroid

The existing evidence to support the ideal treatment of keloids is weak.[24][25]

The first-line treatment will depend on the site, size, etiology, and history of previous treatments. In general terms, single, small keloid scars can be treated with nonsurgical modalities.[17][28]​​​​ Patient preference is a strong determining factor as well, so the number and size of presenting scarring should not preclude consideration of surgery.[17] However, individualized local therapy should typically be considered in patients with small/single keloids before more invasive treatments such as surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

One option for individualized local therapy is corticosteroids. Corticosteroids can be administered as an intralesional or sublesional injection or as a topically applied tape, and may be used in combination with other treatments. Corticosteroid tapes can be used as monotherapy in patients with thin scars. Benefits of a combined approach include enhanced efficacy and minimization of corticosteroid-associated adverse effects.[29][30]​ 

Triamcinolone (as the acetonide salt) is the most commonly used injectable preparation, but little conclusive evidence exists to support definitive treatment protocols. The frequency of administration varies widely in the literature and ranges from 1 to 8 week intervals between each injectable treatment.[33][34]​​​​​​​​ A survey among 102 international plastic surgeons concluded that the most popular interval between injections is 3-4 weeks (31%), closely followed by 4-5 weeks (26%).[35]​ Some proposed protocols also recommended using different doses depending on the volume/dimensions as well as location of the scar.[36][37][38]​​​​​​ Response rates to triamcinolone injections vary considerably from 50% to 100% regression; recurrence rates are estimated to be 33% at year 1 posttreatment and 50% after 5 years.[33]

Intralesional injection is the most popular injection technique. Small diameter needles (ranges between 25 and 30 Gauge) in conjunction with Luer lock or insulin syringes with an integrated needle have been advocated in order to withstand the pressure encountered during injection into stiff scars. Several authors have advised that the needle should be inserted into the papillary dermis (where collagenase is produced) and the substance administered while slowly withdrawing the needle, while others support targeting the mid-dermis level in order to avoid irreversible epidermal atrophy, which is more likely with superficial injection. The principle of inserting the needle within the keloidal lesion (as opposed to neighboring healthy skin) to avoid the development of an iatrogenic keloid has not been substantiated with evidence in the literature. Sublesional injection is an alternative technique to deliver corticosteroid to a keloid scar at the level of deep dermis in an attempt to mitigate the shortcomings of the intralesional technique. A number of different techniques can be employed to minimize discomfort, including local anesthetic creams or injections before the corticosteroid administration. Some clinicians add lidocaine to the corticosteroid to give a 50/50 dilution. Lidocaine has a local anesthetic effect but will not reduce the pain of the injection (though it may make the subsequent pain more tolerable). It is also thought that lidocaine has local effects on fibroblasts, causing reduced collagen production and inhibiting cell proliferation.[39][40]

Complications of intralesional corticosteroid injections are common (reported in up to 63%) and include skin thinning, atrophy of the subdermal fat, telangiectasia, plaque formation, and pigmentary changes.[35] Systemic adverse effects are possible and can lead to adrenal suppression and Cushing syndrome. One systematic review confirmed 18 cases of Cushing syndrome after intralesional triamcinolone administration; 80% of cases occurred in children, and most after administration of more than 40 mg of triamcinolone within a period of 1 month.[35] Systemic hormone imbalance may also develop, which can result in water retention and menstrual irregularities in susceptible women.[24]

Corticosteroid tape (e.g., flurandrenolide) is indicated for first-line treatment of small keloids.[41] Once corticosteroid injections have reduced the thickness of the pathologic scar to a couple of millimeters, corticosteroid tape can be a patient-friendly way to continue corticosteroid delivery to the affected skin. Corticosteroid tape is applied to the index scar with minimal overlap to neighboring skin and needs to be changed regularly. Follow-up is recommended after an initial trial of 3 months in order to assess clinical response.[21] One trial reported no systemic adverse effects after application of flurandrenolide, a moderate-potency corticosteroid tape to scars up to 5% total body surface area for at least 6-8 weeks.[43] One separate observational study reported no systemic complications following at least 12 months of tape application in a mixed adult and pediatric cohort.[44]

Primary options

Corticosteroid injection

triamcinolone acetonide: consult specialist for guidance on intralesional dose

OR

Corticosteroid tape

flurandrenolide topical: (4 micrograms/square cm tape) apply to the affected area(s) every 12-24 hours

1st line – individualized local therapy: antitumor agent

Back
ACUTE
|
small/single keloid
1st line – 

individualized local therapy: antitumor agent

The existing evidence to support the ideal treatment of keloids is weak.[24][25]

The first-line treatment will depend on the site, size, etiology, and history of previous treatments. In general terms, single, small keloid scars can be treated with nonsurgical modalities.[17][28]​​​​ Patient preference is a strong determining factor as well, so the number and size of presenting scarring should not preclude consideration of surgery.[17] However, individualized local therapy should typically be considered in patients with small/single keloids before more invasive treatments such as surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

One option for individualized local therapy is an intralesional/topical antitumor agent (e.g., fluorouracil, bleomycin, mitomycin). Although some guidelines recommend antitumor agents as second-line options for refractory keloids, others suggest they should be considered as part of first-line therapy to help prevent recurrence.[28][45]​​

Intralesional fluorouracil may be used alone or in combination with other treatment modalities (e.g., intralesional corticosteroids, pulse dye laser). The clinical effectiveness of intralesional fluorouracil seems to be similar to corticosteroids, with recurrence rates of up to 47%.[49] One randomized controlled trial (RCT) compared intralesional fluorouracil to triamcinolone injections in 44 keloidal patients. Both treatments were equally effective in reducing keloid volume, but the adverse effects in the fluorouracil group (pain and superficial ulceration) were significantly worse.[50] In another comparative trial of 30 patient with keloids, triamcinolone injection significantly improved volume reduction compared with intralesional fluorouracil, and fluorouracil was associated with more adverse effects (although this difference was nonsignificant).[51]

Bleomycin and mitomycin are alternative injectable treatments to flatten keloids, but they are not commonly used. According to one meta-analysis, intralesional bleomycin significantly improves keloid and hypertrophic scars compared with triamcinolone, fluorouracil, and cryotherapy combined with triamcinolone.[55] In another meta-analysis, topical application of mitomycin on the surgical wound (3-5 minutes every 3 weeks) resulted in a recurrence rate of 16.5% (95% CI: 7.9 to 31.3).[56]

Primary options

fluorouracil: consult specialist for guidance on intralesional dose

Secondary options

bleomycin: consult specialist for guidance on intralesional dose

OR

mitomycin: consult specialist for guidance on intralesional or topical dose

1st line – individualized local therapy: laser therapy

Back
ACUTE
|
small/single keloid
1st line – 

individualized local therapy: laser therapy

The existing evidence to support the ideal treatment of keloids is weak.[24][25]

The first-line treatment will depend on the site, size, etiology, and history of previous treatments. In general terms, single, small keloid scars can be treated with nonsurgical modalities.[17][28]​​​​ Patient preference is a strong determining factor as well, so the number and size of presenting scarring should not preclude consideration of surgery.[17] However, individualized local therapy should typically be considered in patients with small/single keloids before more invasive treatments such as surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

One option for individualized local therapy is laser therapy. Laser modalities are becoming more popular in scar management. In general, flatter keloids are more suitable for laser therapy because the beam can reach an adequate depth of penetration.[21] Two main technologies are employed: vascular lasers and resurfacing lasers (e.g., Er:YAG, carbon dioxide).

One review on laser applications for keloid and hypertrophic scarring concluded that the optimal laser is currently the 585 nanometer (nm) pulsed dye laser (PDL), although the 532 nm frequency laser is also promising; early use of laser modalities in susceptible patients is recommended.[59] One systematic review of eight RCTs concluded that PDL may improve overall scar appearance compared with conventional treatment modalities.[60]

One comparative, randomized split-scar trial compared the effectiveness of PDL (595 nm) versus Nd:YAG laser (1064 nm) modalities in 20 patients with hypertrophic or keloid scars.[61] One month after the last treatment, both modalities produced statistically significant improvements based on Vancouver scar scale assessments (P <0.001), with no significant differences between the two modalities.[61]

The long pulsed Nd:YAG vascular modality should be considered in patients with pigmented skin (Fitzpatrick types IV to VI) to avoid issues with pigmentation changes associated with more superficial wavelengths including PDL therapy.[62]

Resurfacing lasers can be divided into ablative (i.e., removing the epidermis) and nonablative (i.e., leaving the epidermis intact), as well as fractional (i.e., those generating zones of microthermal injury with intervening islands of intact skin, inducing a healing response and scar remodeling) and nonfractional or full beam.[25]

Evidence to support laser-based devices for treatment of keloids is considered early, and further research is warranted to ascertain the strength and longevity of results.[57][63]​​ A review of laser therapy for management of keloids reported a 22% recurrence rate following Er:YAG laser therapy at 8 months’ follow-up.[64]​ After 6 months, recurrence rates following Nd:YAG laser therapy differed based on the keloid site, from 25% over the scapula to 53% for anterior chest lesions. Carbon dioxide laser treatment was associated with recurrence appearing as early as 2 weeks and as late as 3 years posttreatment.[64]​ In general, fully ablative modalities are not recommended for pathologic scars, as they are associated with high recurrence rates.[65]

1st line – individualized local therapy: cryotherapy

Back
ACUTE
|
small/single keloid
1st line – 

individualized local therapy: cryotherapy

The existing evidence to support the ideal treatment of keloids is weak.[24][25]

The first-line treatment will depend on the site, size, etiology, and history of previous treatments. In general terms, single, small keloid scars can be treated with nonsurgical modalities.[17][28]​​​​ Patient preference is a strong determining factor as well, so the number and size of presenting scarring should not preclude consideration of surgery.[17] However, individualized local therapy should typically be considered in patients with small/single keloids before more invasive treatments such as surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

One option for individualized local therapy is cryotherapy. Cryotherapy can be delivered via contact probes or spray formulations. The most popular method involves an intralesional needle probe, which produces rapid freezing from the core of the scar outwards.One literature review concluded that the evidence supporting intralesional cryotherapy is low (level 4).[71]

Clinical experience suggests that intralesional cryotherapy can be considered especially for pedunculated keloids, with scar volume reduction rates reported to range from 51% to 67% after a single treatment. Adverse effects include pain, prolonged healing, and hypopigmentation; rates of recurrence have been reported to be around 24%.[71]

1st line – individualized local therapy: combination therapy

Back
ACUTE
|
small/single keloid
1st line – 

individualized local therapy: combination therapy

The existing evidence to support the ideal treatment of keloids is weak.[24][25]

The first-line treatment will depend on the site, size, etiology, and history of previous treatments. In general terms, single, small keloid scars can be treated with nonsurgical modalities.[17][28]​​​​ Patient preference is a strong determining factor as well, so the number and size of presenting scarring should not preclude consideration of surgery.[17] However, individualized local therapy should typically be considered in patients with small/single keloids before more invasive treatments such as surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

Examples of combination therapies include intralesional fluorouracil plus corticosteroid injections, laser therapy plus corticosteroid injections, or laser therapy plus intralesional fluorouracil.

The consensus in the literature suggests that the addition of intralesional fluorouracil to other scar management modalities - including intralesional corticosteroids and pulse dye laser - improved efficacy versus each treatment alone.[29] The addition of intralesional fluorouracil to triamcinolone injections is believed to ameliorate the combined adverse effect profile because of the decreased dose requirement of each agent. In one meta-analysis of intralesional injections for hypertrophic and keloid scars, the combination of intralesional triamcinolone and fluorouracil injection was more effective than triamcinolone alone in terms of patient assessment, observer assessment, scar height after treatment, as well as erythema score.[30]

In clinical practice, lasers are used in combination with injectables on the basis of good synergistic effects. In one small study, PDL combined with corticosteroid injections yielded a 60% improvement in height, 40% improvement in erythema, and 75% improvement in pruritus.[66]​ Another study used carbon dioxide laser ablation/excision followed with intralesional triamcinolone injections at 3-4 weekly intervals over 6 months, and noted a significant increase in keloid recurrence in patients who did not regularly attend follow-up sessions for corticosteroid administration.[67]​ Fractional carbon dioxide-assisted corticosteroid delivery is gaining in popularity. In a Chinese study of 41 patients with refractory keloids, treatment with eight sessions of fractional carbon dioxide treatment alongside topical triamcinolone application resulted in significant improvement in all components of the patient and observer scar assessment scale.[68]

A very small number of studies have employed intralesional fluorouracil in combination with laser therapy.[52][53][54] ​​​​A 12-week single-blind study of patients with keloid and hypertrophic scars comparing intralesional triamcinolone injection (group 1), intralesional triamcinolone plus fluorouracil injection (group 2), and intralesional triamcinolone plus fluorouracil injection plus 3 sessions of PDL treatment (group 3) concluded that the overall efficacy of groups 2 and 3 were similar, but group 3 produced better results (15% vs. 40% vs. 70% good to excellent improvement for each group according to blinded observers).[52]

2nd line – surgery

Back
ACUTE
|
small/single keloid
2nd line – 

surgery

The existing evidence to support the ideal treatment of keloids is weak.[24][25]

Choice of treatment depends on the site, size, etiology, history of previous treatments, and patient preference.[17] Patients with small/single keloids may be treated with a surgical approach initially if they prefer it. Surgery may be also used for small/single keloids that have not responded adequately to local therapies.

Surgical techniques can be largely divided into intralesional (debulking) and extralesional (radical resection). Surgery should ideally be combined with adjuvant therapies given that the risk of recurrence following surgery alone has been reported to be in the region of 45% to 100%.[72][73]

A number of services offer intralesional (or intramarginal) excision of keloids. This represents a partial excision technique using incisions within the peripheral borders of the keloid scar to a variable depth and wound closure via approximation of the peripheral rims.

There are cellular and histologic arguments to support an extralesional as opposed to the widely practiced intralesional approach; most of the evidence converges toward the fact that intralesional excision leaves behind less apoptotic and more actively fibrogenic fibroblastic populations, explaining the higher recurrence rates following intralesional excision.[74]

A number of parameters have been proposed as key factors for an optimal surgical result including adequate scar excision, undermining, tension relieving deep closure, and dermal approximation using Z-plasty closure.[21]

Adequate scar excision: the scar is ideally removed extralesionally down to a deeper tissue layer, which for an area like the chest would be the deep fascia. It is important to remove the subcutaneous layer of fat in order to allow the visualization of fascial layers and subsequent undermining. In certain situations, total excision is not practical due to the size and location of the scar (e.g., risk of causing deformity in the helical rim) and the core excision method is used; this involves removing the reticular dermal keloid component and using the epidermal and papillary dermal component as a flap.

Undermining: this is an important step in order to slide and approximate layers of tissue and minimize tension during closure.

Tension relieving deep closure: this aspect incorporates the use of deep fascial suture placement. This ensures reduction of tension in the fascial and dermal layers as well as minimization of dead space, which plays a key role in preventing collections. A polydioxanone suture material is recommended in order to maintain tensile strength in the wound/scar for at least 3 months.[73]

Dermal approximation using Z-plasty closure: this aims to disperse superficial tension along the wound, particularly over considerable lengths and/or on high tension areas of the body (e.g., the anterior chest).

Plus – consider postoperative radiation therapy

Back
ACUTE
|
small/single keloid
Plus – 

consider postoperative radiation therapy

Treatment recommended for ALL patients in selected patient group

Radiation therapy is the preferred postoperative adjunct treatment for adults, and referral is recommended. Various types of radiation may be used for the treatment of keloids, including electrons, superficial/orthovoltage x-rays, and brachytherapy.

Radiation therapy is effective for the adjuvant treatment of keloids soon after excision. The evidence for this approach consists of retrospective case series, small RCTs, and comparative cohorts. Most of these studies have flaws, including variable doses and numbers of treatments, the treatment of different keloid sites and hypertrophic scars in the same studies, small patient numbers, short follow-up, and unclear outcomes.[75]

It is generally accepted that theradiation therapy must be started as soon after the surgery as possible (e.g., within 24-48 hours), and that the treatment course should not last more than 1 week.[21] However, there is considerable variation in the dose and numbers of treatments (fractions) used in various centers.[75]

The largest and best-described case series is that of Ogawa et al., in which various cohorts of patients were treated with different doses and numbers of fractions.[76] Up to 2002, they used 15 Gy in 3 fractions for all keloid sites (n=249). They found that earlobe keloids were well controlled with 6% recurrence at 2 years, but that there was a high recurrence rate (40%) with other sites. From 2003 to 2012 the dose was "risk-adapted," so that sites at a high risk of recurrence (e.g., scapular, anterior chest wall, suprapubic) were treated with a higher dose of 20 Gy in 4 fractions, and earlobes (at low risk of recurrence) were treated with a lower dose of 10 Gy in 2 fractions (n=644). This led to a reduction in recurrence of high-risk sites to 13% and preservation of low recurrence rates to earlobes, although auricular sites still had a relatively high risk of 21% recurrence. From 2008 to 2012 there was some modification in surgical technique, in particular the auricular excision technique was changed from wedge excision to core excision, leading to reduction in auricular keloid recurrence rate to 9%. From 2013 to 2017 the radiation therapy fractionation was shortened to 8 Gy in 1 fraction to earlobes, 18 Gy in 3 fractions to high recurrence sites, and other sites to 15 Gy in 2 fractions, with a recurrence rate overall of 9.3% (n=494).[76]

The adverse effects of radiation therapy tend to be minor, with acute skin redness and peeling, leading to changes in pigmentation and telangiectasia (mainly in patients pretreated with corticosteroid injections).[76]​ There is a theoretical risk of radiation-induced carcinoma which is dependent on age, body site, radiation therapy dose, and technique.[78]​ A typical value would be 0.02% lifetime risk of skin cancer for radiotherapy to an earlobe keloid.[76]

Consider – postoperative local therapy

Back
ACUTE
|
small/single keloid
Consider – 

postoperative local therapy

Treatment recommended for SOME patients in selected patient group

Corticosteroid tape or injection may be used as an adjunct following radiation therapy to treat residual inflammation. In select cases, corticosteroids may be used as an alternative to radiation therapy following surgical excision.[17][21]​​​​ This may be done if radiation therapy is contraindicated, if a patient declines radiation therapy, or for keloids on certain areas of the body (e.g., earlobes). However, a specialist should be consulted because corticosteroids alone may not be sufficient to prevent recurrence after surgery. In practice, a nonsurgical approach is often preferred if radiation therapy is not appropriate. Corticosteroid tapes are a patient-friendly way to deliver corticosteroids to the skin and could be used following excision of smaller scars. Corticosteroid injection (intralesional or sublesional) may be preferred for patients with bulkier lesions.

A very small number of studies describe antitumor agents as postoperative adjuncts, but data are scarce and this is not routinely recommended.[54][56]

Primary options

Corticosteroid injection

triamcinolone acetonide: consult specialist for guidance on intralesional dose

OR

Corticosteroid tape

flurandrenolide topical: (4 micrograms/square cm tape) apply to the affected area(s) every 12-24 hours

large/bulky/multiple keloids

1st line – surgery

Back
ACUTE
|
large/bulky/multiple keloids
1st line – 

surgery

The existing evidence to support the ideal treatment of keloids is weak.[24][25]

The first-line treatment will depend on the site, size, etiology, and history of previous treatments. In general, large, bulky, or multiple lesions should be assessed for surgery and adjuvant therapy as these lesions are less likely to respond to local therapies.[17][28]​​​​​ However, patient preference is a strong determining factor as well, so a nonsurgical approach may be used initially for patients who would prefer it.[17] 

Surgical techniques can be largely divided into intralesional (debulking) and extralesional (radical resection). Surgery should ideally be combined with adjuvant therapies given that the risk of recurrence following surgery alone has been reported to be in the region of 45% to 100%.[72][73]

A number of services offer intralesional (or intramarginal) excision of keloids. This represents a partial excision technique using incisions within the peripheral borders of the keloid scar to a variable depth and wound closure via approximation of the peripheral rims.

There are cellular and histologic arguments to support an extralesional as opposed to the widely practiced intralesional approach; most of the evidence converges toward the fact that intralesional excision leaves behind less apoptotic and more actively fibrogenic fibroblastic populations, explaining the higher recurrence rates following intralesional excision.[74]

A number of parameters have been proposed as key factors for an optimal surgical result including adequate scar excision, undermining, tension relieving deep closure, and dermal approximation using Z-plasty closure.[21]

Adequate scar excision: the scar is ideally removed extralesionally down to a deeper tissue layer, which for an area like the chest would be the deep fascia. It is important to remove the subcutaneous layer of fat in order to allow the visualization of fascial layers and subsequent undermining. In certain situations, total excision is not practical due to the size and location of the scar (e.g., risk of causing deformity in the helical rim) and the core excision method is used; this involves removing the reticular dermal keloid component and using the epidermal and papillary dermal component as a flap.

Undermining: this is an important step in order to slide and approximate layers of tissue and minimize tension during closure.

Tension relieving deep closure: this aspect incorporates the use of deep fascial suture placement. This ensures reduction of tension in the fascial and dermal layers as well as minimization of dead space, which plays a key role in preventing collections. A polydioxanone suture material is recommended in order to maintain tensile strength in the wound/scar for at least 3 months.[73]

Dermal approximation using Z-plasty closure: this aims to disperse superficial tension along the wound, particularly over considerable lengths and/or on high tension areas of the body (e.g., the anterior chest).

Plus – consider postoperative radiation therapy

Back
ACUTE
|
large/bulky/multiple keloids
Plus – 

consider postoperative radiation therapy

Treatment recommended for ALL patients in selected patient group

Radiation therapy is the preferred postoperative adjunct treatment for adults, and referral is recommended. Various types of radiation may be used for the treatment of keloids, including electrons, superficial/orthovoltage x-rays, and brachytherapy.

Radiation therapy is effective for the adjuvant treatment of keloids soon after excision. The evidence for this approach consists of retrospective case series, small RCTs, and comparative cohorts. Most of these studies have flaws, including variable doses and numbers of treatments, the treatment of different keloid sites and hypertrophic scars in the same studies, small patient numbers, short follow-up, and unclear outcomes.[75]​

It is generally accepted that the radiation therapy must be started as soon after the surgery as possible (e.g., within 24-48 hours), and that the treatment course should not last more than 1 week.[21] However, there is considerable variation in the dose and numbers of treatments (fractions) used in various centers.[75]

The largest and best-described case series is that of Ogawa et al., in which various cohorts of patients were treated with different doses and numbers of fractions.[76] Up to 2002, they used 15 Gy in 3 fractions for all keloid sites (n=249). They found that earlobe keloids were well controlled with 6% recurrence at 2 years, but that there was a high recurrence rate (40%) with other sites. From 2003 to 2012 the dose was "risk-adapted," so that sites at a high risk of recurrence (e.g., scapular, anterior chest wall, suprapubic) were treated with a higher dose of 20 Gy in 4 fractions, and earlobes (at low risk of recurrence) were treated with a lower dose of 10 Gy in 2 fractions (n=644). This led to a reduction in recurrence of high-risk sites to 13% and preservation of low recurrence rates to earlobes, although auricular sites still had a relatively high risk of 21% recurrence. From 2008 to 2012 there was some modification in surgical technique, in particular the auricular excision technique was changed from wedge excision to core excision, leading to reduction in auricular keloid recurrence rate to 9%. From 2013 to 2017 the radiation therapy fractionation was shortened to 8 Gy in 1 fraction to earlobes, 18 Gy in 3 fractions to high recurrence sites, and other sites to 15 Gy in 2 fractions, with a recurrence rate overall of 9.3% (n=494).[76]

The adverse effects of radiation therapy tend to be minor, with acute skin redness and peeling, leading to changes in pigmentation and telangiectasia (mainly in patients pretreated with corticosteroid injections).[76] There is a theoretical risk of radiation-induced carcinoma which is dependent on age, body site, radiation therapy dose, and technique.[78] A typical value would be 0.02% lifetime risk of skin cancer for radiation therapy to an earlobe keloid.[76]

Consider – postoperative local therapy

Back
ACUTE
|
large/bulky/multiple keloids
Consider – 

postoperative local therapy

Treatment recommended for SOME patients in selected patient group

Corticosteroid tape or injection may be used as an adjunct following radiation therapy to treat residual inflammation. In select cases, corticosteroids may be used as an alternative to radiation therapy following surgical excision.[17][21]​​​​ This may be done if radiation therapy is contraindicated, if a patient declines radiation therapy, or for keloids on certain areas of the body (e.g., earlobes). However, a specialist should be consulted because corticosteroids alone may not be sufficient to prevent recurrence after surgery. In practice, a nonsurgical approach is often preferred if radiation therapy is not appropriate. Corticosteroid tapes are a patient-friendly way to deliver corticosteroids to the skin and could be used following excision of smaller scars. Corticosteroid injection (intralesional or sublesional) may be preferred for patients with bulkier lesions.

A very small number of studies describe antitumor agents as postoperative adjuncts, but data are scarce and this is not routinely recommended.[54][56]

Primary options

Corticosteroid injection

triamcinolone acetonide: consult specialist for guidance on intralesional dose

OR

Corticosteroid tape

flurandrenolide topical: (4 micrograms/square cm tape) apply to the affected area(s) every 12-24 hours

2nd line – individualized local therapy: corticosteroid

Back
ACUTE
|
large/bulky/multiple keloids
2nd line – 

individualized local therapy: corticosteroid

​The existing evidence to support the ideal treatment of keloids is weak.[24][25]

Choice of treatment depends on the site, size, etiology, history of previous treatments, and patient preference.[17] Patients with large/bulky/multiple keloids may be treated with local therapies initially if they prefer it. Local therapies may be also used to treat residual or recurrent lesions after surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

One option for individualized local therapy is corticosteroids. Corticosteroids can be administered as an intralesional or sublesional injection or as a topically applied tape, and may be used in combination with other treatments. Corticosteroid tapes can be used as monotherapy in patients with thin scars. However, bulkier lesions require a more reinforced approach, involving either induction with injectables or combination with other modalities (e.g., lasers). Benefits of a combined approach include enhanced efficacy and minimization of corticosteroid-associated adverse effects.[29][30]

Triamcinolone (as the acetonide salt) is the most commonly used injectable preparation, but little conclusive evidence exists to support definitive treatment protocols. The frequency of administration varies widely in the literature and ranges from 1 to 8 week intervals between each injectable treatment.[33][34] A survey among 102 international plastic surgeons concluded that the most popular interval between injections is 3-4 weeks (31%), closely followed by 4-5 weeks (26%).[35] Some proposed protocols also recommended using different doses depending on the volume/dimensions as well as location of the scar.[36][37][38] Response rates to triamcinolone injections vary considerably from 50% to 100% regression; recurrence rates are estimated to be 33% at year 1 posttreatment and 50% after 5 years.[33]

Intralesional injection is the most popular injection technique. Small diameter needles (ranges between 25 and 30 Gauge) in conjunction with Luer lock or insulin syringes with an integrated needle have been advocated in order to withstand the pressure encountered during injection into stiff scars. Several authors have advised that the needle should be inserted into the papillary dermis (where collagenase is produced) and the substance administered while slowly withdrawing the needle, while others support targeting the mid-dermis level in order to avoid irreversible epidermal atrophy, which is more likely with superficial injection. The principle of inserting the needle within the keloidal lesion (as opposed to neighboring healthy skin) to avoid the development of an iatrogenic keloid has not been substantiated with evidence in the literature. Sublesional injection is an alternative technique to deliver corticosteroid to a keloid scar at the level of deep dermis in an attempt to mitigate the shortcomings of the intralesional technique. A number of different techniques can be employed to minimize discomfort, including local anesthetic creams or injections before the corticosteroid administration. Some clinicians add lidocaine to the corticosteroid to give a 50/50 dilution. Lidocaine has a local anesthetic effect but will not reduce the pain of the injection (though it may make the subsequent pain more tolerable). Lidocaine may also have local effects on fibroblasts, causing reduced collagen production and inhibiting cell proliferation.[39][40]

Complications of intralesional corticosteroid injections are common (reported in up to 63%) and include skin thinning, atrophy of the subdermal fat, telangiectasia, plaque formation, and pigmentary changes.[35] Systemic adverse effects are possible and can lead to adrenal suppression and Cushing syndrome. One systematic review confirmed 18 cases of Cushing syndrome after intralesional triamcinolone administration; 80% of cases occurred in children, and most after administration of more than 40 mg of triamcinolone within a period of 1 month.[35] Systemic hormone imbalance may also develop, which can result in water retention and menstrual irregularities in susceptible women.[24]

Corticosteroid tape (e.g., flurandrenolide) is indicated for first-line treatment of small keloids.[41] Once corticosteroid injections have reduced the thickness of the pathological scar to a couple of millimeters, corticosteroid tape can be a patient-friendly way to continue corticosteroid delivery to the affected skin. Corticosteroid tape is applied to the index scar with minimal overlap to neighboring skin and needs to be changed regularly. Follow-up is recommended after an initial trial of 3 months in order to assess clinical response.[21] One trial reported no systemic adverse effects after application of flurandrenolide, a moderate-potency corticosteroid tape to scars up to 5% total body surface area for at least 6-8 weeks.[43] A separate observational study reported no systemic complications following at least 12 months of tape application in a mixed adult and pediatric cohort.[44]

Primary options

Corticosteroid injection

triamcinolone acetonide: consult specialist for guidance on intralesional dose

OR

Corticosteroid tape

flurandrenolide topical: (4 micrograms/square cm tape) apply to the affected area(s) every 12-24 hours

2nd line –  individualized local therapy: antitumor agent

Back
ACUTE
|
large/bulky/multiple keloids
2nd line – 

individualized local therapy: antitumor agent

​The existing evidence to support the ideal treatment of keloids is weak.[24][25]

Choice of treatment depends on the site, size, etiology, history of previous treatments, and patient preference.[17] Patients with large/bulky/multiple keloids may be treated with local therapies initially if they prefer it. Local therapies may be also used to treat residual or recurrent lesions after surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

One option for individualized local therapy is an intralesional/topical antitumor agent (e.g., fluorouracil, bleomycin, mitomycin).

Intralesional fluorouracil may be used alone or in combination with other treatment modalities (e.g., intralesional corticosteroids, pulse dye laser). The clinical effectiveness of intralesional fluorouracil seems to be similar to corticosteroids, with recurrence rates of up to 47%.[49] One randomized controlled trial (RCT) compared intralesional fluorouracil to triamcinolone injections in 44 keloidal patients. Both treatments were equally effective in reducing keloid volume, but the adverse effects in the fluorouracil group (pain and superficial ulceration) were significantly worse.[50] In another comparative trial of 30 patient with keloids, triamcinolone injection significantly improved volume reduction compared with intralesional fluorouracil, and fluorouracil was associated with more adverse effects (although this difference was nonsignificant).[51]

Bleomycin and mitomycin are alternative injectable treatments to flatten keloids, but they are not commonly used. According to one meta-analysis, intralesional bleomycin significantly improves keloid and hypertrophic scars compared with triamcinolone, fluorouracil, and cryotherapy combined with triamcinolone.[55] In another meta-analysis, topical application of mitomycin on the surgical wound (3-5 minutes every 3 weeks) resulted in a recurrence rate of 16.5% (95% CI: 7.9 to 31.3).[56]

Primary options

fluorouracil: consult specialist for guidance on intralesional dose

Secondary options

bleomycin: consult specialist for guidance on intralesional dose

OR

mitomycin: consult specialist for guidance on intralesional or topical dose

2nd line –  individualized local therapy: laser therapy

Back
ACUTE
|
large/bulky/multiple keloids
2nd line – 

individualized local therapy: laser therapy

​The existing evidence to support the ideal treatment of keloids is weak.[24][25]

Choice of treatment depends on the site, size, etiology, history of previous treatments, and patient preference.[17] Patients with large/bulky/multiple keloids may be treated with local therapies initially if they prefer it. Local therapies may be also used to treat residual or recurrent lesions after surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

One option for individualized local therapy is laser therapy. Laser modalities are becoming more popular in scar management. In general, flatter keloids are more suitable for laser therapy because the beam can reach an adequate depth of penetration.[21] Two main technologies are employed: vascular lasers and resurfacing lasers (e.g., Er:YAG, carbon dioxide).

One review on laser applications for keloid and hypertrophic scarring concluded that the optimal laser is currently the 585 nanometer (nm) pulsed dye laser (PDL), although the 532 nm frequency laser is also promising; early use of laser modalities in susceptible patients is recommended.[59]​ One systematic review of eight RCTs concluded that PDL may improve overall scar appearance compared with conventional treatment modalities.[60]

​One comparative, randomized split-scar trial compared the effectiveness of PDL (595 nm) versus Nd:YAG laser (1064 nm) modalities in 20 patients with hypertrophic or keloid scars.[61] One month after the last treatment, both modalities produced statistically significant improvements based on Vancouver scar scale assessments (P <0.001), with no significant differences between the two modalities.[61]

The long pulsed Nd:YAG vascular modality should be considered in patients with pigmented skin (Fitzpatrick types IV to VI) to avoid issues with pigmentation changes associated with more superficial wavelengths including PDL therapy.[62]

Resurfacing lasers can be divided into ablative (i.e., removing the epidermis) and nonablative (i.e., leaving the epidermis intact), as well as fractional (i.e., those generating zones of microthermal injury with intervening islands of intact skin, inducing a healing response and scar remodeling) and nonfractional or full beam.[25]

Evidence to support laser-based devices for treatment of keloids is considered early, and further research is warranted to ascertain the strength and longevity of results.[57][63]​​ A review of laser therapy for management of keloids reported a 22% recurrence rate following Er:YAG laser therapy at 8 months’ follow-up.[64]​ After 6 months, recurrence rates following Nd:YAG laser therapy differed based on the keloid site, from 25% over the scapula to 53% for anterior chest lesions. Carbon dioxide laser treatment was associated with recurrence appearing as early as 2 weeks and as late as 3 years posttreatment.[64]​ In general, fully ablative modalities are not recommended for pathologic scars, as they are associated with high recurrence rates.[65]

2nd line –  individualized local therapy: cryotherapy

Back
ACUTE
|
large/bulky/multiple keloids
2nd line – 

individualized local therapy: cryotherapy

​The existing evidence to support the ideal treatment of keloids is weak.[24][25]

Choice of treatment depends on the site, size, etiology, history of previous treatments, and patient preference.[17] Patients with large/bulky/multiple keloids may be treated with local therapies initially if they prefer it. Local therapies may be also used to treat residual or recurrent lesions after surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

One option for individualized local therapy is cryotherapy. Cryotherapy can be delivered via contact probes or spray formulations. The most popular method involves an intralesional needle probe, which produces rapid freezing from the core of the scar outwards. One literature review concluded that the evidence supporting intralesional cryotherapy is low (level 4).[71]

Clinical experience suggests that intralesional cryotherapy can be considered especially for pedunculated keloids, with scar volume reduction rates reported to range from 51% to 67% after a single treatment. Adverse effects include pain, prolonged healing, and hypopigmentation; rates of recurrence have been reported to be around 24%.[71]

2nd line –  individualized local therapy: combination therapy

Back
ACUTE
|
large/bulky/multiple keloids
2nd line – 

individualized local therapy: combination therapy

​The existing evidence to support the ideal treatment of keloids is weak.[24][25]

Choice of treatment depends on the site, size, etiology, history of previous treatments, and patient preference.[17] Patients with large/bulky/multiple keloids may be treated with local therapies initially if they prefer it. Local therapies may be also used to treat residual or recurrent lesions after surgery.

Treatments may be combined or used sequentially to improve efficacy and minimize adverse effects. Preferred options are not well defined due to limited evidence. Take an individualized approach after discussing treatment options and goals with the patient.

Examples of combination therapies include intralesional fluorouracil plus corticosteroid injections, laser therapy plus corticosteroid injections, or laser therapy plus intralesional fluorouracil.

The consensus in the literature suggests that the addition of intralesional fluorouracil to other scar management modalities - including intralesional corticosteroids and pulse dye laser - improved efficacy versus each treatment alone.[29] The addition of intralesional fluorouracil to triamcinolone injections is believed to ameliorate the combined adverse effect profile because of the decreased dose requirement of each agent. In one meta-analysis of intralesional injections for hypertrophic and keloid scars, the combination of intralesional triamcinolone and fluorouracil injection was more effective than triamcinolone alone in terms of patient assessment, observer assessment, scar height after treatment, as well as erythema score.[30]

In clinical practice lasers are used in combination with injectables on the basis of good synergistic effects. In one small study, PDL combined with corticosteroid injections yielded a 60% improvement in height, 40% improvement in erythema, and 75% improvement in pruritus.[66] Another study used carbon dioxide laser ablation/excision followed with intralesional triamcinolone injections at 3-4 weekly intervals over 6 months, and noted a significant increase in keloid recurrence in patients who did not regularly attend follow-up sessions for corticosteroid administration.[67] Fractional carbon dioxide-assisted corticosteroid delivery is gaining in popularity. In a Chinese study of 41 patients with refractory keloids, treatment with eight sessions of fractional carbon dioxide treatment alongside topical triamcinolone application resulted in significant improvement in all components of the patient and observer scar assessment scale.[68]

A very small number of studies have employed intralesional fluorouracil in combination with laser therapy.[52][53][54] A 12-week single-blind study of patients with keloid and hypertrophic scars comparing intralesional triamcinolone injection (group 1), intralesional triamcinolone plus fluorouracil injection (group 2), and intralesional triamcinolone plus fluorouracil injection plus three sessions of PDL treatment (group 3) concluded that the overall efficacy of groups 2 and 3 were similar, but group 3 produced better results (15% vs. 40% vs. 70% good to excellent improvement for each group according to blinded observers).[52]

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