A Randomized Controlled Trial to Compare the Effectiveness of Fractional CO2 Laser with Topical Steroid Application Under Occlusion Versus Steroid Injection Using Vancouver Scar Scale and Ultrasonographic Measurements

Abstract Background: Keloids pose a persistent therapeutic challenge in dermatology because of their progressive nature, high recurrence rates, and suboptimal response to many available treatments. While several modalities such as intralesional corticosteroids, cryotherapy, surgical excision, and laser therapies are employed, none provide uniformly satisfactory outcomes. Intralesional triamcinolone acetonide (ITA) is widely regarded as a first-line treatment due to its ability to suppress fibroblast activity and collagen synthesis, but it is often associated with significant procedural pain and patient discomfort. Fractional CO 2 laser therapy has emerged as a promising alternative, as it creates controlled micro-thermal zones that promote collagen remodeling and simultaneously facilitate enhanced transdermal delivery of topical agents into the dermis. This study aimed to compare the effectiveness of ITA injections with fractional CO 2 laser therapy followed by topical clobetasol propionate application (FCOC) in the management of keloids. Materials and Methods: A total of 20 patients completed the study, with 11 patients receiving ITA injections and 9 patients undergoing FCOC treatment. The therapeutic response was assessed over a period of three months using both clinical and objective evaluation tools. Clinical improvement was measured using the Vancouver Scar Scale (VSS), while objective assessment was performed using ultrasonography (USG) to evaluate changes in scar thickness, compressibility, echogenicity, and vascularity. These parameters were recorded at baseline and at subsequent follow-up visits. Results: Both treatment groups demonstrated improvement in VSS and USG parameters by the third visit. However, the ITA group showed a greater normalized mean improvement in VSS (35.61%) and USG parameters (29.15%) compared to the FCOC group, which showed improvements of 27.73% and 12.59%, respectively. The difference in USG improvement between the two groups was statistically significant ( P = 0.022), whereas the difference in VSS scores was not statistically significant ( P = 0.287). This disparity underscores the limitation of VSS in accurately assessing scar changes in darker-skinned individuals. Conclusion: ITA injections demonstrated superior effectiveness compared to fractional CO 2 laser therapy with topical steroids in the treatment of keloids. The study also highlights the need for more objective and inclusive scar assessment tools that are reliable across diverse skin types.