Comparative efficacy of intralesional therapies for keloid scars: a network meta-analysis

Keloids are pathological scars causing pain, pruritus, and emotional distress. While common treatments exist, emerging options such as insulin and botulinum toxin A (BTX-A) are underrepresented in comparative analyses. This network meta-analysis (NMA) aimed to evaluate the efficacy and safety profiles of various intralesional therapies for keloid scars. A PRISMA-guided search across seven databases was conducted on July 2025 and preregistered on PROSPERO (CRD420251088758). Included studies were randomized, non-randomized, and crossover trials of intralesional therapies. Pairwise and NMA were conducted for efficacy (keloid size/volume reduction), recurrence, and safety (adverse effects). Treatment rankings were based on surface under the cumulative ranking curve (SUCRA) scores. Statistical significance was set at (p From 51 studies (3234 participants, 23 interventions), 5-fluorouracil (5-FU) + corticoids significantly improved keloid reduction compared to corticoids alone (RR = 1.59; 95% CI: 1.31–1.92; p p p = 0.04) and Verapamil (RR = 0.35; 95% CI: 0.14–0.84; p = 0.01) compared to corticoids; others showed no significant effects. This NMA provides a comparative overview, indicating that combination therapies, most notably 5-FU + corticoids + YAG:Laser, offer the greatest benefit. While data for novel agents (insulin and BTX-A) suggest potential, further research with standardized methodologies and longer-term follow-up is crucial to define optimal treatment algorithms.