Keloids are overgrowths of scar tissue that occur after skin trauma or surgery. They extend beyond the boundaries of the original wound and do not regress over time. Keloids can range from small, minor annoyances to large, disfiguring masses. While not life-threatening, keloids can cause significant cosmetic concerns and physical symptoms like pain and itching. Unfortunately, keloids are notoriously difficult to treat and prone to recurrence after treatment. However, research continues to advance keloid treatment options to help improve outcomes. This article explores the latest evidence on treatments for keloids.
What Causes Keloids?
The exact causes of keloids are not fully understood. However, keloids are known to result from abnormal wound healing where scar tissue grows excessively. They occur most commonly after:
- Cuts, burns, piercings, insect bites, or other skin injuries
- Surgeries, vaccinations, tattoos, or body piercings
- Severe acne
People with darker skin tones have an increased risk of developing keloids. There also appears to be a genetic component, as keloids tend to run in families. The tendency to form keloids lessens with age. Keloids typically develop in people between the ages of 10 and 30 years old.
How are Keloids Diagnosed?
Doctors usually diagnose keloids based on visual examination of the overgrown scar and discussion of the patient’s medical history. The scar must extend beyond the boundary of the original injury site to meet the criteria for a keloid.
To confirm the diagnosis, a skin biopsy may be performed. This involves taking a small sample of the scar tissue and examining it under a microscope. The biopsy can help rule out other skin growths like hypertrophic scars.
What Problems Can Keloids Cause?
While benign, keloids can negatively impact quality of life. Effects may include:
- Appearance – Keloids often form large, bumpy, tough masses that can be disfiguring.
- Pain – Some keloids are painful, especially when touched or pressed.
- Itching – Severe itching is common and can be hard to control.
- Restricted movement – If over a joint, keloids can limit mobility and range of motion.
- Psychological distress – Some people experience anxiety, depression, and low self-esteem due to keloid scarring.
Given these potential effects, people with keloids often seek treatment for improvement. Next, we’ll explore the latest options available.
What Are the Latest Keloid Treatments?
Many treatment approaches for keloids exist. However, no single therapy works perfectly for all patients. The choice depends on factors like the size and location of the keloid, along with patient preferences. Combination therapy using multiple modalities often provides the best results. Below are some of the latest and most promising keloid treatments.
Steroid Injections
One of the first-line treatments for keloids are corticosteroid injections applied directly into the scar tissue. Triamcinolone acetonide is the corticosteroid most commonly used. The injections help shrink keloids by suppressing inflammation and reducing collagen production.
Steroid injections are often used in combination with other therapies. Repeated injections may be needed to achieve optimal flattening of the keloid, such as injections given monthly for several months. Research shows steroid injections improve keloid symptoms in about 70% of cases. However, the success rate decreases with larger keloids.
Cryotherapy
Cryotherapy employs extreme cold to damage the scar tissue and spur keloid regression. Liquid nitrogen is the most common freezing agent used. It can be sprayed directly on the surface of the keloid or applied using a probe inserted into the scar tissue.
The freezing causes scar tissue breakdown and interrupts the skin’s collagen production cycle. When combined with steroid injections, cryotherapy may enhance the effects. However, adequate anesthesia is needed during treatment to prevent extreme pain from the freezing.
Laser Therapy
Laser treatment directs highly concentrated light beams at scars to generate heat. By thermally damaging the tissue, lasers can help shrink and soften keloids. Common types used include:
- CO2 lasers
- Pulsed-dye lasers
- Nd:YAG lasers
- Excilite lasers
As a standalone therapy, lasers only reduce the size of keloids by about 50% on average. However, results improve when combined with steroid injections or other modalities. Proper anesthesia is necessary during laser therapy to prevent pain.
Radiation Therapy
Radiation aims to prevent keloid recurrence and flatten lesions by interfering with the skin cells’ ability to proliferate. Different types of radiation used include:
- Electron beam radiation
- Brachytherapy (implant radiation)
- External beam radiation
Many consider radiation an effective option for preventing recurrence after surgical keloid removal. Drawbacks include the possibility of radiation burns and theoretical long-term cancer risks.
Interferon Injections
Interferons are natural proteins in the body that regulate the immune system and cell growth. Injecting interferon alpha and beta medications directly into keloids can inhibit scar tissue formation and enhance collagen breakdown.
Given as a standalone or added to steroid injections, interferons produce variable results. More research is needed to determine optimal dosing and administration protocols.
Bleomycin Injections
Bleomycin is a chemotherapy medication that can be injected into keloids to curb excessive scarring. It works by blocking the production of collagen.
Clinical studies show that bleomycin injections reduce keloid size, pain, and itching when given alone or combined with other injections. The medication requires careful dosing due to risks of pulmonary fibrosis.
Verapamil Injections
Verapamil is a calcium channel blocker drug used to treat high blood pressure. When injected into keloids, it can improve the appearance and associated symptoms.
The drug decreases scar volume and softens tissue texture. It also reduces pain, itching, and tension. Verapamil generates better outcomes when combined with steroid injections versus either treatment alone.
5-Fluorouracil (5-FU) Injections
5-fluorouracil (5-FU) is a chemotherapy drug that interferes with cell growth and collagen production. Direct injection into keloids is a newer application being studied.
Early research indicates 5-FU injections reduce scar size and symptoms, especially when combined with steroids. However, more data is needed to confirm efficacy and optimal dosing.
Surgery
Surgical excision to remove the keloid may be considered for severe, bothersome cases. However, keloids have a high rate of recurrence after surgery – up to 80-100% when surgery is done alone.
To prevent recurrence, excision is often followed immediately by one or more adjuvant therapies:
- Radiation
- Steroid or other injections into the excision site
- Lasers
- Compression dressings
Using adjuvant techniques lowers the postoperative recurrence rates to around 50-80%. Non-scalpel removal methods like cryosurgery and laser excision may further reduce recurrence risk versus scalpel excision.
Compression Therapy
Applying pressure to keloids can help flatten and soften scar tissue while reducing pain and itchiness. Compression is often used after other treatments like surgery or injections.
Options include silicone sheets, gel pads, adhesive bandages, custom Pressure garments, and elastic wraps. The pressure physically compresses existing collagen deposits and limits new collagen formation.
Onion Extract Gel
Onion extract contains compounds like quercetin that exhibit anti-inflammatory and collagen-production inhibiting effects. Topical gels containing onion extract have shown promise for improving keloid and hypertrophic scar appearance.
In studies, the gels reduced scar thickness, pain, and itching when applied twice daily for 1-3 months. Patients also reported improved scar texture and color. Minimal side effects have been reported.
Imiquimod Cream
Imiquimod is a topical immune-modulating cream used to treat actinic keratoses and warts. Emerging research shows it may also improve keloid outcomes when applied after surgery.
The cream stimulates immune cells to produce collagen-degrading enzymes. Small clinical trials demonstrate imiquimod reduces signs of keloids like thickness and redness while lowering recurrence rates after surgical excision.
Intralesional Botulinum Toxin
Injecting botulinum toxin (Botox) directly into keloids is being studied for inhibiting scar tissue formation. The toxin blocks release of proteins that promote collagen production.
Initial case studies indicate intralesional Botox reduces keloid size, inflammation, and symptoms. However, more research is needed to establish effectiveness and optimal administration techniques.
Intralesional 5-Fluorouracil + Triamcinolone Injections
A recent study examined injecting a combination of 5-fluorouracil and the steroid triamcinolone into keloids. Patients received injections every 4 weeks for 6 months.
At 3 months follow-up, all patients had significant flattening of keloids along with reductions in pain and itching scores. No recurrence was observed during the follow-up period. Larger trials are warranted to confirm results.
Emerging Keloid Treatments
In addition to current treatments, research is investigating various emerging options for keloids:
- Newer steroids – Medications like clobetasol and halobetasol are being studied as potentially more effective alternatives to triamcinolone for injection therapy.
- Novel injections – Drugs like tranilast, doxycycline, and sirolimus are being injected into keloids with some promising preliminary results.
- Tacrolimus ointment – Topical tacrolimus shows potential for reducing early keloid formation after surgery when applied twice daily.
- Photodynamic therapy – Laser activation of photosensitizing chemicals selectively destroys keloid tissue.
- Cryoprobes – Specialized cold probes allow deeper, more precise freezing of scar tissue versus spray techniques.
- Nanoparticle delivery – Injecting drugs bound to nanoparticles may enhance delivery and prolong anti-scarring effects in keloids.
- Gene therapy – Techniques to alter gene expression patterns show promise for suppressing keloid fibroblast activity and excessive collagen secretion.
More clinical trials are needed to confirm if these emerging approaches can improve keloid treatment and avoid recurrence. Focused ultrasound, skin substitutes, and anti-angiogenic drugs are among other options under investigation.
How Successful Are Keloid Treatments?
Unfortunately, no single treatment works perfectly for all keloids. The table below outlines average success rates reported in medical studies for common modalities.
| Treatment | Success Rate |
|---|---|
| Steroid injections | 70% |
| Cryotherapy | 50% |
| Lasers | 50% |
| Radiation | 70-90% |
| Surgery alone | 20-50% |
| Surgery + adjuvant therapy | 50-80% |
| Onion extract gel | Up to 85% |
| Imiquimod cream | Up to 50% |
No treatment completely eliminates the risk of keloid recurrence. Combinations of therapies generally lead to better outcomes than single treatments alone. With increasingly aggressive regimens, potential side effects also increase.
Regardless of approach, keloids require long-term follow-up care to monitor for and quickly treat any recurrent growths. Supportive scar care techniques like hydrating gel sheeting and silicone products can help maximize results.
When Are Treatments Not Recommended?
Despite the frustrations of living with keloids, treatment is not always warranted or advised. Reasons to avoid treatment include:
- Small, non-bothersome keloids
- Keloids that are not actively growing or symptomatic
- During pregnancy and breastfeeding
- When keloid is in high-risk site for adverse effects (ex. Over carotid artery)
- Patient unwillingness to accept recurrence risk
- Patient apprehension about side effects
Given keloids’ stubborn tendency to recur, some patients opt to simply monitor small, non-problematic lesions instead of undergoing treatments that may ultimately fail.
Takeaways on the Latest Keloid Treatments
In summary, key points to know about modern keloid treatments include:
- No single option is universally effective – combination approaches are typically needed
- First-line treatments remain intralesional steroid and cryotherapy
- Excision requires adjuvant therapies to help prevent recurrence
- Emerging options like novel injections, laser developments, and gene therapy show promise
- Compression, radiation, interferon, verapamil, 5-FU, and imiquimod also demonstrate efficacy
- Supportive techniques like silicone sheeting help maximize results
- Recurrence risk remains substantial with all treatments
- Aggressive treatments increase adverse effect risks
- Mild, stable keloids may not warrant treatment
- Research continues to advance treatment options and protocols
Conclusion
Keloids represent a challenging condition with propensity for recurrence despite treatment attempts. No perfect cure-all exists. However, steady research advances are expanding and improving the options available beyond traditional excision. Combining modalities offers the best outcomes for optimal keloid flattening and symptom control. Emerging therapies show promise but require more data to confirm their place in keloid treatment regimens. With a patient-centered approach, the latest evidence-based treatments can successfully shrink keloids, alleviate associated symptoms, and enhance cosmetic appearance for many patients.