Keloid Treatment — SCE Dermatology MCQ

Correct answer: D — Intralesional corticosteroid injection (Triamcinolone acetonide 10-40 mg/mL) — surgical excision ALONE has an 80-100% recurrence rate

The correct answer is D, intralesional corticosteroid injection (triamcinolone acetonide 10 to 40 mg/mL), because it directly targets the excess fibroblast activity and collagen overproduction that drives keloid formation, reducing lesion volume, itch and pain while flattening the scar over repeated sessions typically spaced 4 to 6 weeks apart. This is the recognised first-line intervention in UK dermatology practice for keloid and hypertrophic scars, as reflected in British Association of Dermatologists patient guidance on intralesional steroid therapy. The stem specifically flags that surgical excision alone carries an 80 to 100 percent recurrence rate, which is the discriminating fact ruling out surgery as monotherapy and steering the answer toward a non-surgical, anti-fibrotic first-line approach. Triamcinolone works by suppressing inflammatory mediators and inhibiting fibroblast proliferation and collagen synthesis, making it effective even as sole therapy in many keloids. Why the other options are wrong: C. Topical retinoid: Topical retinoids have poor penetration into dense keloid tissue and are not established as effective monotherapy; they are used in some pigmentary or acne scarring contexts, not as first-line keloid treatment. A. Surgical excision alone: As stated in the stem, excision alone has an extremely high recurrence rate (80 to 100 percent) because the surgical wound itself can trigger further keloid formation in predisposed individuals; excision is only used combined with adjuvant therapy such as steroid injection or radiotherapy. E. Observation only: Keloids do not spontaneously regress and tend to enlarge over time, so withholding treatment risks progression, symptoms and cosmetic deterioration. B. Oral retinoid: Systemic retinoids carry significant toxicity (teratogenicity, hepatotoxicity, lipid derangement) and lack evidence for keloid regression, so they are not used for this indication. Key point: Intralesional triamcinolone is first-line for keloids because surgery alone recurs in up to 100 percent of cases without adjuvant anti-fibrotic treatment.

Reference: British Association of Dermatologists, Intralesional Steroid Therapy patient information leaflet (reviewed 2019), https://cdn.bad.org.uk/uploads/2021/12/29200301/Intralesional-Steroid-Therapy-Update-November-2019-lay-reviewed-November-20192.pdf