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Keloid scar removal injections - Beyond just steroids

by Dr Wan Chee Kwang
June 2, 2022

Excessive scarring represents aberrant wound healing that rises beyond the skin's surface. It can occur in up to 15% of wounds and is classified as either hypertrophic or keloid scarring. While hypertrophic scars are restricted to the original injury and occasionally spontaneously retreat, keloid scars spread beyond the borders of the original lesion and continue to invade the neighboring normal skin.

Keloid scars are a sort of physical and cosmetic disability and can cause severe discomfort, itching, stiffness, and scar contracture. They might also have psychological consequences, such as decreased self-esteem, disturbance of everyday life, anxiety, and depression, that can reduce patients' quality of life even further.

Young adults with pigmented skin are more prone to keloids. Type A blood, hyper-immunoglobulin E syndrome with a high risk of allergy, and hormonal peaks such as puberty and pregnancy are all established risk factors. Keloids are particularly common in body parts that are under tension. In Singapore, I often treat keloids in the following areas:

  • lower abdomen after surgery such as caesarean section
  • shoulder area after tattoos, injections
  • sternal or chest area after acne
  • earlobes after ear piercings
  • jawline and lower face after acne or procedures such as mole removal

Steroid injections for keloid removal

Many medical aesthetics, plastic surgery, dermatology, and even GP clinics in Singapore offer keloid removal treatment. Intralesional steroid injections are first-line and probably the most common form of intervention offered in Singapore clinics. Steroids induce keloid regression through many different mechanisms such as suppressing inflammation, constricting blood supply, inhibiting cell division, and reducing collagen production. Steroid injections may cause complications such as the formation of new blood vessels, pigmentary changes, thinning of the skin, subcutaneous fat or even underlying tendons or bone, or even skin necrosis and ulcerations. They may also cause problems elsewhere in the body such as acne flares or Cushing’s syndrome.

I have personally treated a patient who developed sunken scarring from a deep ulcer on the cheek after a steroid injection gone wrong elsewhere. Steroid injections have to be done with the utmost care, paying attention to the depth, amount, concentration, and angle of injection.

Steroid injections are typically quite painful as the thick fibrous keloid tissue is very difficult to inject into. Some patients dread or even discontinue treatment because of this. I've developed some techniques to greatly reduce the pain from the injection.

The cost for steroid injections has also risen over the years, with a particularly pronounced jump after an orthopedic specialist was fined $100,000 after a patient developed complications after a steroid injection (for a non-keloid condition) that lead many doctors to avoid performing steroid injections for fear of being sued or hefty malpractice insurance premiums. Intralesional steroid injections for keloid treatments used to start from $50-100 years ago but the costs have increased a few times at least, now ranging from $150-200 up to a few hundred dollars or even more.

Intralesional steroid injection

Alternative injections for keloid removal in Singapore

Chemotherapeutic Agents

Antimetabolites such as pyrimidine analogs can block collagen synthesis, reducing fibroblast activity. The reduction in keloid volume (flattening, decrease in length and width), decrease in itching, and recurrence rate appeared to be comparable to steroids. However, side effects (such as pain, hyperpigmentation, and ulceration) were significantly more common.

Antiproliferative Antibiotics

Water-soluble glycopeptide antibiotics can induce apoptosis and reduce TGF-β1-induced collagen synthesis. Side effects include pain, superficial ulceration and crusting at injection sites, transient hyperpigmentation, and dermal atrophy.

Calcium channel blockers

Commonly used calcium antagonists can increase collagen degradation. Intralesional calcium antagonists had a lower complication rate but were slower, less effective, and had higher recurrence rates than steroids.

Neurotoxins

Intralesional neurotoxin injections may improve and prevent hypertrophic scars and keloids by suppressing scar tension and fibroblast activities. Tension is one of the causes of keloid scars. Neurotoxins reduce tension on the wound edges by preventing muscle contraction during the healing process, thereby reducing scar formation. In one study, intralesional neurotoxin injections resulted in improvement of keloids and decreased keloid volume more effectively than intralesional corticosteroid injections.

Unlike most injectable keloid treatments, neurotoxin injections are relatively benign and are less likely to have serious side effects. However, neurotoxins cost significantly more than steroids, and relatively large amounts have to be used. Hence neurotoxin injections for keloid treatment can cost double or more compared to intralesional steroid injections.

Treating keloids in Singaporean skin: My approach

Steroid injections are indispensable to steroid treatment. While well-researched and effective, drawbacks include the potential for severe side effects, pain, and cost. Combination treatment with other injectable medications has been shown to improve response and reduce side effects. However, most of the alternative treatments are expensive and difficult to find in Singapore as most clinics would not stock these due to the low volume and high cost. Furthermore, they may have even higher complication rates than steroid injections.

Personally, I find neurotoxins to be a valuable addition to the range of treatments we have for keloid treatments. Firstly, we already stock neurotoxins for medical aesthetics treatments like anti-aging and wrinkle reduction treatments. Secondly, the risk of side effects is low compared to steroid injections. Lastly, its mechanism of action is different from steroid injections, providing some synergy and a better, faster response to treatment.

Combination injections are also an essential part of other keloid removal treatments such as vascular lasers, or advanced keloid removal surgery.

Keloids are undoubtedly difficult to treat but it is not impossible — especially in the hands of an experienced doctor. Successful keloid removal treatment, while harder than you might expect, can produce gratifying and dramatic results from the right treatment regimen. 

Here's to a keloid-free life!

References

  1. Ogawa R. The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago. Plast Reconstr Surg. 2022 Jan 1;149(1):79e-94e. https://doi.org/10.1097/PRS.0000000000008667
  2. Kim, Sang Wha. “Management of keloid scars: noninvasive and invasive treatments.” Archives of plastic surgery vol. 48,2 (2021): 149-157. https://doi.org/10.5999/aps.2020.01914
  3. Morelli Coppola, Marco et al. “Triamcinolone acetonide intralesional injection for the treatment of keloid scars: patient selection and perspectives.” Clinical, cosmetic and investigational dermatology vol. 11 387-396. 24 Jul. 2018, https://doi.org/10.2147/CCID.S133672

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