The Saudi Journal of Medical Insights

ABSTRACT
Background: Keloids frequently recur after surgical excision alone, and adjuvant corticosteroid injection and adjuvant radiotherapy are the two most widely used strategies to prevent recurrence. They have rarely been compared within a single connected evidence network that also reports aesthetic outcomes.
Objective: To compare surgery plus corticosteroid injection with surgery plus radiotherapy, using surgery alone as the common comparator, for keloid recurrence and aesthetic outcomes.
Methods: MEDLINE/PubMed, Embase, Scopus, Web of Science and the Cochrane Library were searched for studies published from 2010 to 2026 (PRISMA 2020). Recurrence risk ratios (RR) were synthesized in a frequentist random-effects network meta-analysis of a closed three-node network, with a direct-versus-indirect consistency check, P-scores, and pooled node-level recurrence proportions.
Results: Of 753 records, 13 sources were included (6 primary studies, 7 existing syntheses); four primary studies (two RCTs, two comparative clinical studies) formed the network. Both adjuvants markedly reduced recurrence versus surgery alone (corticosteroid RR 0.08, 95% CI 0.03–0.26; radiotherapy RR 0.15, 0.05–0.44; I² = 0%). Radiotherapy versus corticosteroid showed a borderline difference favoring corticosteroid (RR 1.85, 0.99–3.45; P = 0.052), with consistent direct and indirect evidence (P = 0.82). Corticosteroid ranked highest (P-score 0.99 vs 0.51). The one trial reporting both strategies found comparable VSS and POSAS improvement. Certainty was low.
Conclusion: Both combination strategies are strongly superior to excision alone and appear broadly comparable in recurrence and aesthetics, with a possible edge for corticosteroid that remains imprecise. Adequately powered head-to-head trials with standardized radiotherapy dosing are the clear next step.