Ointments for keloid scars: effectiveness and application

A keloid scar is an overgrowth of scar tissue that extends beyond the original injury and often remains active for a long time. This distinguishes a keloid from a hypertrophic scar, which typically remains within the wound and often partially flattens over time. [1]

The main problem with "keloid ointments" is that topical treatments almost never completely eliminate an established keloid. The realistic goal of topical therapy is usually different: to reduce itching and discomfort, soften the scar, slightly reduce its height, improve its color, and reduce the risk of further growth, especially if the scar is still "fresh" or prone to irritation. [2]

Modern reviews and treatment algorithms emphasize that the most lasting effect on keloids is achieved by a combination of methods, rather than a single ointment. First-line treatment recommendations often include silicone-based treatments and corticosteroid injections into the scar, while ointments are considered a conservative component of care and maintenance therapy. [3]

Another important point: "absorbable ointments" containing antiseptics, antibiotics, tar, methyluracil, and similar ingredients are not intended for the treatment of keloids as fibroproliferative scars. They may be appropriate for other conditions, such as wound infection, but they have little to do with the structure of a mature keloid and sometimes irritate the skin, increasing itching and inflammation around the scar. [4]

Finally, the results of topical therapy depend greatly on the stage of the scar. Silicone treatments and some other topical options are usually recommended only after complete epithelialization, that is, when the skin is closed and no longer oozing. Scar ointments should not be applied to an open wound, as this increases the risk of irritation and infection. [5]

Table 1. What is considered successful topical therapy for keloids?

Target	Realistic for ointments and gels	What usually requires procedures
Reduction of itching, burning, discomfort	Often yes	Sometimes corticosteroid injections into the scar are needed
Reduced redness and "brightness"	Sometimes yes	Laser for vascular component according to indications
Flattening and decreasing density	Sometimes in moderation	Injections, cryotherapy, combination regimens
Complete disappearance of the keloid	Almost none	Even after removal, there is a high risk of recurrence without adjuvant therapy
Preventing deterioration after injury	Yes, if done regularly	In high-risk settings, combination prophylaxis is often needed.

[6]

Silicone gels and sheets: the most proven "ointment" option

Silicone gels and silicone sheets are considered the most common non-invasive therapy for pathological scars, including keloids. They are considered a first-line option because they typically have a good safety profile, and their effects are often focused on key symptoms: itching, discomfort, stiffness, and, to some extent, scar height. [7]

Cochrane Library reviews of silicone sheeting for keloid scars rate the evidence as low or very low quality, with mixed results across studies. This means silicone is often recommended, but it's important to be honest: for some people, it produces a noticeable effect, while for others, the effect is moderate or minimal, making it difficult to predict. [8]

Despite the limitations of the evidence base, clinical guidelines and protocols for burn and dermatology services regularly include silicone-based scar treatments as standard care. These documents typically emphasize three expected effects: improved color and texture, reduced scar height, and reduced itching. [9]

The practical effectiveness of silicone is almost always limited by the application regimen. National Health Service (NHS) guidelines and regional protocols often recommend wearing silicone for at least 12 hours a day for at least 2-3 months, and using it longer if the effect persists. [10]

The product format is chosen based on convenience. Sheets are convenient for smooth areas and provide long-lasting contact, but they don't hold up as well on active areas and can cause maceration in hot weather. Gels are suitable for difficult areas and when "invisible" application is desired, but require regular application and discipline. [11]

It's important to remember basic safety rules: silicone should only be used on closed skin, the area should be clean and dry, if irritation occurs, the application should be reduced or a break should be taken, and if there is oozing or signs of infection, an in-person assessment is required. These same principles are usually included in patient sick leave notes. [12]

Table 2. Silicone: how to use it to have a chance of being effective

Parameter	Practical guideline	Why is this important?
When to start	After complete epithelialization	Do not use on wet or open areas [13]
Duration of contact	From 12 hours a day	Short wearing often does not produce results [14]
Minimum course	2-3 months	The scar changes slowly [15]
Common mistakes	Irregularity, application "from time to time"	The effect depends on the discipline [16]
Common side effects	Irritation, maceration, itching from occlusion	Usually solved by selecting a mode [17]

Prescription Corticosteroid Ointments and Patches: When Topical Therapy Becomes 'Curative'

When it comes to topical medications, corticosteroids are considered the most "active" option for keloids, particularly in the form of special tapes and patches containing corticosteroids. A number of clinical schools, including Japanese guidelines and algorithms, consider corticosteroid tapes and patches as first-line therapy for pathological scars. [18]

The logic is simple: prolonged contact with a corticosteroid can reduce inflammation in the scar, alleviate itching, and gradually soften the tissue. Unlike conventional ointments, tape and patches provide a steady supply of the substance while simultaneously creating occlusion, which enhances penetration. [19]

British and European clinical literature also mentions steroid tape as a conservative method: it is worn for long periods, sometimes day and night, in courses, depending on tolerance and scar dynamics. In practice, this is more often used for small keloids and hypertrophic scars, as well as for "fresh" active scars. [20]

Strong corticosteroid creams and ointments are sometimes used for early pathological scar formation, especially if the scar is itchy and inflamed. However, many guidelines emphasize that topical corticosteroids are less effective than intra-scar corticosteroid injections and require careful monitoring of side effects. [21]

Side effects of topical corticosteroids, especially long-term occlusion, include skin thinning, vascular changes, pigmentation changes, and irritation. Therefore, such treatments are generally best considered as a doctor's prescription with a planned duration, area, and outcome monitoring, rather than as a "month-long self-treatment." [22]

It's important to clearly define the limits of treatment options: if the keloid is large, dense, and long-standing, topical steroid therapy can reduce itching and slightly soften the tissue, but it often doesn't result in significant flattening. In such cases, many recommendations recommend corticosteroid injection therapy, sometimes in combination with other methods, as the key treatment method. [23]

Table 3. Corticosteroid tapes, patches, and ointments: a practical comparison

Form	What does it give?	Who is it most suitable for?	Main risks
Corticosteroid tape or patch	Long-term contact, occlusion, gradual softening	Minor to moderate scarring, active itching areas [24]	Irritation, skin atrophy with prolonged use
Strong corticosteroid ointment	Anti-inflammatory effect during exacerbation	Early stages, itching, inflammation, when the tape is uncomfortable [25]	Skin atrophy, vascular changes, dyschromia
Corticosteroid injections into the scar	The most pronounced effect of flattening and reducing symptoms	Keloids with significant height and symptoms [26]	Pain, atrophy, pigmentation changes, relapses

Popular ointments and gels: What the evidence says

Products containing onion extract, heparin, and allantoin are often advertised as "absorbable" and are frequently prescribed for fresh post-surgical scars. Clinical studies and reviews suggest that this group has some evidence to support improvements in a number of early scar parameters, but this is typically focused on prevention and early therapy, not the treatment of mature keloids. [27]

When compared with silicone, the results are mixed. In a clinical study comparing silicone gel and onion extract gel for hypertrophic scars of the upper limb, both approaches were assessed as topical options with some effect, but the overall conclusion from systematic reviews is often that silicone appears to be a more sustainable option, especially for treatment, not just prevention. [28]

It's important to understand that onion extract may have a greater impact on color and subjective characteristics than on the height and density of pathological scars. Reviews of natural scar products note that color improvement is more common, while height reduction is less convincing in severe pathological scars. [29]

Vitamin E is often used alone, but the evidence base is weak, and the risk of contact dermatitis has been reported in clinical reviews. Therefore, vitamin E as a "keloid ointment" is not generally considered a rational monotherapy, especially for skin prone to irritation. [30]

The immunomodulatory cream imiquimod 5% has sometimes been used after surgical removal of keloids to reduce the risk of recurrence. Meta-analyses show very different recurrence rates depending on the location: for the earlobe, results appear better, while for the trunk and tension zones, recurrence remains high, so it is not a universal solution and certainly not a "regular home ointment." [31]

Finally, there is a group of remedies that are often mentioned in everyday life but have no proven mechanism for treating keloids: Vishnevsky ointments, topical antibiotics without infection, and "healing" stimulants as a universal scar therapy. These may be useful for other skin conditions, but for keloids as excess scar tissue, they have no proven role. [32]

Table 4. Common components of "scar ointments" and the expected effect on keloids

Component or group	Where data is more powerful	What to realistically expect	Comment
Silicone gel or plate	Prevention and early treatment, symptoms	Softening, reduction of itching, partial flattening [33]	Evidence is mixed, but it is the standard of non-invasive therapy [34]
Onion extract plus heparin plus allantoin	Early scars and prevention	Improvement of individual parameters, most often color and subjective sensations [35]	For mature keloids, the effect is usually limited.
Corticosteroid tape or patch	Pathological scars, especially active ones	Gradual softening and reduction of symptoms [36]	Requires monitoring of side effects
Vitamin E	The data is weak	The effect is unpredictable, dermatitis is possible [37]	As monotherapy it is not usually recommended
Imiquimod 5% after excision	Postoperative prophylaxis, individual localizations	May reduce recurrence on the earlobe, often not on the trunk [38]	Not standard for all patients

How to use ointments and gels: regimen, timing, effectiveness criteria

Any topical keloid treatment must begin with the right starting point: the skin must be completely healed, free of oozing and crusting. This is crucial for silicone products and tapes, as otherwise the risk of irritation and infection increases. [39]

Next, consistency is paramount. For silicone products, practical recommendations often specify a minimum of 12 hours a day and a course of at least 3 months, as scar changes occur slowly. For gels, this means daily application according to the instructions; for sheets, this means daily, long-term wear and proper care. [40]

Topical corticosteroids, and especially corticosteroid tapes, are best used under a doctor's prescription. If a patch or tape is chosen, prolonged contact is usually essential, even wearing it for most of the day. However, at the first sign of skin atrophy or severe irritation, the regimen should be adjusted. [41]

Evaluation of effectiveness should be based on measurable signs, not just the feeling of "feeling better." Practical criteria include: reduction in itching and pain, decreased firmness upon palpation, slight reduction in height, and lightening of redness. If there is no improvement after 8-12 weeks, it usually makes sense to reconsider the treatment plan and consider injection or device-based methods. [42]

It's important to note that keloids often recur. Therefore, even with a good response to silicone or tape, therapy is often considered long-term, especially if the scar is located in a tension zone and is easily irritated by clothing. [43]

If the keloid is itchy and the patient constantly rubs it, mechanical scar protection becomes part of the treatment. A silicone sheet acts both as a friction barrier and a moisture retainer, so in real life, it often works better than a "bare ointment," especially around belts, straps, and collars. [44]

Table 5. Home monitoring protocol: how to understand that the treatment is working

Term	What to record	How to fix	What is considered alarming?
Day 0	Basic dimensions and symptoms	Photo taken under the same lighting, ruler, itch scale 0-10	Rapid enlargement and severe pain
4 weeks	Dynamics of itching and density	The same photos and scale	No changes at all with good discipline
8-12 weeks	Outline, height, color	Photo and height measurement if possible	Scar growth, oozing, cracks
3-6 months	Sustainability of the effect	Re-fixation and evaluation of therapy comfort	Constant skin irritation from the product

[45]

When ointments aren't enough: where topical treatments fit into modern treatment regimens

If the keloid is significantly raised, dense, painful, or rapidly growing, topical therapy is usually considered adjunctive. In such situations, the most common method remains corticosteroid injections into the scar, with repeated courses as directed by the doctor. Silicone and tapes help maintain the effect between treatments and reduce symptoms. [46]

Systematic reviews of keloid treatments indicate that combination approaches often produce better results than monotherapy. These combinations include corticosteroid injections with the addition of 5-fluorouracil, bleomycin, or verapamil as indicated, as well as laser therapy. [47]

Surgical removal of a keloid without adjuvant therapy is generally not recommended because of the high risk of recurrence. If removal is performed for indications, recurrence prevention is almost always planned in advance. Topical therapies, including silicone and sometimes imiquimod in certain scenarios, may be part of the plan, but are not a substitute for full adjuvant therapy. [48]

Indications for in-person consultation include rapid growth, ulceration, bleeding, severe pain, signs of infection, and situations where the scar interferes with movement or is constantly traumatized. In such cases, it is important not to spend months trying too many ointments, but to move on to methods with a higher likelihood of controlling symptoms and growth. [49]

The risk of contact dermatitis from cosmetic ingredients should also be considered. If redness, burning, and itching around the scar increase while using an anti-scar cream, this may not be a "keloid flare-up," but rather irritation or an allergic reaction to the product itself, in which case the treatment should be changed. [50]

Table 6. When home ointment therapy is appropriate, and when it is better to see a doctor immediately

Situation	Ointments and gels as the main approach	Consultation and procedures needed
The scar is fresh, the skin is closed, the itching is moderate.	Yes, it's common to start with silicone.	If growth continues despite the regime [51]
The keloid is small, but active and itchy.	Sometimes, especially silicone plus tape as intended	A corticosteroid injection is often required [52]
The keloid is large, dense, and painful.	Usually not enough	Combination therapy, injections, sometimes cryotherapy or laser [53]
Ulceration, oozing, pus, fever	No	Urgent assessment, ruling out infection
The scar interferes with movement or is constantly injured	Partially	Treatment plan with a specialist

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