Keloid Treatment Options: When Silicone Sheets and Gels Are Not Enough
A keloid that appeared after an ear piercing, a sternotomy or a shoulder operation will usually be treated with silicone first, and that is the right place to start. Silicone gel sheeting and silicone gel have the widest evidence base of any non-invasive scar therapy, they are well tolerated, and they can be used by the patient at home.
The problem is what happens next. Silicone changes how a scar looks and feels, but it does not reliably stop a keloid from growing, and it does not address the itch and pain that bring many patients to a clinic in the first place. When silicone has been used correctly for several months and the lesion is still raised, spreading or symptomatic, continuing to explain the same product to the same patient is not a treatment plan.
This guide sets out the escalation options for keloids, what each is used for, and where the boundary sits between what a clinic can stock and what has to be referred.
First, confirm that it is a keloid
Keloid and hypertrophic scar are not the same lesion, and the difference changes the plan. A hypertrophic scar stays within the boundary of the original wound and tends to flatten over time. A keloid grows beyond the original wound margin, into surrounding skin that was never injured, and it does not regress on its own.
Several features raise the probability that a raised scar is a keloid: a site such as the ear lobe, sternum, upper back or shoulder; a history of a previous keloid; a family history; darker skin phototypes, where keloid incidence is higher; and continued growth months after the wound has closed. Wound tension at the time of healing is a contributing factor, which is why a scar across a joint or over the sternum behaves differently from one in loose tissue.
Getting that classification right also sets expectations. A hypertrophic scar may respond to silicone, pressure and time. A keloid is treated as a chronic condition that is managed rather than cured, and patients who understand that from the start are more likely to stay with a multi-month plan.
Why silicone remains the first step
Silicone gel sheeting and topical silicone gel reduce scar thickness, colour and symptoms in a large share of patients, and systematic reviews of the format — including a Cochrane review of silicone gel sheeting and a systematic review of topical silicone gel — support their use for hypertrophic and keloid scars, most often as first-line therapy or as an adjunct to something else.
Silicone works by occluding and hydrating the scar, which alters the local environment during remodelling; pressure and temperature effects are part of the proposed mechanism. What the evidence does not support is the idea that silicone alone resolves a mature keloid. It is a good first step with a modest effect size, and its role in a keloid plan is often as the maintenance layer around a procedure rather than as the treatment for the whole lesion.
A clinical point follows from the evidence. Silicone needs time — months, not weeks — and it needs adherent use. A patient who has used a sheet intermittently for three weeks and reports no change has not completed a trial of silicone therapy, and the clinic should confirm duration and adherence before escalating.
When silicone is not enough
Escalation is reasonable when any of four things is true after an adequate trial.
The lesion is still growing, or has grown since therapy started. The lesion is symptomatic, with itch or pain that interferes with sleep or daily activity. The lesion is large or thick enough that a home therapy cannot plausibly reduce it, such as a bulky sternal keloid or an ear lobe keloid with a firm core. Or the patient's concern is the raised profile itself and the timeline for silicone has not delivered enough change to be acceptable.
The escalation ladder
| Option | What it involves | Where it fits |
|---|---|---|
| Intralesional corticosteroid | Triamcinolone acetonide injected into the lesion, often every four to six weeks | First-line injection for a symptomatic or growing keloid; softens and flattens the lesion |
| Corticosteroid with 5-fluorouracil | Combined injection, sometimes with a lower steroid dose | Used for lesions that respond poorly to steroid alone, or to reduce steroid side effects |
| Cryotherapy | Freezing the lesion, sometimes combined with intralesional injection | Useful for smaller lesions; combination therapy shows better results than freezing alone |
| Laser therapy | Pulsed dye laser and other platforms, often in a series | Improves redness, texture and symptoms; usually an adjunct rather than a stand-alone cure |
| Pressure therapy | Ear lobe clips or pressure devices | Site-specific, useful on the ear lobe, often combined with silicone |
| Adjuvant radiotherapy | Low-dose radiation after surgical excision | Reserved for keloids that recur after excision, delivered by a radiation oncology service |
| Surgical excision | Removal of the lesion | Recurrence is high without adjuvant treatment, so it is usually paired with steroid, pressure or radiotherapy |
| Multi-modal plans | Combinations of the above | The practical norm for recurrent or complex keloids |
Two clinical points are worth stating plainly. First, intralesional injection is a medical procedure with a technique requirement — the injection has to be delivered into the substance of the lesion rather than beneath it — and outcomes from a series of injections are more consistent when it is done by a clinician who does it regularly. Second, excision without an adjuvant is the treatment with the highest recurrence rate in the list, which is why the trials of post-excision radiotherapy exist at all.
Where a clinic's role ends and referral begins
A clinic that stocks scar therapy products can carry a keloid patient a long way, and should know the point at which the case belongs elsewhere.
Care that suits a clinic or a practitioner with injection skills includes skin assessment and classification, a silicone therapy trial with documented adherence, intralesional corticosteroid injection where the practitioner is trained and equipped, and ongoing measurement. Pressure devices for ear lobe keloids, silicone sheeting used as an adjunct after a procedure, and the patient education that keeps a multi-month plan on track all sit comfortably in a clinic setting.
Referral belongs to dermatology, plastic surgery or a radiation oncology service for lesions that have recurred after excision, bulky lesions that need surgical management, keloids where radiotherapy is being considered as an adjuvant, and cases where symptoms are severe or the lesion is changing in a way that needs another diagnosis excluded.
Matching the finding to the next step
| What the clinic sees | What it suggests | Usual next step |
|---|---|---|
| Still growing after three months of adherent silicone | Incomplete response to first-line therapy | Intralesional corticosteroid, alone or with 5-fluorouracil |
| Itch or pain interfering with sleep | Active inflammation in the lesion | Intralesional injection; cryotherapy as an adjunct |
| Firm, bulky lesion with a hard core | Mature keloid tissue | A series of injections; consider referral |
| Recurrence after surgical excision | High-risk lesion behaviour | Multidisciplinary plan, including adjuvant radiotherapy where offered |
| Ear lobe keloid with a firm core | Site-specific keloid | Pressure device plus injection, with silicone as maintenance |
Measuring progress honestly
Keloid treatment is judged over months, and a clinic that does not measure tends to see improvement as disappointment. Two practical tools cover most of it.
Photographs taken at a fixed distance, angle and light, at each visit, with a ruler or a reference marker in frame, give the patient and the clinic a record that can be compared. Validated scar assessment scales such as the Patient and Observer Scar Assessment Scale add a structured way to record colour, thickness, pliability, surface area and the patient's own symptoms. Neither takes long, and both turn a subjective conversation into a trend line.
Symptoms belong in the record as well. Itch and pain are the symptoms patients most often want reduced, and they often improve before the lesion's height changes, which is useful information when a patient is deciding whether to continue.
Practical considerations for the products
Silicone gel and silicone sheeting are both reasonable formats, and the choice usually follows the site and the patient's routine. A sheet holds itself in place on flat, immobile surfaces such as a sternum or an abdomen and can be washed and reused until it no longer adheres. Gel suits areas that move, hairy or irregular surfaces, and the face, and it needs to dry after application.
Three practical points improve adherence. Clean and dry the skin before application, with no creams or oils underneath the silicone. Keep the sheet clean and replace it when adhesion fails, and keep a spare so the plan does not lapse between orders. And record the start date, because a patient who knows a twelve-week trial began on a specific date is more likely to complete it.
References and sources
- Silicone gel sheeting for preventing and treating hypertrophic and keloid scars
- Efficacy of topical silicone gel in scar management: a systematic review
- Triamcinolone acetonide intralesional injection for the treatment of keloids
- Unlocking better keloid treatment: corticosteroid, 5-fluorouracil and combination therapy
- Efficacy and safety of cryotherapy combined with intralesional steroid for keloids
- Laser therapy for treating hypertrophic and keloid scars
- Adjuvant radiotherapy after surgical excision in keloids
- Post-excision soft X-ray radiotherapy for keloids
- Keloids: current and emerging therapies
- Therapeutic methods and effect on keloid and hypertrophic scars: a systematic review
- Management of keloids and hypertrophic scars
- Keloids: review of pathogenesis and evidence-based treatment
- Infection prevention and control: focus on wound care
- Patient and Observer Scar Assessment Scale: validation and reproducibility studies
- Wounds Canada wound care and infection prevention guidance
Related Reading
- Clinical and supply guidance for clinics and care homes
- Silicone scar therapy: how silicone sheets and gels treat keloids and hypertrophic scars
- Keloid vs hypertrophic scars: what changes treatment
- Silicone scar sheets vs silicone scar gel: which should you choose?
- Silicone scar gel for keloid and scar management
- Reusable medical grade silicone scar sheet
- Clinics that reprocess instruments can request a 5-pack biological indicator trial
- Ask for a bulk quote for your practice
- free Ontario sterilization compliance log
Frequently Asked Questions
How long should silicone be used before adding another treatment?
Give an adherent trial of at least two to three months of daily use. If the keloid is still growing, is symptomatic, or has not changed meaningfully at that point, adding an intralesional injection or another modality is reasonable. Silicone can continue afterwards as maintenance.
Are injections into a keloid safe?
Intralesional corticosteroid injection is a standard treatment for keloids, and the main side effects are local: skin thinning, pigment change, small blood vessels becoming visible, and discomfort during the injection. Response varies between patients, and most plans involve a series of injections rather than a single one.
Can a keloid be removed surgically?
It can be excised, but excision alone has a high recurrence rate, which is why surgery is usually paired with an adjuvant such as steroid injection, pressure therapy or low-dose radiotherapy. The decision belongs with a surgeon or dermatologist rather than in a clinic setting.
Do silicone sheets work on old keloids?
They can improve appearance, colour and symptoms on older lesions, but the change is usually modest and slow on a mature keloid with a firm core. Older lesions are the group most likely to need an additional treatment such as intralesional injection alongside silicone.
What is the difference between a keloid and a hypertrophic scar?
A hypertrophic scar stays within the boundary of the original wound and often flattens over time. A keloid grows beyond the original wound margin into uninjured skin and does not regress on its own. That difference is what makes keloids a long-term management plan rather than a waiting game.
Is silicone gel or a sheet better for a keloid?
Sheets hold themselves in place on flat, immobile surfaces and can be washed and reused. Gel suits moving areas, hairy skin, irregular surfaces and the face. The choice is driven by the site and the patient's routine, since a format the patient will actually use every day outperforms a format they will not.
Does pressure help an ear lobe keloid?
Pressure devices and clips are used on ear lobe keloids, often combined with silicone, and they are site-specific rather than general. They work as part of a plan that also includes assessment and, where needed, injection.
When should a keloid patient be referred?
Refer for lesions that have recurred after excision, bulky lesions needing surgical management, cases where radiotherapy is being considered, keloids that continue to grow despite adequate treatment, and any lesion whose appearance suggests that another diagnosis should be excluded.
Last updated: September 2026
CliniEco Medical holds a medical device establishment licence. Health Canada MDEL #35334. Devices in Class II to IV that we list are covered by their manufacturer's licence.
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