Dr. Baldwin dismissed the dogma of not exceeding 40 mg per month, given that this translates to a dose of just 50 mg of prednisone. "I will sometimes use 80 [mg] in one sitting. I don’t really have that kind of a restriction because it doesn’t make a ton of sense," she said.
For pre-injection anesthesia, Dr. Baldwin recommended applying topical anesthetic followed by a lidocaine ring block. When treating hard keloids, to prevent backwash of the corticosteroid along the needle track, she said she preapplies Krazy Glue and, immediately after removing the needle, applies a strip of precut tape.
Patients should be advised of the possible complications of hypopigmentation, telangiectasia, and atrophy. "You also have to warn your patients about what I call the Play-Doh effect," whereby the keloid spreads as it softens, Dr. Baldwin said. "So the footprint is ultimately much bigger than it was originally, although it’s now flatter."
Intralesional injection of 5-fluorouracil can be used alone or with admixed steroids. However, Dr. Baldwin said that in her hands, the combination has been disappointing, perhaps because the triamcinolone is diluted in the process. "So I’ve reconsidered recently the possibility of doing the steroids the way I like it and following [with 5-fluoruracil] in addition to it, rather than diluting my triamcinolone," she said.
The newest nonsurgical therapy is intralesional cryotherapy, whereby the keloid is frozen from the inside out with a probe attached to a cryotherapy device, so it eventually undergoes necrosis while the skin is preserved. The reduction in volume achieved has ranged from 51% to 93% across studies, with minimal to no hypopigmentation.
"The probe itself unfortunately costs $450 and is not reusable, which is a problem. At the present time this is not covered by insurance," said Dr. Baldwin, who disclosed no relevant conflicts of interest. "But for keloids that really can’t be treated any other way, it has been quite helpful."
The meeting was presented by the Caribbean Dermatology Symposium.