Posted April 26, 2026 in plastic surgery
Keloids can be one of the most frustrating conditions we treat. They can be painful, raised, itchy, and often recur despite multiple treatments. Over the past several years, combination therapies have significantly improved outcomes—and one protocol in particular has been truly game-changing.
The Power of Combination Therapy
At Mountcastle Medical Spa & Laser Center, we utilize a combination of:
- Intralesional Kenalog (triamcinolone)
- 5-Fluorouracil (5-FU)
- SRT (superficial radiation therapy) when appropriate
This multi-modal approach targets keloids at multiple levels, improving both short-term flattening and long-term control.
Kenalog + 5-FU: Why the Ratio Matters
A key part of this protocol is the intralesional combination of Kenalog and 5-FU.
While many published studies describe mixtures such as 4:1 (5-FU:steroid), more recent clinical experience and emerging data support lower steroid concentrations with balanced dosing.
👉 In our practice, we have found a 1:1 ratio of Kenalog 40 mg/mL and 5-FU to be highly effective.
Why this matters:
- Combination therapy is already proven to be more effective than steroid alone
- Lower steroid burden helps reduce side effects such as:
- skin atrophy
- telangiectasia
- hypopigmentation
- 5-FU directly suppresses fibroblast activity and collagen production
Recent literature supports that 1:1 combinations are effective and well tolerated, reinforcing the concept of balanced dosing rather than steroid-heavy mixtures
Clinical Advantages of the 1:1 Approach
In practice, this ratio has been:
- More consistent in softening and flattening scars
- Better tolerated over repeated sessions
- Associated with fewer steroid-related complications
- Easier to titrate based on scar response
This represents a shift away from older protocols that relied heavily on steroid dominance.
The Role of SRT (Superficial Radiation Therapy)
For more aggressive or recurrent keloids, we often combine injections with SRT following excision.
This “triple therapy” approach:
- reduces recurrence at the cellular level
- improves long-term scar quality
- is especially effective in resistant cases
What to Expect
- Treatments are performed in-office
- Typically require a series of sessions
- Gradual improvement over time
- Fully customized based on scar type and location
The Bottom Line
There is no single “magic” treatment for keloids—but combination therapy, especially with optimized Kenalog and 5-FU ratios, has significantly improved outcomes.
Refining technique, dosing, and treatment sequencing is what separates average results from excellent ones.
Schedule a Consultation
If you’ve struggled with keloids or recurrence, we’d be happy to discuss advanced treatment options with Double Board Certified Plastic Surgeon Dr Timothy Mountcastle, M.D.
📞 703-858-3208
📧 frontdeskmpsvi@gmail.com
