Keloid Steroid Injection:
Steroids have been long used in treatment of various skin disorders. Injecting steroids directly inside the keloid tissue, known as intra-lesional injection, is a commonly used method of treating small keloids. This treatment however, is only partially effective. Triamcinolone acetonide, know as Kenalog, is the most commonly used drug for treatment of keloids. Efficacy of this treatment was first reported in 1960, but ever since, no clinical studies have ever been conducted to determine the proper dose of this drug for usage in medical management of keloid disorder.
Indeed, even as of 2016, there are some physicians who falsely believe that a higher dose of steroids will result in better treatment outcomes, and as such, inject their patients with the highest available dose of Kenalog.
Like all other human illnesses, when it gets to steroid usage in keloid disorder, there are keloid lesions that are Steroid Sensitive, and there are also lesions that Steroid Resistant. In treating Steroid Sensitive Keloid Lesions, the lowest doses of steroids will do the job and will induce a response, with no need to use higher doses. On the other hand, in treating Steroid Resistant Keloid Lesions, even the highest doses of steroids will NOT induce a response, but will for sure contribute to side effects from this drug. There is a linear relationship between the dose of steroids and the resultant side effects. Dr. Tirgan is aware of a case of Cataracts of eyes, secondary to repeated high dose steroid injects, and fluctuation of blood sugar among diabetics who receive steroid injections for treatment of keloid lesions.
Repeated steroid injections, specially with high doses will often cause skin atrophy (loss of normal skin tissue) and discoloration and loss of normal skin pigments. Image below is an example of this side effect from repeated steroid injection in a chest wall keloid. Take notice that this linear keloid has not responded to the treament and is classified as Steroid Resistant.
Another issue with usage of intra-lesional steroids is the size, length and thickness of the needle used to inject the keloid lesions. Some physicians falsely believe that a large and thick needle should be used to inject large keloid lesions. This belief comes from the fact that injecting some old and dense keloid lesions is a rather difficult task. In treating keloid lesions, the smaller and thinner the needle is, the less damage it causes to the keloid tissue. Dr. Tirgan only uses the smallest and thinnest needles, those that are used to inject insulin under the skin. With this method, Dr. Tirgan is able to inject any keloid.
The very dense and thick keloids are hard to inject, will never respond to steroid injections, and should not even be treated in this manner. Very large and dense keloid lesions are best treated with cryotherapy, will result in reduction of the mass of these keloids.
Last but not the least, is the expertise of the physician who injects keloid lesions. An unfortunate fact these days is that the task of injecting keloid lesions, in busy dermatology practices, is often delegated to non-physicians. As such, a non-physician is put in charge of deciding (1) the dose and (2) volume of steroid that is used, and (3) the size of the needle and (4) choosing where and what to inject. This approach of treating keloid lesions is obviously less than satisfactory.
Below is a video that demonstrates how Dr. Tirgan injects steroids.