Effectiveness of intralesional triamcinolone in the treatment of keloids in children
Pediatric Dermatology Vol. 33 No. 1 75–79, 2016
Eﬀectiveness of Intralesional Triamcinolone in
the Treatment of Keloids in Children
Silvana Acosta, M.D.,* Ester Ureta, M.D.,† Ricardo Ya nez, M.D.,* Natalia Oliva, M.D.,‡
Susana Searle, M.D.,* and Claudio Guerra, M.D.*
*Plastic Surgery Section, Surgery Division, Medical School, Pontificia Universidad Cat
olica de Chile, Santiago,
Chile, †Radiology Unit, Clınica Alemana, Puerto Varas, Chile, ‡Faculty of Chemistry, School of Pharmacy,
Pontificia Universidad Cat
olica de Chile, Santiago, Chile
Background: The current treatment of keloids includes surgery, intralesionalsteroids, and radiotherapy, among others. Radiotherapy is not recommended inchildren due to its effects on growing tissues. Our aim was to study intralesionaltriamcinilone therapy of keloids in children and analyze the impact of bodylocation, age of the lesion, and etiology of the keloid on clinical response.
Methods: We conducted a prospective clinical trial with patients 1 to 14 years ofage evaluated for keloid treatment. A soft tissue ultrasound was performed tomeasure the keloid volume, prior to intralesional infiltration with triamcinoloneacetonide. A posttreatment ultrasound quantified the volume differencesattributed to therapy. For the analysis, Mann–Whitney/Wilcoxon test for pairedsamples and a multiple regression analysis were performed.
Results: Twenty-one patients with a total of 25 keloids were enrolled, with amedian age of 12 years (range 6–14 yrs). The initial lesional volume was 1.25 cc(range 0.2–6.3 cc) and the final volume was 0.2 cc (range 0.0–1.53 cc),corresponding to 82.7% of size reduction (p < 0.001). Regarding the rela-tionships between response and body location, etiology and age of the lesion,the multiple regression analyses obtained p-values of 0.46, 0.16, and 0.87,respectively. One patient failed to improve. Average follow-up was 30 months.
Conclusions: Triamcinolone acetonide is highly effective for the treatment ofpediatric keloids. There is no relationship between clinical response and thefactors evaluated, such as lesion location, etiology and age of the keloid.
Address correspondence to Silvana Acosta M.D.,, Secci
Cirugıa Plastica, Divisi
on de Cirugıa, Escuela de Medicina, Pon-
tiﬁcia Universidad Cat
olica de Chile, Marcoleta 350, Santiago
8330024, Chile, or e-mail: [email protected]
This study was presented at "LXXXV Congreso Chileno e
Internacional de Cirugıa" and the "XLVII Jornadas de Investi-gaci
on Pediatrica Santiago Norte."
2016 Wiley Periodicals, Inc.
Pediatric Dermatology Vol. 33 No. 1 January/February 2016
Keloids are pathologic scars that are challenging for
performed a repeat ultrasound to compare volume
physicians because no single treatment has been shown
diﬀerences attributable to therapy. If a palpable or
to be 100% eﬀective and capable of rendering the
visible lesion persisted after ultrasound, the keloid was
keloid free of recurrence. Several therapeutic modal-
reinjected each month with the same dose until no
ities have been tested for the management of keloids
volume change was perceived between one session and
(1), and new ones are described regularly, including
the next. Three months after the last procedure,
radiofrequency tissue volume reduction and hyaluro-
another ultrasound was performed to assess for any
nic acid intradermal injection with pneumatic tech-
recurrence. Subjects received one injection and then
nology (2,3). Most alternatives have not been
were evaluated at 1 month to monitor for side eﬀects.
evaluated in children, and there are no published
At month 3 they were reevaluated and treated if
series with a large number of children.
optimal improvement not achieved.
Intralesional triamcinolone acetonide is the most
No compression treatment (i.e., silicone plates) or
frequently used steroid for keloid treatment, but
other treatment that could inﬂuence the keloid was
children were excluded from most studies. We aimed
administered during the study period.
to study keloid treatment with intralesional triamci-nolone acetonide to determine its eﬀectiveness as a
single therapy and to determine whether it is a validoption for children, especially because surgical keloid
The data are presented as medians and ranges; lesion
removal in children may require general anesthesia.
dimensions were measured in cubic centimeters.
In our daily practice, some patients respond more
Normality tests were applied and a signiﬁcance level
favorably to steroid therapy than others. A second
of 95% was established. Pre- and posttherapy volume
aim of this study was to determine whether the
diﬀerences were analyzed using the Mann–Whitney/
aﬀected area, the etiology of the lesion, and
Wilcoxon test for paired samples. The relationship
the duration of a scar are factors that could determine
between the causal agent, the duration of the lesion,
the success or failure of the treatment.
and body location of the keloid was studied usingmultiple regression analysis. The data were analyzedusing SPSS version 21 (SPSS, Chicago, IL).
PATIENTS AND METHODS
A prospective study was conducted with children ages
1 to 14 years who consecutively visited our plasticsurgery outpatient clinic for keloid treatment. Patients
Our series included 21 patients with a median age of
were included if they had not received any treatment
12 years (range 6–14 yrs) with a total of 25 keloids.
in the 12 months before the beginning of the study.
The principal etiology was vaccination (measles,
Keloids were diagnosed clinically as an abnormal
mumps and rubella [second dose], administered at
proliferation of scar tissue that forms at the site of a
6 yrs of age), varicella infection, and trauma
cutaneous injury. Hypertrophic scars were not
(Table 1). Regarding the location of the lesion, the
left arm and the chest were the most frequently
During the evaluation, soft tissue ultrasound
involved sites, constituting 48% of cases (Table 2).
(ALOKA ProSound Alpha 10, Hitachi Aloka Med-
The mean time from onset to start of treatment was
ical America, Wallingford, CT), was performed by the
67 months (range 12–96 mos). The initial volume of
second author, a senior radiologist, using a high-
the lesion was 1.25 cm2 (range 0.2–6.3 cm2) and the
frequency small parts transducer that measured the
ﬁnal volume was 0.2 cm2 (0.0–1.53 cm2), resulting in
greatest dimensions of the longitudinal, transverse,and deep lesion axes. The keloid volume was calcu-lated from these data. Intralesional triamcinolone
TABLE 1. Keloid Etiology
acetonide (Kenalog suspension 40 mg/mL; Bristol-
Myers Squibb, New York, NY) was administered,without local anesthesia, using a 23 Fr needle at a
BCG vaccine (neonatal period)
dose of 0.5 mL/cm3 of the lesion (20 mg/cm3, with a
Measles, mumps, rubella (MMR) vaccine (6 yrs old)
Skin graft donor site
maximum dose of 40 mg per session).
Follow-up visits were conducted 1 week and 1
month after inﬁltration to detect possible complica-
Varicella lesion scars
tions. At 3 months posttreatment, the same radiologist
Acosta et al: Intralesional Triamcinolone in Children
TABLE 2. Anatomic Location of Keloids
Figure 3. The same patient after two treatment sessionswith intralesional triamcinolone.
The median number of injections required per
keloid was two (range one to ﬁve). The median dosefor each session was 16 mg of triamcinolone acetonide(range 4–40 mg) and the median dose to complete thetreatment was 32 mg (range 4–80 mg).
Analyzing the aﬀected body zone, the average
percentage decrease in volume by area was 86% forthe arms, 81% for the chest, 82% for the shoulder, and72% for the auricular area (p < 0.46). The originalvolume diminished by 69% for the keloids resulting
Figure 1. Volume comparison before and after therapy.
from varicella, 76% for those after vaccination, and88% for those resulting from trauma or surgical scars(p < 0.16). We observed no correlation between thetime before the start of treatment and response(percentage of reduction) (p < 0.87).
A single inﬁltration was suﬃcient in six of the
keloids (25%). Generally, two sessions were requiredto achieve the desired eﬀect (range two to ﬁve). Threelesions disappeared completely on sonographic exam-ination, and all of them were secondary to wounds.
Central depression at the inﬁltrated zone was noted inthree patients and was considered a complication ofthe procedure (12.5%). Telangiectasias and fat depos-its appeared in six of the lesions (20.8%). These arewell-described side eﬀects of intralesional steroidinjection, and the patients were advised accordingly(Fig. 4). One keloid did not respond to treatment even
Figure 2. A 36-month-old keloid scar secondary to
after ﬁve inﬁltrations. It was the only failure in the
trauma. Preinjection image.
All patients experienced pain during administra-
tion, but only one patient withdrew from the study
a decrease of 0.92 cm2 (range 0.05–6.29 cm2), corre-
because of pain.
sponding to an 82.7% (0.25–100%) reduction in size
Follow-up was 30 months (range 18–53 mos), with
between the ﬁrst and last treatments (p < 0.001)
one case of partial recurrence (4%). All patients
Pediatric Dermatology Vol. 33 No. 1 January/February 2016
with earlobe keloids. The recurrence rate was 4%,which is in agreement with our results and with theresults of the study by Ogawa et al (8). Hamrick'spatients each required at least four injection sessions,which the body area aﬀected could explain; in ourseries, the earlobe was the area that needed the mostinﬁltrations and showed the least volume decrease. Inseveral of the studies, the follow-up periods rangedfrom 2 months to 7 years, with a median time ofapproximately 25 months (1,2,9). In our study, themedian follow-up was 30 months (range 18–53 mos).
Although a recurrence could present many years aftertreatment, in our study, the recurrence rate was low inthe short term.
The use of intralesional or topical steroids is one of
Figure 4. Fat deposits and telangiectasias.
the most widespread practices in keloid treatment. Itssuccess rate has been reported to range from 50% to100%, with a recurrence rate of 9% to 50% (9). Local
side eﬀects include thinning and atrophy of the skin
Keloids have been a medical challenge for decades.
and subcutaneous tissues, telangiectasia, fat deposits,
The uncertainty of the etiopathogenesis has probably
and hypopigmentation (10). Side-eﬀect occurrence
prevented eﬀective intervention for avoiding keloid
was observed in 20.8% of the cases in our series.
formation. It is diﬃcult to assess the results of therapy
Because of low recurrence rate, surgical resection
because of the heterogeneity in the study designs
followed by radiotherapy is one of
regarding race, small series size, the combination of
treatments of keloids and is widely used throughout
associated therapies, and particularly because of the
the world, although there is ongoing fear of the
lack of objective measures that ensure comparability
development of malignant tumors. Ogawa et al's (10)
of results. Many publications deﬁne success or failure
literature review reported carcinogenesis attributable
based on subjective measures such as "good, regular,
to the use of radiotherapy for keloids between 1901
and bad." Our study design incorporated the dimen-
and 2009. They reported ﬁve cases: one in the treated
sions of the lesions observed with sonography, which
area and four in adjacent tissues. They assert that
allows an objective evaluation of the lesion before and
radiotherapy is safe with adequate preventive mea-
after treatment. Others researchers have used diﬀerent
sures, which are particularly crucial in delicate tissues
direct measurements of lesions, including Weshashy
such as the neck and mammary glands. Lundell et al
and Abdel Hay (4), who used an alginate mold ﬁlled
(11) conducted a study of thousands of adults
with saline solution to estimate the volume more
irradiated in childhood for infantile hemangiomas
precisely. Sadeghinia and Sadeghinia (5) used a
and found a greater incidence of thyroid and mam-
caliper to measure the largest dimension of keloid
mary gland cancer. Although retinoids have been used
width, length, and height.
as an adjunct to surgery, they are not considered ﬁrst-
The injection of triamcinolone acetonide was
line therapy. Side eﬀects of long-term systemic
shown to be eﬀective in our patients (84.6% volume
retinoids in children have been extensively docu-
decrease). The analysis of the response to treatment
mented and include potential irreversible bone dam-
according to the etiology of the keloid and the body
age (osteoporosis, ligaments calciﬁcation, premature
area aﬀected is an important aspect of keloid treat-
epiphysis fusion). Although these adverse reactions
ment research that has not received suﬃcient atten-
are not related to topical use of retinoids or short
tion. Anthony et al (6) treated 256 patients with
courses, there are insuﬃcient studies demonstrating
intralesional triamcinolone and found diﬀerences in
eﬃcacy and safety in children younger than 12 years
the number of required inﬁltrations according to the
old (2,9). Many studies have examined imiquimod 5%
aﬀected area, although their results were expressed
cream use in the postoperative period, applying the
only in frequency percentage.
medication during a variable period of time of 6 to
In the only series conducted exclusively in children,
24 weeks after surgery. Although the recurrence rates
Hamrick et al (7) studied the response of excision and
were low, nearly all of the reports involved earlobe
intralesional triamcinolone acetonide in 15 patients
keloids and were small case series. Cacß ao et al (12)
Acosta et al: Intralesional Triamcinolone in Children
reported the failure of imiquimod 5% cream in the
2. Fruth K, Gouveris H, Kuelkens C et al. Radiofre-
prevention of chest keloid recurrence.
quency tissue volume reduction for treatment of auricle
Regarding size estimation, the Vancouver scar
keloids. Laryngoscope 2011;121:1233–1236.
3. Kim HK, Park MK, Kim BJ et al. The treatment of
scale (13) is a good method for evaluating clinical
keloids with pneumatic technology: a pilot study. Int J
follow-up, but we hypothesize that it is not suﬃciently
objective to compare results between studies. Nicho-
4. Weshahy AH, Abdel Hay R. Intralesional cryosurgery
las et al (14) evaluated the Patient and Observer Scar
and intralesional steroid injection: a good combination
Assessment Scale in keloids and found that it had no
therapy for treatment of keloids and hypertrophic scars.
Dermatol Ther 2012;25:273–276.
pediatric adaptation and that area calculation could
5. Sadeghinia A, Sadeghinia S. Comparison of the eﬃcacy
be diﬃcult when assessing nonsurgical scars. The use
of intralesional triamcinolone acetonide and 5-ﬂuor-
of ultrasound has been attempted, but developing a
ouracil tattooing for the treatment of keloids. Dermatol
more accurate method is necessary (15).
Our study provides accurate information regarding
6. Anthony ET, Lemonas P, Navsaria HA et al. The cost
eﬀectiveness of intralesional steroid therapy for keloids.
keloids, allowing patients and their parents to decide
Dermatol Surg 2010;36:1624–1626.
which treatment is best for them, taking into account
7. Hamrick M, Boswell W, Carney D. Successful treat-
the keloid characteristics such as location and etiology.
ment of earlobe keloids in the pediatric population. JPediatr Surg 2009;44:286–288.
8. Ogawa R, Huang Ch, Akaishi S et al. Analysis of
surgical treatments for earlobe keloids: analysis of 174lesions in 145 patients. Plast Reconstr Surg 2013;
Intralesional triamcinolone acetonide therapy for
keloids is highly eﬀective in children, without any
9. Gauglitz GG, Korting HC, Pavicic T et al. Hyper-
adjuvant method. The average decrease in lesion
trophic scarring and keloids: pathomechanisms and
volume was 84.6%, and 96% of cases had no
current and emerging treatment strategies. Mol Med2011;17:113–125.
recurrence during 18 to 53 months of follow-up.
10. Ogawa R, Yoshitatsu S, Yoshida K et al. Is radiation
Complications, seen in 21%, were mild and aesthetic
therapy for keloids acceptable? The risk of radiation-
in nature and included hypopigmentation, skin atro-
induced carcinogenesis. Plast Reconstr Surg 2009;124:
phy, and telangiectasia. Our ﬁndings indicate a trend
toward better response in those lesions caused by a
11. Lundell M, Mattsson A, Hakulinen T et al. Breast
cancer after radiotherapy for skin hemangioma in
trauma or a surgical scar than in those caused by
infancy. Radiat Res 1996;145:225–230.
varicella or vaccination, although this diﬀerence was
12. Cacß ao FM, Tanaka V, Messina MC. Failure of
not statically signiﬁcant. Keloids on the earlobe had a
imiquimod 5% cream to prevent recurrence of surgi-
worse response than those on the arm, chest, or other
cally excised trunk keloids. Dermatol Surg 2009;35:629–
locations, although the diﬀerence was not statistically
13. Sullivan T, Smith J, Kermode J et al. Rating the burn
signiﬁcant. The small size of the sample could have
scar. J Burn Care Rehabil 1990;11:256–260.
inﬂuenced these results. The duration of the keloid
14. Nicholas RS, Falvey H, Lemonas P et al. Patient-
before starting treatment had no eﬀect on the
related keloid scar assessment and outcome measures.
Plast Reconstr Surg 2012;129:648–656.
Considering the lack of published data on keloid
15. Aya R, Yamawaki S. Ultrasound elastography to
evaluate keloids. Plast Reconstr Surg Glob Open
treatment in children, our work contributes by pro-
viding evidence of the safety and eﬀectiveness ofintralesional triamcinolone acetonide therapy.
1. Viera MH, Amini S, Valins W et al. Innovative ther-
apies in the treatment of keloids and hypertrophic scars.
J Clin Aesthet Dermatol 2010;3:20–26.
Graefes Arch Clin Exp OphthalmolDOI 10.1007/s00417-012-2226-y Visual outcomes and complications following posterioriris-claw aphakic intraocular lens implantation combinedwith penetrating keratoplasty Johannes Gonnermann & Necip Torun &Matthias K. J. Klamann & Anna-Karina B. Maier &Christoph v. Sonnleithner & Antonia M. Joussen &Peter W. Rieck & Eckart Bertelmann Received: 21 August 2012 / Revised: 31 October 2012 / Accepted: 21 November 2012
LIVE-CELL BIOSENSOR Novel Biosensors to Monitor Cellular Events in Live Cells Review of Fan, F. et al. (2008) Novel genetically encoded biosensors using firefly luciferase. ACS Chem. Biol. 3, 346–51. Neal Cosby, Promega Corporation entists targeted the hinge region of the luciferase mol- Drug discovery and life science researchers desire to