RISK FACTORS: Family history of keloids, Dark skin pigment, Certain locations on the body, e.g., deltoids, chest, earlobes, Pregnancy, Adolescence
GENERAL MEASURES
“Step care is warranted, adding pressure and then radiation if steroid injections fail.
• Intralesional corticosteroid injections: cause atrophy and are most successful therapy
• Pressure bandages: must maintain 24 mm Hg, and should be worn for 6-12 months. Bandages should not
be removed for more than 30 minutes/day. Pressure clips (Zimmer splints) useful for earlobes. Designer
splints look like fashion earrings.
• Radiation: no advantage over other methods, therefore use if other methods fail, and then use in conjunction
with steroids and pressure
• Topical agents: No evidence to support effi cacy; e.g., retinoic acid, vitamin E, antineoplastic agents, silicone gel
SURGICAL MEASURES
• Surgery - high recurrence rate (45-100%), therefore used only for debulking of large keloids or if a lesion is
unresponsive to steroid injections or other therapy
• Laser surgery - no defi nitive evidence of efficacy
PATIENT EDUCATION
• Stress possibility of recurrence despite appropriate treatment
• May require many months of treatment with combined modalities
DRUG(S) OF CHOICE
. Triamcinolone (Kenalog) suspension 10 mg/mL
. Using 27-30 gauge needle and a TB syringe (total dose 20-30 mg of triamcinolone). May inject 3 lesions
at a time, using 10 mg/lesion.
. Advance needle while injecting in order to evenly distribute medication
. Early keloids are more responsive to this therapy than older lesions
. Reinject every 4 weeks until keloid shrinks to near skin surface
. If no response to 10 mg/mL triamcinolone suspension, may try 40 mg/mL suspension
. May mix dilute triamcinolone (5-10 mg/mL) with local anesthetic for excision of keloids. Postoperative steroid injections at 2-4 weeks and then monthly for 6 months helps prevent recurrences.
ALTERNATIVE DRUGS
• Verapamil locally may be helpful. One study (D’Andrea, 2002) supports repeated intralesional injections of
2.5 mg/mL of verapamil at repeated intervals as an adjuvant following excision and topical silicone.
• Interferon-alpha 2b may be helpful after excision
• Imiquimod 5% cream daily for 8 weeks following surgical keloid excision prevented recurrence in small series
of 11 patients (Berman and Kaufman 2002)
• Intralesional 5-fluorouracil
• Intralesional bleomycin
PATIENT MONITORING Monthly visits, up to a year, for evaluation and possible steroid re-injections
PREVENTION/AVOIDANCE
• Primary prevention: avoid elective surgery or body piercing in high-risk patients
• When feasible, laparoscopic approaches are preferred in keloid formers
• Compressive pressure dressings may be useful in high risk (e.g., burn) patients. Local steroid injection
postoperatively in high risk patients is also effective.
POSSIBLE COMPLICATIONS Skin atrophy, ulceration, depigmentation, telangiectasias can occur as a result of local steroid injections
EXPECTED COURSE/PROGNOSIS
When treatment is successful, lesions gradually diminish with therapy over a 6-18 month period, leaving a
flat, shiny scar