Recommendations on the Use of Intralesional Corticosteroids for the Treatment of Patients With Keloids

Keloids are characterized by an abnormal overgrowth of wound tissue extending beyond the original injury.¹ Keloid lesions present both cosmetic and symptomatic challenges, including pruritus, pain, and a diminished quality of life. Keloids contribute to significant physical and psychosocial burdens, impacting over 5.5 million people globally, with people of color being affected disproportionately.^2,3 Intralesional corticosteroid administration (ICA) is often the first-line therapy for small to moderate keloids. However, ICA is associated with the need for repeated and ongoing treatments and adverse effects, including skin atrophy and systemic complications.^3–5 There is a critical need for clear evidence-based guidelines to optimize corticosteroid use and improve patient outcomes.

The KECORT study by Yin et al aims to address the urgent need for evidence-based treatment recommendations by leveraging the clinical expertise of dermatologists and plastic surgeons with numerous publications in the field and at least 5 years of experience in keloid management.⁶ The experts reached a consensus on several key treatment parameters, including a preferred triamcinolone acetonide (TAC) concentration of 40 mg/mL, a maximum TAC dose of 80 mg per month to mitigate systemic side effects, 4-week intervals between treatments, avoiding subcutaneous injection, and using blanching as an endpoint for infiltration.⁶ Although the expert group endorsed 4-week treatment intervals, we have achieved excellent clinical safety and outcomes with 6-week intervals between ICA. Furthermore, although we agree that 40 mg/mL is often an appropriate TAC starting concentration, clinical judgment should guide treatment dose quantities and volume and concentration reductions as the keloid improves, particularly to minimize the risk of corticosteroid-related hypo- and hyperpigmentation, which is especially important in patients with skin of color.^7,8

Interestingly, some of the consensus findings — or lack thereof — highlight the nuances of clinical practice, even among seasoned practitioners well-versed in the literature. For example, although local skin cooling is a proven method for anesthesia, it was not endorsed as an adequate local anesthetic.^6,9 Additionally, 1-mL polycarbonate syringes with a 25-gauge 16-mm needle have been shown to be the most ergonomic for injecting keloids; yet, the use of both 25- and 27-gauge needles was endorsed depending on scar pliability and pretreatments.^6,10 Given the density of keloid tissues, we recommend utilizing a minimum needle gauge of 25, with a range of 22- to 25-gauge being acceptable depending on the keloid size, thickness, and pliability. We would like to highlight that additional methods to augment keloid scar treatment exist, including combining TAC with other injectable agents such as 5-fluorouracil, cryotherapy to the keloid prior to ICA, non-ablative or ablative laser monotherapy, and the administration of TAC via fractionated CO₂ laser–assisted drug delivery, underscoring the value of clinical experience in keloid management.^6,11–14 Management of keloids using immunomodulatory agents may augment ICA in the future.^15–17 Ultimately, the KECORT study Delphi consensus provides a strong foundation for ICA keloid management guidelines while simultaneously emphasizing the immense value of clinical experience and individualized patient care in achieving effective keloid treatment outcomes.

This commentary received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

1. Limmer EE, Glass DA 2nd. A Review of Current Keloid Management: Mainstay Monotherapies and Emerging Approaches. Dermatol Ther (Heidelb). 2020;10(5),931–948. https://link.springer.com/article/10.1007/s13555-020-00427-2
2. El Kinani M, Duteille F. Scar Epidemiology and Consequences. In: Téot L, Mustoe TA, Middelkoop E, Gauglitz GG, eds. Textbook on Scar Management: State of the Art Management and Emerging Technologies [Internet]. Springer; 2020:45–49. https://link.springer.com/chapter/10.1007/978-3-030-44766-3_6
3. Ekstein SF, Wyles SP, Moran SL, et al. Keloids: A Review of Therapeutic Management. Int J Dermatol. 2021;60(6):661–671. https://onlinelibrary.wiley.com/doi/10.1111/ijd.15159
4. Fredman R, Tenenhaus M. Cushing's Syndrome After Intralesional Triamcinolone Acetonide: A Systematic Review of the Literature and Multinational Survey. Burns. 2013;39(4):549–557. https://www.sciencedirect.com/science/article/abs/pii/S0305417912003099?via%3Dihub
5. Dhar S, Seth J, Parikh D. Systemic Side-Effects of Topical Corticosteroids. Indian J Dermatol. 2014;59(5):460–464. https://journals.lww.com/ijd/fulltext/2014/59050/systemic_side_effects_of_topical_corticosteroids.6.aspx
6. Yin Q, Wolkerstorfer A, Lapid O, et al. KECORT Study: An International e-Delphi Study on the Treatment of KEloids Using Intralesional CORTicosteroids in Clinical Practice. Am J Clin Dermatol. 2024 Sep 19. doi: 10.1007/s40257-024-00888-7. Online ahead of print. https://link.springer.com/article/10.1007/s40257-024-00888-7
7. Vasile G, Hosseinipour M, Hoffman C, et al. Linear Depigmentation After an Intralesional Corticosteroid Injection. J Clin Aesthet Dermatol. 2020;13(9):49–51. https://jcadonline.com/linear-depigmentation-intralesional-corticosteroid-injection/
8. Gupta A, Garg M, Johnson N, et al. Hypopigmentation After Intra-Articular Corticosteroid Injection. BMJ Case Rep. 2019;12(3):e228921. https://casereports.bmj.com/content/12/3/e228921
9. Wang X, Wu X, Liu K, et al. Topical Cryoanesthesia for the Relief of Pain Caused by Steroid Injections Used to Treat Hypertrophic Scars and Keloids. Medicine (Baltimore). 2017;96(43);e8353. https://journals.lww.com/md-journal/fulltext/2017/10270/topical_cryoanesthesia_for_the_relief_of_pain.43.aspx
10. Vo A, Doumit M, Rockwell G. The Biomechanics and Optimization of the Needle-Syringe System for Injecting Triamcinolone Acetonide Into Keloids. J Med Eng. 2016;2016:5162394. https://onlinelibrary.wiley.com/doi/10.1155/2016/5162394
11. Kraeva E, Ho D, Jagdeo J. Successful Treatment of Keloid With Fractionated Carbon Dioxide (CO2) Laser and Laser-Assisted Drug Delivery of Triamcinolone Acetonide Ointment in an African-American Man. J Drugs Dermatol. 2017;16(9):925–927. https://jddonline.com/articles/successful-treatment-of-keloid-with-fractionated-carbon-dioxide-co2-laser-and-laser-assisted-drug-de-S1545961617P0925X/
12. Khan MA, Bashir MM, Khan FA. Intralesional Triamcinolone Alone and in Combination With 5-Fluorouracil for the Treatment of Keloid and Hypertrophic Scars. J Pak Med Assoc. 2014;64(9):1003–1007. https://www.archive.jpma.org.pk/article-details/6924
13. El-Hamid El-Azhary EA, Abd Al-Salam FM, El-Hafiz HSA, et al. Fractional Carbon Dioxide (CO₂) Laser Alone Versus Fractional CO₂ Laser Combined With Triamcinolone Acetonide or Trichloroacetic Acid in Keloid Treatment: A Comparative Clinical and Radiological Study. Dermatol Pract Concept. 2022;12(2), e2022072. https://dpcj.org/index.php/dpc/article/view/1890
14. Rossi A, Lu R, Frey MK, et al. The Use of the 300 Microsecond 1064 nm Nd:YAG Laser in the Treatment of Keloids. J Drugs Dermatol. 2013;12(11):1256–1262. https://jddonline.com/articles/the-use-of-the-300-microsecond-1064nm-ndyag-laser-in-the-treatment-of-keloids-S1545961613P1256X/
15. Nguyen JK, Austin E, Huang A, et al. The IL-4/IL-13 Axis in Skin Fibrosis and Scarring: Mechanistic Concepts and Therapeutic Targets. Arch Dermatol Res. 2020;312(2):81–92. https://link.springer.com/article/10.1007/s00403-019-01972-3
16. Bitterman D, Patel P, Wang JY, et al. Systematic Review of Dupilumab Safety and Efficacy for Treatment of Keloid Scars. Arch Dermatol Res. 2024;316(8):560. https://link.springer.com/article/10.1007/s00403-024-03277-6
17. Bitterman D, Wang JY, Collins A, et al. The Role of IL-17 and Th17 Cells in Keloid Pathogenesis. Arch Dermatol Res. 2024;316(9):626. https://link.springer.com/article/10.1007/s00403-024-03352-y