Once the keloid is anesthetized, the corticosteroid should be injected directly into the middle of the keloid until the keloid blanches. I find it easiest to advance
the needle to the tip of the keloid, and then as I withdraw the needle I inject into the canal that I have created with the needle. I do not try to achieve blanching to the edge of the keloid as this runs the risk of the steroid diffusing into the surrounding normal skin and inducing a rim or atrophy around the keloid. The nearer the keloid the more responsive it is to steroid injections. Generally, I start with Kenalog, 20 mg/cc, and inject the keloid approximately every three to four weeks. If the keloid is shrinking, I continue to use the same strength. If it is not responding, I increase the concentration by 10 mg/cc with each injection until I use a maximum of 40 mg/cc.
