Cryotherapy with Intralesional Corticosteroids

Compare To Other Treatments

Raised (hypertrophic) and keloid scars are raised scars containing excessive collagen, or in other words, scars caused by an overgrowth of collagen. 

Cryotherapy, which stands for “extreme cold therapy,” is a technique that uses liquid nitrogen to freeze raised and keloid scars, helping to reduce scars in two ways:

  • Killing old scar tissue: Freezing destroys some of the scar tissue that forms the raised scar. It also stimulates the formation of new scar tissue, which ideally will contain less collagen than the original scar, making the new scar smaller and more level with the surrounding skin.
  • Reducing the number of fibroblasts: Fibroblasts are cells that produce collagen and other scar tissue components. Freezing kills some of the fibroblasts in the skin, which means that when new scar tissue forms to replace the destroyed scar tissue, the new scar will contain less collagen and thus be more level with the surrounding skin.1-3

Cryotherapy is sometimes combined with intralesional corticosteroid treatment to achieve better results. 

Intralesional corticosteroid treatment involves injecting drugs called corticosteroids directly into the scar (intralesionally).4,5 Corticosteroids are synthetic (made in a laboratory) drugs that may help reduce scar size by:

  • Stimulating collagen breakdown
  • Decreasing collagen production
  • Decreasing fibroblasts (cells that produce collagen)
  • Reducing inflammation (which is what led to scar formation in the first place)

As with all scar revision treatments, the combination of cryotherapy with intralesional corticosteroids is sometimes combined with other scar revision procedures to achieve the desired results.

Before agreeing to undergo cryotherapy with intralesional corticosteroid treatment, discuss your options, expected outcomes, and prices with multiple doctors.

Procedure details:

The first step of cryotherapy with intralesional corticosteroid treatment is the application of cryotherapy. A doctor sprays the raised scar with liquid nitrogen from a hand-held pressurized container. The doctor holds the container a few centimeters (about an inch) from the skin surface and sprays the scar in a zigzag fashion for several seconds until the treated scar freezes.6

About 5-10 minutes later, after the scar has thawed, the doctor injects corticosteroids directly into the raised scar. 

Cryotherapy device and keloid

The most commonly used intralesional corticosteroid for raised and keloid scar treatment is triamcinolone, although other corticosteroids are also now being used. It is injected into the middle of the dermis, the deeper skin layer underneath the raised scar.7 In addition, injecting into the middle of the dermis reduces the chances of skin thinning (atrophy), which can be a side effect of intralesional corticosteroids.8

Cryotherapy-with-Intralesional-Corticosteroids-1

Depending on the extent of the scarring, the doctor may adjust several factors in cryotherapy with intralesional corticosteroid treatment:

  • Number of treatment sessions: Larger scars sometimes require more sessions than smaller scars, but in general, 4 sessions are usually necessary.
  • Corticosteroid dose: Typical doses of corticosteroids are 10-20 mg/ml, but can be as high as 40 mg/ml for very thick scars. Your doctor must weigh the efficacy of the treatment, which tends to increase with a higher dose, against the risk of side effects, which also increases with a higher dose.7

Anesthesia:

Cryotherapy is mildly uncomfortable. The extreme cold causes a stinging sensation on the skin. With smaller scars, the discomfort is short-lived and rarely requires anesthesia. However, for larger scars, your doctor may choose to numb your skin with:

  • Topical anesthesia: A dressing containing a numbing cream is applied to the skin 30-60 minutes prior to the procedure
  • Local anesthesia: An anesthetic is injected into the skin prior to the procedure9

Intralesional injection of corticosteroids can also be painful, usually more painful than cryotherapy. In some cases, even if no anesthetic is applied before cryotherapy, an anesthetic will be used to reduce the pain of intralesional corticosteroid injection with:

  • Topical anesthesia: A topical numbing cream is applied to the skin 30-60 minutes prior to the injection
  • Local anesthesia: An anesthetic is mixed with the corticosteroid in the same syringe and injected when it is time to inject the corticosteroid

Before-and-after:

Cryotherapy-with-Intralesional-Corticosteroids-Before-and-After

A raised scar before and 20 days after the 3rd session of combinational cryotherapy and intralesional corticosteroid treatment

References
  1. Levy LL, and Zeichner JA. Management of acne scarring, part II. A comparative review of non-laser-based, minimally invasive approaches. Am J Clin Dermatol. 13(5), 331-340 (2012).
  2. van Leeuwen MC, et al. Intralesional cryotherapy for the treatment of keloid scars: evaluating effectiveness. Plastic and Reconstructive Surgery Global Open. 3(6), (2015).
  3. Ledon JA, Savas J, Franca K, Chacon A, and Nouri K. Intralesional treatment for keloids and hypertrophic scars: a review. Dermatologic Surgery. 39(12), 1745-57 (2013).
  4. Khalid FA, Mehrose MY, Saleem M, Yousaf MA, Mujahid AM, Rehman SU, Ahmad S, Tarar MN. Comparison of efficacy and safety of intralesional triamcinolone and combination of triamcinolone with 5-fluorouracil in the treatment of keloids and hypertrophic scars: Randomised control trial. Burns. 45(1), 69-75 (2019).
  5. Hietanen KE, Järvinen TA, Huhtala H, Tolonen TT, Kuokkanen HO, Kaartinen IS. Treatment of keloid scars with intralesional triamcinolone and 5-fluorouracil injections – a randomized controlled trial. J Plast Reconstr Aesthet Surg. 72(1), 4-11 (2019).
  6. Gupta S, and Kumar B. Intralesional cryosurgery using lumbar puncture and/or hypodermic needles for large, bulky, recalcitrant keloids.  Int J Dermatol. 40(5), 349-53 (2001).
  7. Rho NK. Revisiting the Role of Local Cryotherapy for Acne Treatment: A Review and Update. J Clin Med. 12(1), 26 (2022).
  8. Ledon JA, Savas J, Franca K, Chacon A, and Nouri K. Intralesional treatment for keloids and hypertrophic scars: a review. Dermatol Surg. 39(12), 1745-57 (2013).
  9. Rusciani L, Paradisi A, Alfano C, Chiummariello S, and Rusciani A. Cryotherapy in the treatment of keloids. J Drugs Dermatol. 5(7), 591-5 (2006).
  10. Zouboulis CC, Zouridaki E. Cryosurgery as a Single Agent and in Combination with Intralesional Corticosteroids Is Effective on Young, Small Keloids and Induces Characteristic Histological and Immunohistological Changes: A Prospective Randomized Trial. Dermatology. 237(3), 396-06 (2021).
  11. Jwa, S. J., Won, J., Suh, Y. C., & Lee, W. J. Extralesional cryotherapy combined with intralesional triamcinolone injections after keloid excision. Archives of Aesthetic Plastic Surgery, 29(1), 8-13 (2023).