- A diagnosis of keloids (secondary acne) is rendered
- Intralesional triamcinolone (20 mg/cc) injections
- Follow-up in 4 weeks
Follow-up evaluation strategy
4-week follow-up evaluation:
- Improved (lesions much smaller in size, flatter, softer)
- No adverse effects noted (atrophy, telangiectasia)
- Repeat injections to several persistently thickened
- Several lesions require intralesional triamcinolone (40
- Follow-up in 4-week intervals (requires a total of four
additional visits to improve the majority of lesions)
Scarring is a common complication of wound healing. Keloids are
defined as scars that grow beyond the boundaries of the original
wound site and are often marked by significant, persistent
thickening and are pruritic or painful. They may occur between 3
and 12 months following the inciting skin trauma and clinically,
are firm and raised and can be hyperpigmented or marked with
telangiectasia. Common sites for keloid formation include the ears,
upper back, chest, and upper arms. Keloids are more common in
certain populations, including those with a family history of
keloid scars and individuals of Asian, African and Hispanic
Fibroblast dysfunction, including increased production of type I
procollagen, cytokines, and connexins, may underlie the development
of keloids, and thickened collagen bundles are the histologic
hallmark on biopsy. Keloids can be symptomatic, marked by pruritus,
tenderness, or extreme hyperesthesia.
Intralesional corticosteroids remain the first-line therapy of
choice and have good safety profiles, although cryosurgery is also
considered safe and effective and may be used in conjunction.
Corticosteroids may be effective in 50-100% of cases but often
require multiple injections with on-going monitoring for atrophy,
telangiectasia and hypopigmentation. Start with triamcinolone
acetonide (20 mg/cc) injection with a ½ inch, 30-gauge Luer lock
needle and tuberculin syringe at several adjacent sites at 0.5-1.0
cm apart. Repeat this at monthly intervals until the degree of
involution and/or symptomatic relief is achieved and if no change
occurs, increase the dose to 40 mg/cc. After this, consider
In addition, isotretinoin can be considered for treatment in
patients with persistent acne and in patients with keloids to
prevent further formations.
Surgical excision may be effective if keloids remain
unresponsive, although consider concomitant injection with
triamcinolone acetonide (20 mg/cc at 2-week intervals over 3-4
months) at multiple loci along the excision site to avoid
Following excision, alternative steps include silicone sheeting,
imiquimod 5%* (used for 8 weeks), laser ablation and radiotherapy,
although there is limited evidence to support their use. In
addition, intralesional 5-fluorouracil* or bleomycin* and topical
mitomycin C* can be used, but are associated with adverse
Management of side effects may be achieved with pulse dye laser
(for minimizing erythema or telangiectasia) and some anecdotal
evidence suggests that scar massage may help to relieve
A common pitfall is the recurrence of keloids after excision.
Recurrences can be more disfiguring than the original lesions,
particularly if an ablative method, such as electrosurgery, was
employed. Elective surgery should be avoided in patients with a
history of keloid formation, especially at sites where keloids are
likely to occur.
Chike-Obi CJ, et al. Keloids: pathogenesis, clinical features,
and management. Semin Plast Surg 2009;23:178-184.
Shin TM, Bordeaux JS. The role of massage in scar management: a
literature review. Derm Surgery 2012;38:414-423.
Tziotzios C, et al. Cutaneous scarring: pathophysiology,
molecular mechanisms, and scar reduction therapeutics, Part II.
J Amer Acad Dermatol 2012;66:13-24.