A keloid is the only scar that behaves like a growth. It does not stop at the edge of the wound that started it; it invades the skin around it, keeps going, and returns when cut away. Patients arrive at my Dubai clinic having had one excised elsewhere, and having watched it come back larger than the original.
I say the same thing to each of them, here in Dubai. That is not misfortune, and it is not a poorly performed operation. Excision alone recurs in 45 to 100 percent of keloids. The interesting question in keloid surgery has never been how to cut it out. It is what you add to the cutting — and how honestly the person recommending it will describe what that addition costs.
Key takeaways: keloids and combination therapy
- Excision alone recurs in 45–100% of keloids, often larger.
- About half of keloids resist steroid, the standard first-line drug.
- Adding 5-fluorouracil works better and causes fewer complications.
- Steroid alone thins the skin in 44%; with 5-FU, 8%.
- Radiotherapy after excision gives 14–18% recurrence, not under 10%.
- It is radiation for a benign lesion, and carries a small cancer risk.
A note on scope: this article is about keloids specifically. How scar treatments are graded across the whole field, why a treatment weakly supported for preventing a scar can be strongly supported for treating one, and how hypertrophic, atrophic and contracture scars differ, is the subject of my article on what the evidence actually grades.
Why cutting it out is the wrong operation
A keloid is a fibroproliferative lesion. Its fibroblasts have escaped the ordinary regulation that tells a wound when to stop building collagen, and they continue producing it long after healing should have finished. Cut the keloid out, and you have created precisely the stimulus — a fresh wound in keloid-prone skin — that produced it in the first place.
This is why excision as a solitary treatment is not merely ineffective but counterproductive. It is also why the first thing I tell a patient in Dubai asking me to remove one is that I will not do it that way, and that anyone offering to is not describing a plan.
Why keloid excision requires adjuvant therapy, and what each addition honestly achieves, by Dr. Nazmi Baycin, Dubai.
The drug that half of keloids ignore
Intralesional triamcinolone — a corticosteroid injected directly into the lesion — is the accepted first-line treatment. It suppresses the inflammation driving collagen production, and it flattens many keloids convincingly.
Two facts about it are less often mentioned. Roughly half of keloids are steroid-resistant, which is a remarkable thing to say about a first-line therapy. And the steroid leaves its own mark: skin atrophy at the injection site, visible broken vessels, and a pale depressed patch that some patients find no better than the keloid it replaced.
Adding a second drug, and getting fewer side effects
5-fluorouracil is an antimetabolite. Where the steroid calms inflammation, the second drug interrupts fibroblast division directly — it stops the cells that build the keloid from multiplying. The two act on different parts of the same problem.
A systematic review and meta-analysis comparing triamcinolone alone with triamcinolone plus 5-fluorouracil found the combination more effective, with a faster response, and — the part that surprises people — with fewer complications. In the trials, skin atrophy occurred in around forty-four percent of steroid-alone patients and around eight percent of those receiving the combination.
More effective and safer is an unusual thing to be able to say in medicine. It is why the combination is my routine for injectable therapy in Dubai, and it is worth asking any surgeon who offers you steroid alone why he does not use it.
| Treatment | What is often claimed | What the evidence shows | Where it belongs |
|---|---|---|---|
| Excision alone | Removes the keloid | 45–100% recurrence | Never on its own |
| Steroid alone | Standard first line | Half resist; 44% atrophy | First, but not last |
| Steroid with 5-FU | An alternative | Better and safer, 8% atrophy | The injectable default |
| Radiotherapy | Recurrence under 10% | 14–18%; range 2–55% | Last, for the recalcitrant |
Radiotherapy, stated honestly
Excision followed by radiation is genuinely the most effective option for a keloid that has defeated everything else. It is also the treatment about which the most confident and least accurate claims are made, and I want to correct three of them.
The first concerns the number. A systematic review and meta-analysis of 106 studies covering 10,745 keloid lesions reports recurrence of eighteen percent after X-ray therapy, fourteen percent after brachytherapy, and sixteen percent after electron beam. You will read that radiation brings recurrence below ten percent. Across the literature the reported range runs from under two percent to over fifty-five, and quoting only its floor is not the same as reporting a result.
The second concerns the protocol. A single dose within twenty-four hours is often presented as settled practice. The regimens actually studied are fractionated, delivered over several days, and the same meta-analysis found no significant difference between early and late administration. Timing has not been settled; it has been assumed.
The third is the sentence almost nobody writes. This is radiation, delivered to healthy tissue, for a benign lump. It carries a small but real risk of inducing a cancer, a question the literature has asked directly. The risk is low. It is not zero, and it is not yours to accept unless someone has told you it exists. That is why I reserve radiotherapy for keloids that have already recurred after proper combination treatment, rather than offering it as a routine adjunct.
The order matters more than the choice
Most of the harm I see in keloid treatment comes not from choosing a bad option but from choosing a reasonable option too early. The sequence is what protects a patient:
- Begin conservatively: silicone, pressure, and intralesional injection, with the combination rather than steroid alone.
- Escalate when it stalls, rather than when the patient becomes impatient.
- Reserve excision for what genuinely resists, and never perform it as a solitary treatment.
- Consider radiation last, for the keloid that has recurred despite adequate adjuvant therapy.
When I do excise, the surgical detail matters: an intramarginal excision that stays within the keloid’s own boundary, closure without tension, and tension-relieving sutures beneath the skin. But all of that is a refinement of the operation, not a substitute for what must accompany it.
What a keloid costs a person
I want to say something about the burden, because the clinical literature discusses it rarely and patients think about it constantly. Keloids itch, they hurt, they catch on clothing, and they sit where everyone can see them — the earlobe, the chest, the shoulder, the jaw. Patients cover them, avoid photographs, and stop wearing what they would like to wear.
None of that is vanity, and none of it needs to be justified to me. It is also the reason I am cautious rather than enthusiastic: a patient distressed by a keloid is a patient who may accept an operation, or a course of radiation, that a calmer conversation would have deferred. My job is to be the person in the room who is not in a hurry.
The question to ask
If a surgeon proposes to excise your keloid, ask what he intends to add to the excision. If the answer is nothing, decline, and understand that he is offering you a larger keloid in a year.
And if the answer is radiation, ask him for the recurrence figure and the range around it, ask him why the timing he proposes is the right one, and ask him what the radiation risks. A surgeon who answers those three plainly has thought about your keloid rather than his schedule. That is the standard I hold as a leading plastic surgeon in Dubai.
FAQs about keloid treatment in Dubai
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Can you just cut my keloid out?
I can, and I will not, because excision as a solitary treatment recurs in between forty-five and one hundred percent of keloids, frequently larger than the original. The reason is mechanical rather than mysterious. Cutting the keloid out creates a fresh wound in keloid-prone skin, which is precisely the stimulus that produced the keloid in the first place. So anyone offering you a straightforward excision is not describing a plan. The question worth asking is what will be added to it.
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Why do steroid injections sometimes not work?
Because roughly half of keloids are steroid-resistant, which is a remarkable thing to say about a first-line drug. Triamcinolone suppresses the inflammation that drives collagen production, and it flattens many keloids convincingly. It does nothing to stop the fibroblasts themselves from dividing. So when a keloid stalls under steroid alone, the answer is usually not more steroid. It is a second drug that acts on a different part of the problem.
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What does adding 5-fluorouracil do?
It interrupts fibroblast division directly. Where the steroid calms inflammation, 5-fluorouracil stops the cells building the keloid from multiplying, so the two act on different parts of the same process. A systematic review comparing steroid alone with the combination found the combination more effective, faster acting, and with fewer complications. So it is more effective and safer, which is an unusual thing to be able to say. It is my routine for injectable therapy, and worth asking about if you have been offered steroid alone.
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Does the steroid injection have side effects?
Yes, and they are visible. Skin atrophy at the injection site occurred in around forty-four percent of steroid-alone patients in the trials, along with broken vessels and a pale depressed patch of skin. Some patients find that result no better than the keloid it replaced, which is a fair judgment rather than an ungrateful one. So this is the second reason I use the combination. In those same trials, atrophy fell to around eight percent when 5-fluorouracil was added.
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Does radiotherapy really cut recurrence below ten percent?
Not reliably, and you will read that it does. A systematic review of 106 studies covering more than ten thousand keloid lesions reports recurrence of eighteen percent after X-ray, fourteen percent after brachytherapy, and sixteen percent after electron beam. Across the wider literature, reported recurrence runs from under two percent to over fifty-five. Quoting only the floor of that range is not reporting a result. So radiation genuinely helps, and it helps by less than it is usually said to. I would rather you knew the number and its spread.
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Is radiotherapy dangerous?
This is the sentence almost nobody writes down for you. It is radiation, delivered to healthy tissue, for a benign lump, and it carries a small but real risk of inducing a cancer. The literature asks that question directly. The risk is low. It is not zero, and it is not yours to accept unless someone has told you it exists. So I reserve radiotherapy for keloids that have already recurred after proper combination treatment, rather than offering it as a routine adjunct to every excision.
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Must the radiation be given within 24 hours?
It is often stated so, and the evidence does not support it. The regimens actually studied are fractionated, delivered over several days rather than as a single dose. The same large meta-analysis found no significant difference in recurrence or complications between radiotherapy given early and given late. So the timing has not been settled; it has been assumed. A surgeon quoting you a rigid window is repeating something rather than reporting it.
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Why are you so cautious about treating my keloid?
Because keloids itch, hurt, catch on clothing, and sit where everyone can see them. Patients cover them and avoid photographs, and none of that is vanity or needs justifying to me. It is also precisely why caution matters. A patient distressed by a keloid is a patient who may accept an operation, or a course of radiation, that a calmer conversation would have deferred. So my job is to be the person in the room who is not in a hurry. We begin conservatively, escalate when the treatment stalls rather than when patience does, and keep the strongest options in reserve.
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