Journal of Clinical Dermatology & Therapy Category: Clinical Type: Review Article

Insights into the Management of Keloid Scars: A Survey-Based Protocol

Kenneth Hughes1, Charles S Brown1* and Victor Perez2
1 Department of radiology, Geisinger Medical Center, Danville, United states
2 Department of radiology, Geisinger Medical Center, Pennsylvania, United states

*Corresponding Author(s):
Charles S Brown
Department Of Radiology, Geisinger Medical Center, Danville, United States
Tel:+1 5702716203,

Received Date: Jul 17, 2015
Accepted Date: Nov 01, 2015
Published Date: Nov 13, 2015


In the broad array of literature as it relates to keloid treatment, there is a global absence of definitive protocols in the management of keloid scars.

The goal of this project was to find some common ground in treatment regimens among plastic surgeons and to determine how our treatment protocol compares with those of other plastic surgeons. To this end, a web-based survey was designed and over 700 random emails were sent to plastic surgeons worldwide, with 54 completing the survey, representing several hundred years of cumulative experience from the plastic surgeons who responded. These results were then tabulated and the more common regimens identified.

The results of the survey, while useful in identifying common regimens and helping to substantiate the validity of our protocol, underscore the need for randomized, controlled trials to bring about more consistency in regimens used


Background:Keloids arise as an aberrant tissue response to cutaneous insult characterized by the production of excessive fibrous tissue. Keloids extend beyond the original boundaries of tissue injury and may appear months to years after injury. They occur with equal frequency in males and females and occur most commonly in younger people.

Keloids have a predilection for the earlobes, chest, back, neck, and shoulders. Keloids tend to afflict those people that are more pigmented, with blacks being the most susceptible. Keloids may be symptomatic; commonly causing itching, tenderness, and pain. The etiology of keloids is unknown. Some have demonstrated that increased extracellular matrix production is characteristic [1-4]. Keloids remain difficult to treat under even the most optimal of conditions, and they frequently recur.

Treatments:An array of adjunctive therapies including silicone gel sheeting, pressure garments, intralesional steroids, and radiotherapy have been employed with variable success. Intralesional cryotherapy, a newer technique, though showing some promise with improvement of symptomatic keloids, remains controversial for use in a wider range of fitzpatrick types [5].

Silicone sheeting:Several randomized, controlled trials have confirmed the validity and effectiveness of silicone sheeting [6-13]. Though effective, the silicone material be worn continuously for months at a time to prevent rebound hypertrophy [14].

Pressure therapy:Pressure therapy involves the exertion of at least 24 mmHg to exceed the inherent capillary pressure [15,16]. Much like silicone materials, pressure garments should be worn 18 to 24 hours a day for several months [17-20]. Surgery in conjunction with pressure therapy has produced success rates of up to 90 percent [21-25].

Corticosteroid injections:Steroids have been demonstrated to soften the contours and reduce the bulk of keloids [26-30]. Response rates vary from 50 to 100 percent, with recurrence rates of up to 50 to 80 percent [26-30]. Steroids purportedly decrease collagen synthesis by increasing metalloproteinase activity [31-36]. The optimal number of injections to be performed and the amounts injected to produce an optimal response are largely up for speculation. 

Radiotherapy:Radiotherapy has been employed as both adjunctive and primary treatment. Radiation therapy is presumed to destroy the proliferating fibroblasts, resulting in diminished collagen production [37]. Radiation treatments are typically administered over five to six sessions in the early postoperative period [38,39]. The combination of surgery and perioperative radiation therapy reduces recurrence to 10 percent according to some authors [37]. Historically, radiation therapy has been reserved for abnormal scars resistant to other treatments due to the presumed risks posed by radiation. 

Excision and intralesional steroids:Though all of the modalities presented thus far have roles to play in keloid management, local excision in combination with intralesional kenalog has long been the definitive treatment for keloids. However, there is lack of a standardized protocol (including specific steroid, strength, number, and frequency of doses to be administered) in the published literature [40].

Intralesional cryotherapy:Intralesional cryotherapy is an emerging technique where the scar is frozen from inside. A recent comprehensive review demonstrated decreased clinical symptomatology and scar volume, however, complete eradication was not achieved and some patients experienced hypopigmentation and/or recurrences [5]. While showing some promise with improvement of symptomatic keloids, intralesional cryotherapy remains controversial for use in a wider range of fitzpatrick types.


To undertake this task of searching for a treatment protocol, a random compilation of board certified plastic surgeons was made comprising over 700 names. Next all of these selectees were emailed a letter asking for participation in filling out a web-based survey. Ultimately, 54 respondents filled out the survey. Lesions treated ranged in size from 0.5 cm to 15+ cm. Limitations of this study would include sample size and self-selection bias.Participants were queried on steroid preference, concentration and volume injected, number of treatments, frequencies, and the temporal relationship of those injections to excision. Finally, those surveyed were asked to provide additional therapies they found useful in treating keloids.


The results were then tabulated and expressed as percentages. Only the most common responses have been tabulated.


Table 1 illustrates that triamcinolone (kenalog®) appears to be the overwhelming favorite for steroid injection. Triamcinolone (kenalog®) has long been used to treat keloid scars and is manufactured in standard concentrations from 10 to 40 mg/ml. Although the majority of the respondents used 40 mg/ml concentrations, many of these were diluted 2 to 1. After accounting for dilution, relatively equal numbers used each of the concentrations of kenalog. The concentration of the triamcinolone is easily ascertained, but the volume of injection for a certain surface area or a volume of scar tissue is not easily enumerated upon inspection alone. Thus, blanching of the involved scar area is recommended at the titration end point.

Steroid choice   Kenalog concentrations  
Kenalog 96% 10 mg/ml 35%
Celestone 4% 20 mg/ml 31%
    40 mg/ml 35%

Table 1: Surveyed surgeons’ steroid preferences and the dosage of their preferred agent.

Table 2 reveals that all of the plastic surgeons surveyed practice excision, which is what one expects when referred to a surgeon for treatment of a keloid. One also notices that the majority of surgeons injected 1 ml and that the majority administer perioperative steroids. As far as dosing intervals go, q month dosing for a total of 3 treatments was the most common preoperative and postoperative regimen, with q6 week dosing for 3 doses being the second most common.

Preoperative Steroids 26% q month x 3 50% Q 6 weeks x 3 25%
Postoperative Steroids 70% q month x 3 39% Q 6 weeks x 3 32%
Perioperative Steroids 63%    

Table 2: Preoperative versus postoperative steroid treatment strategies and dosage regimens.

While excision and intralesional kenalog® constitute the most common treatment algorithm, it was interesting to note that (see table 3) 22% used radiation as a primary form of treatment following excision, and that almost ½ used radiation at some point in their treatment algorithm. Silicone gel sheeting (26%), compression garments (22%), and cordran tape (17%) constituted the majority of the other adjunctive therapies.


Postoperative Adjunctive Management Radiation Silicone Gel Sheeting Compression Garments Cordran tape

22% as primary form of treatment after excision 46% for refractory keloids




Table 3: Survey results for adjunctive strategies (see discussion below).

Injection #1

Excision after 2 weeks Injection #2 at 1 week post op

Injection # 3 at 4 weeks,

Injection #4 at 8 weeks

Table 4: Authors’ preferred treatment regimen.


  1. Adzich N (1997) Wound healing: Biologic and clinical features. In: Sabiston DC, Lylery HK (eds.). Textbook of Surgery and the Biological Basis of Modern Surgical Practices. (15thedn), Saunders, Philadelphia, USA. Pg. no: 207-220.
  2. Murray JC, Pinnell SR (1992) Keloids and excessive dermal scarring. In: Cohen IK, Diegelmann RF, Lindblad WJ (eds.). Wound Healing: Biochemical and Clinical Aspects. Saunders, Philadelphia, USA.
  3. Bettinger DA, Yager DR, Diegelmann RF, Cohen IK (1996) The effect of TGF-beta on keloid fibroblast proliferation and collagen synthesis. Plast Reconstr Surg 98: 827-833.
  4. Bayat A, McGrouther DA, Ferguson MW (2003) Skin scarring. BMJ 326: 88-92.
  5. Ketchum LD (1977) Hypertrophic scars and keloids. Clin Plast Surg 4: 301-310.
  6. Agarwal US, Jain D, Gulati R, Bhargava P, Mathur NK (1999) Silicone gel sheet dressings for prevention of post-minigraft cobblestoning in vitiligo. Dermatol Surg 25: 102-104.
  7. Su CW, Alizadeh K, Boddie A, Lee RC (1998) The problem scar. Clin Plast Surg 25: 451-465.
  8. Berman B, Flores F (1999) Comparison of a silicone gel-filled cushion and silicon gel sheeting for the treatment of hypertrophic or keloid scars. Dermatol Surg 25: 484-486.
  9. Gold MH (1994) A controlled clinical trial of topical silicone gel sheeting in the treatment of hypertrophic scars and keloids. J Am Acad Dermatol 30: 506-507.
  10. Gold MH (2000) The role of CICA-CARE in preventing scars following surgery: A review of hypertrophic and keloid scar treatments. Oral presentation at the Annual Meeting of the American Academy of Dermatology, San Francisco, California, USA.
  11. Borgognoni L, Martini L, Chiarugi C, Gelli R, Giannotti V, et al. (2000) Hypertrophic scars and keloids: Immunophenotypic features and silicone sheets to prevent recurrences. Annals of Burns and Fire Disasters.
  12. Niessen FB, Spauwen PH, Schalkwijk J, Kon M (1999) On the nature of hypertrophic scars and keloids: a review. Plast Reconstr Surg 104: 1435-1458.
  13. Sawada Y (1993) Alterations in pressure under elastic bandages: experimental and clinical evaluation. J Dermatol 20: 767-772.
  14. Kischer CW, Shetlar MR, Shetlar CL (1975) Alteration of hypertrophic scars induced by mechanical pressure. Arch Dermatol 111: 60-64.
  15. Murray JC (1993) Scars and keloids. Dermatol Clin 11: 697-708.
  16. Sherris DA, Larrabee WF Jr, Murakami CS (1995) Management of scar contractures, hypertrophic scars, and keloids. Otolaryngol Clin North Am 28: 1057-1068.
  17. Su CW, Alizadeh K, Boddie A, Lee RC (1998) The problem scar. Clin Plast Surg 25: 451-465.
  18. Davies DM (1985) Plastic and reconstructive surgery. Scars, hypertrophic scars, and keloids. Br Med J (Clin Res Ed) 290: 1056-1058.
  19. Haq MA, Haq A (1990) Pressure therapy in treatment of hypertrophic scar, burn contracture and keloid: the Kenyan experience. East Afr Med J 67: 785-793.
  20. Berman B, Bieley HC (1996) Adjunct therapies to surgical management of keloids. Dermatol Surg 22: 126-130.
  21. Brent B (1978) The role of pressure therapy in management of earlobe keloids: preliminary report of a controlled study. Ann Plast Surg 1: 579-581.
  22. Mercer DM, Studd DM (1983) “Oyster splints”: a new compression device for the treatment of keloid scars of the ear. Br J Plast Surg 36: 75-78.
  23. Pierce HE (1986) Postsurgical acrylic ear splints for keloids. J Dermatol Surg Oncol 12: 583-585.
  24. Urioste SS, Arndt KA, Dover JS (1999) Keloids and hypertrophic scars: review and treatment strategies. Semin Cutan Med Surg 18: 159-171.
  25. Rockwell WB, Cohen IK, Ehrlich HP (1989) Keloids and hypertrophic scars: a comprehensive review. Plast Reconstr Surg 84: 827-837.
  26. Alster TS, West TB (1997) Treatment of scars: a review. Ann Plast Surg 39: 418-432.
  27. Murray JC (1994) Keloids and hypertrophic scars. Clin Dermatol 12: 27-37.
  28. Griffith BH, Monroe CW, McKinney P (1970) A follow-up study on the treatment of keloids with triamicinolone acetonide. Plast Reconstr Surg 46: 145-150.
  29. Alaish SM, Yager DR, Diegelmann RF, Cohen IK (1995) Hyaluronic acid metabolism in keloid fibroblasts. J Pediatr Surg 30: 949-952.
  30. McCoy BJ, Diegelmann RF, Cohen IK (1980) In vitro inhibition of cell growth, collagen synthesis, and prolyl hydroxylase activity by triamcinolone acetonide. Proc Soc Exp Biol Med 163: 216-222.
  31. Kauh YC, Rouda S, Mondragon G, Tokarek R, diLeonardo M, et al. (1997) Major suppression of pro-alphal (I) type I collagen gene expression in the dermis after keloid excision and immediate intrawound injection of triamcinolone acetonide. J Am Acad Dermatol. 37: 586-589.
  32. Lavker RM, Schechter NM (1985) Cutaneous mast cell depletion results from topical corticosteroid usage. J Immunol 135: 2368-2373.
  33. Gadson PF, Russell JD, Russell SB (1984) Glucocorticoid receptors in human fibroblasts derived from normal dermis and keloid tissue. J Biol Chem 259: 11236-11241.
  34. Krusche T, Worret WI (1995) Mechanical properties of keloids in vivo during treatment with intralesional triamcinolone acetonide. Arch Dermatol Res 287: 289-293.
  35. Urioste SS, Arndt KA, Dover JS (1999) Keloids and hypertrophic scars: review and treatment strategies. Semin Cutan Med Surg 18: 159-171.
  36. Cosman B, Crikelair GF, Ju DM, et al. (1961) The surgical treatment of keloids. Plast Reconstr Surg 27: 335.
  37. Brown LA Jr, Pierce HE (1986) Keloids: scar revision. J Dermatol Surg Oncol 12: 51-56.
  38. Shaffer JJ, Taylor SC, Cook-Bolden F (2002) Keloidal scars: a review with a critical look at therapeutic options. J Am Acad Dermatol 46: 63-97.
  39. van Leeuwen MC, Bulstra AE, Ket JC, Ritt MJ, van Leeuwen PA, et al. (2015) Intralesional Cryotherapy for the Treatment of Keloid Scars: Evaluating Effectiveness. Plast Reconstr Surg Glob Open 3: 437.
  40. Katz BE (1995) Silicone gel sheeting in scar therapy. Cutis 56: 65-67.

Citation: Brown CS, Perez V, Hughes K (2015) Insights into the Management of Keloid Scars: A Survey-Based Protocol. J Clin Dermatol Ther 2: 015.

Copyright: © 2015  Kenneth Hughes, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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