Methotrexate is given weekly as an intramuscular injection of 15 to 25 mg. Side effects are rare and include leukopenia and hypersensitivity interstitial pneumonitis. Hepatic fibrosis is the most severe potential sequela of long-term therapy. Patients with concomitant alcohol abuse and/or morbid obesity are more likely to develop hepatic fibrosis and therefore should not be treated with methotrexate. It is prudent to obtain a baseline chest radiograph and to monitor complete blood count, liver function and renal function every two weeks until the patient is receiving oral therapy, and every one to three months thereafter. Before methotrexate therapy is initiated, the risks of treatment and the possible need for a liver biopsy should be discussed with the patient.
Intralesional fluorouracil (50 mg per mL, two to three times per week) appears to shrink keloids safely while avoiding the tissue atrophy and telangiectasia that may occur with repeated corticosteroid injections. 30 Combining fluorouracil with corticosteroid injections and pulsed dye laser produced superior results more rapidly than corticosteroid injections alone or corticosteroids with fluorouracil. 13 Good to excellent responses at 12 weeks as rated by a blinded observer were 15 percent for triamcinolone acetonide, 40 percent for triamcinolone plus fluorouracil, and 70 percent for all three modalities (all significant). Combining corticosteroids and fluorouracil diminished the adverse effects of corticosteroids. Rare skin complications of fluorouracil may include hyperpigmentation and wound ulceration. No systemic adverse effects (., anemia, leucopenia, thrombocytopenia) occurred in this study.