Keloid remodeling: improved outcomes with fractional CO₂ laser plus intralesional triamcinolone in a Fitzpatrick IV patient

Abstract

Keloid scarring is more prevalent in individuals with pigmented skin and can be particularly challenging to treat due to the risk of dyspigmentation and limited response to first-line therapies. This case describes a Fitzpatrick type IV patient whose keloid remodeling plateaued with intralesional corticosteroids but improved significantly following adjunctive fractional CO₂ laser therapy. The report highlights the safe use of lasers in darker skin types and reinforces the need to expand equitable access to such treatment modalities.

KEY POINTS

• Keloids are more prevalent and treatment resistant in patients with skin of color.

• Fractional CO₂ laser therapy, when used conservatively, can safely improve keloid appearance and symptoms in Fitzpatrick IV–VI skin.

• Concerns about postinflammatory hyperpigmentation should be weighed against clinical benefit.

• Disparities in laser access for skin of color populations may reflect cost barriers, training gaps, and limited representation in clinical trials.

CME

CME Information: https://ce.bswhealth.com/BUMC_Proceedings_CME_info

Credit Claim Process: To claim CME for this activity, read the entire article and go to ce.bswhealth.com/2026BUMC_Proceedings_Mar_Keloid. You will register for the course, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit.

Dates for credit claim: March 1, 2026, to March 1, 2027.

For questions about CME credit, visit our website ce.bswhealth.com/contact-us.

CASE DESCRIPTION

A 28-year-old woman with Fitzpatrick type IV presented for follow-up of a longstanding keloid scar on the right upper arm, which had developed several years earlier. She had previously undergone four rounds of intralesional Kenalog (ILK) injections over 2 years but reported minimal progress due to inconsistent access to care. Physical examination revealed a keloid scar with surrounding postinflammatory hyperpigmentation (PIH) (Figure 1a).

Figure 1.

Keloid (a) after four rounds of intralesional kenalog (ILK), before fractional CO₂ laser treatment; (b) after five rounds of ILK, before fractional CO₂ laser treatment; (c) after one session of fractional CO₂ laser therapy plus six rounds of ILK.

CME

CME Information: https://ce.bswhealth.com/BUMC_Proceedings_CME_info

Credit Claim Process: To claim CME for this activity, read the entire article and go to ce.bswhealth.com/2026BUMC_Proceedings_Mar_Keloid. You will register for the course, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit.

Dates for credit claim: March 1, 2026, to March 1, 2027.

For questions about CME credit, visit our website ce.bswhealth.com/contact-us.

She was treated with 0.5 mL of 40 mg/mL triamcinolone acetonide injected directly into the lesion. She was also prescribed a compounded lightening cream containing hydroquinone 4%, tretinoin 0.05%, and triamcinolone 0.025%, applied nightly in alternating 6-week “on” and “off” cycles, with tretinoin 0.05% cream as monotherapy during breaks from the lightening cream.

The patient was followed up at the 3-month mark, where she had noticeable overall improvement after ILK injections and consistent use of the topical agents. However, there was persistent focal hypertrophy of the scar and residual PIH (Figure 1b). Given the plateauing response to ILK monotherapy and the patient’s desire to enhance cosmetic outcomes, fractional CO₂ laser therapy was initiated as adjunctive treatment with 0.3 mL of 10 mg/mL triamcinolone acetonide added to the focal area of hypertrophy during that time. The initial session targeted the scar using the settings in Table 1. The procedure was well tolerated, and appropriate post-laser care instructions, including sun protection, were provided. The patient was advised to continue the lightening cream regimen and was informed that a total of three CO₂ laser sessions would likely be required.

Table 1.

CO₂ laser processing parameters

Parameter	Value
Power (watts)	20
Dot mode spacing (microns)	500
Dwell time (microseconds)	800
Number of passes	1

At 2-month follow-up, following six total ILK treatments and one CO₂ laser session, the scar showed partial but notable improvement. The hypertrophic components softened, with marked flattening of the left and right borders of the lesion, while focal hypertrophy persisted centrally. There was also a visible reduction in erythema compared to baseline, though mild induration remained (Figure 1c). Although surrounding pigmentary changes were not clinically significant, a subtle area of hypopigmentation was observed at the rightmost border of the scar. The patient expressed satisfaction with the results to date and wanted to continue with the planned treatment regimen. However, she did not return for additional follow-up, and therefore, longer-term outcomes and the potential need for maintenance therapy could not be assessed.

CLINICAL QUESTIONS

1. A 28-year-old woman with Fitzpatrick type IV skin presents with a long-standing keloid scar on her upper arm. She has undergone multiple intralesional corticosteroid injections with minimal improvement. She is interested in additional treatment options to improve texture and pigmentation. Which of the following represents the most appropriate next step in her management?

   1. Continue intralesional corticosteroid injections alone, as additional treatment modalities increase the risk of side effects in darker skin tones.

   2. Initiate fractional CO₂ laser therapy with conservative parameters combined with intralesional corticosteroid and adjunctive topical lightening agents.

   3. Perform surgical excision of the keloid without adjuvant therapy.

   4. Begin systemic corticosteroid therapy to reduce scar hypertrophy.

2. Which of the following best describes the role of fractional CO₂ laser in treating keloids?

   1. Not effective and contraindicated in all skin of color patients

   2. Most effective when combined with surgical excision

   3. Can safely remodel collagen with reduced recurrence when used conservatively

   4. Ineffective without concurrent systemic therapy

Answers are provided at the end of the article.

DISCUSSION

Keloids are fibroproliferative scars that extend beyond the original wound margin due to dysregulated collagen deposition. Individuals with darker skin are disproportionately affected and are 15 times more likely to form keloids. Traditional, first-line therapy for keloids is ILK injection, which can help flatten scars by suppressing inflammation and fibroblast activity; however, it is often associated with incomplete responses, skin atrophy, dyspigmentation, and recurrence.¹

There has been an increased use of fractional CO₂ laser as an alternative or adjunct to ILK. Fractional lasers ablate microthermal columns of tissue while sparing the surrounding epidermis, triggering dermal remodeling and collagen reorganization, consequently debulking scar tissue.² Historically, this modality was avoided in skin of color (SOC) due to concerns over PIH. However, newer fractional laser technologies have significantly improved safety profiles in darker skin when used with conservative settings, such as the parameters in Table 1.³

Melanin absorbs a broad range of wavelengths (250–1200 nm), with peak absorption between 300 and 600 nm.^4,5 Patients with darker skin tones, who have more melanin, absorb more laser energy, increasing the risk of thermal injury to the surrounding skin. Side effects such as PIH, hypopigmentation, and permanent pigment loss are more common in SOC, with PIH being the most frequent. In one study, 92% of patients with Fitzpatrick type IV developed transient PIH after treatment with a 15 W fractional CO₂ laser, which resolved within 5 weeks using 4% hydroquinone therapy.⁶ Our patient’s treatment regimen, including 4% hydroquinone, 0.05% tretinoin, and intermittent topical corticosteroids used between and after treatments, reflects best practices for mitigating the risk of PIH. These topical agents reduce melanocyte activity through various mechanisms and, when used right after procedural treatments like CO₂ laser, help mitigate the risks of hyperpigmentation.

As a result, careful guidelines must be followed when using laser treatments in these patients. Precautions include avoiding overheating of the epidermis by using lower energy settings, limiting the number of passes or pulse stacking, selecting longer wavelengths that minimize epidermal melanin absorption, and allowing longer recovery periods between treatment sessions to enable resolution of any transient hyperpigmentation or inflammation.⁴ If there is concern about significant dyspigmentation following CO₂ laser treatment, performing a test spot in a less exposed area, such as the postauricular region, is recommended before proceeding with full treatment.

This case also highlights key health equity issues. Despite the higher prevalence and severity of keloids in African American and Hispanic populations, access to fractional CO₂ laser therapy remains limited for many patients with SOC. Insurance providers often classify laser resurfacing as cosmetic, even when treating symptomatic or disfiguring keloids, resulting in extra out-of-pocket costs that many patients cannot afford.⁷

Another concern is the underrepresentation of darker-skinned individuals in clinical trials of laser therapies. A recent analysis found that participants with Fitzpatrick types V and VI were often excluded or unreported.⁸ This data gap has contributed to conservative or avoidant treatment approaches in SOC due to safety uncertainties. However, emerging research supports that fractional lasers yield favorable outcomes for a range of dermatologic conditions in Fitzpatrick types IV to VI.⁹ Patients of color often experience a greater keloid burden and more extensive scarring, yet have less access to advanced treatments.¹⁰ Advocating for insurance coverage, implementing training in safe laser techniques for all skin types, and expanding research into tailored therapies for SOC can promote equity in scar treatment.

Our case supports the growing view that, when used with appropriate precautions, fractional CO₂ laser therapy is not only safe but potentially transformative for patients with SOC. This case adds to the expanding body of evidence that fractional CO₂ laser therapy, when combined with safeguards and adjunctive topical or intralesional treatments, can be a safe and effective option for treating keloids in SOC. While the combination of intralesional corticosteroids and fractional CO₂ laser is well established, the novelty of this report lies in its focus on a patient with Fitzpatrick type IV skin, where the risk of pigmentary complications remains a major barrier to treatment.

However, there are several limitations to this study. The relatively short follow-up period prevents assessment of long-term durability and recurrence, and no objective scar scales, such as the Vancouver Scar Scale, were applied. In addition, because the patient did not return for continued follow-up, the potential role of maintenance therapy could not be evaluated. Future research in patients with SOC, with standardized measures and extended follow-up, is needed to guide protocols and evaluate long-term outcomes.

ANSWERS TO CLINICAL QUESTIONS

Question 1, b. Fractional CO₂ laser therapy, when used with appropriate precautions, can safely improve keloid texture and hypertrophy in patients with SOC. Combination therapy with intralesional corticosteroids enhances efficacy, while topical hydroquinone and tretinoin help reduce the risk of PIH. Surgical excision alone carries high recurrence rates, while systemic corticosteroids are not indicated for localized lesions.

Question 2, c. Fractional CO₂ laser ablates microscopic zones of tissue, stimulating collagen remodeling while sparing surrounding skin. In both monotherapy and combination protocols (e.g., with ILK), it can safely improve scar texture, pliability, and symptoms, particularly when protocols are tailored to skin phototype.^2,9

Funding Statement

The planners and faculty for this activity have no relevant financial relationships to disclose. The patient consented to publication of this case report.

Disclosure statement

The planners and faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patient consented to publication of this case report.