Keloids: a review of therapeutic management

Key points

• Keloids extend beyond the original wound and fail to regress; there is still no gold-standard treatment with a consistently low recurrence rate, so management is multimodal.
• Intralesional triamcinolone acetonide (10-40 mg/ml every 4-6 weeks) remains the most common first-line treatment, with recurrence of about 33% at 1 year and 50% at 5 years.
• Triamcinolone combined with 5-fluorouracil was more effective than triamcinolone alone in a meta-analysis.
• Excision alone carries a recurrence rate above 50%; brachytherapy after excision gave the lowest recurrence (15%), compared with 23% for x-ray and electron beam radiation.
• For ear keloids, pressure therapy after excision showed recurrence of 6.7%-10.6% in observational studies, and triamcinolone after excision 15.4%.

Overview

This review consolidates narrative reviews, systematic reviews and meta-analyses published in 2016-2019 on keloid treatment. Risk factors include personal or family history, skin of colour, pregnancy, puberty and injuries over bony surfaces; the incidence in Hispanic and African American populations is 4.5% to 16%. Keloids are often painful and itchy and can cause functional and psychological burden.

Medical therapies

After excision, topical mitomycin C had a recurrence rate of 16.5% and imiquimod 5% cream 24.7%. Intralesional bleomycin had recurrence from 0% to 50% depending on follow-up and caused hyperpigmentation in 71.4% in one study of darker skin. Interferon, botulinum toxin A and onion extract gave mixed results, and meta-analyses conclude silicone is not effective for keloid prevention, although it may improve scar colour and thickness.

Lasers and cryotherapy

Recurrence was 22% at 8 months with the Er:YAG laser and 25%-52.9% with the Nd:YAG laser depending on site; the Nd:YAG laser may be an option for darker skin types. Pulsed dye or CO2 lasers combined with triamcinolone improved results. Intralesional cryotherapy reduced volume, pain and itching, with recurrence of 0% to 24%, but caused persistent hypopigmentation in Fitzpatrick types 4-6.

Combined surgical treatment

In a meta-analysis, triamcinolone after excision did not lower recurrence overall, except for ear keloids, while 5-fluorouracil after excision did (risk ratio 0.18). Radiotherapy after excision was more effective than radiotherapy alone (22% vs 37% recurrence), and pigmentation changes occurred in 32.5%; chest keloids had the highest recurrence. Emerging options include verapamil, UV-A1 phototherapy, ACE inhibitors, rapamycin, stem cells and fat grafting.

FAQ

What is the usual first-line treatment for a keloid?

Intralesional triamcinolone injections, which are low cost and minimally invasive, followed by combination therapy if results are inadequate.

Is surgical excision alone enough?

No. Excision alone has a recurrence rate above 50% and should be combined with another treatment.

Which approach has the lowest recurrence?

Brachytherapy after excision (15%), and for ear keloids pressure therapy after excision (6.7%-10.6% in observational studies).

Source

Ekstein SF, Wyles S, Moran S, Meves A. Keloids: A Review of Therapeutic Management. Int J Dermatol 2021;60(6):661-671. DOI: 10.1111/ijd.15159. HHS Public Access author manuscript, available in PMC. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.