Use of Adjunct Oral Methotrexate in the Management of Keloid Formation Following Syndactyly Revision Surgery: A Case Report and Review of the Literature

Keloid formation following elective syndactyly surgery is an uncommon but difficult complication to manage. This report presents a case in which oral methotrexate was successfully used as an adjunctive postoperative therapy to prevent keloid recurrence in a paediatric patient. A 12-month-old Somali girl developed extensive, treatment-resistant keloids after syndactyly release of the second web space on her right hand. Conventional treatments with silicone gel and intralesional triamcinolone proved ineffective. Surgical excision of the keloids and reconstruction with full-thickness skin grafts from the groin were followed by nine months of adjunctive oral methotrexate (0.4 mg/kg weekly), which was well tolerated and resulted in successful healing without recurrence. Methotrexate, a well-established antimetabolite used in autoimmune disorders, appears to influence the wound healing process by reducing fibroblast proliferation, modulating collagen synthesis, and controlling inflammation through adenosine pathway activation. In this case, the combination of surgery, grafting, and systemic methotrexate therapy effectively prevented keloid recurrence while maintaining hand function. Compared with traditional topical or intralesional approaches, methotrexate offers a systemic and relatively safe method of modulating the pathological mechanisms underlying keloid formation. However, existing evidence remains largely anecdotal, underscoring the need for larger, controlled studies to determine standardised dosing, treatment duration, and long-term safety in keloid prevention.