Impact of the A.S.A.P. Protocol on Quality of Life and Depression in Keloid Disorder: A Pre–Post Longitudinal Study
Maria Eduarda Barbieri Orta, MS1 , Sofia de Carvalho Leal, MS2, Débora Barbosa Rocha Ribas, MS3, Luciana Nacif da Costa Valle, MD4 ,Gisele Viana de Oliveira, PhD5
BACKGROUND
Keloids are scars resulting from an exacerbated inflammatory response that leads to abnormal fibrous skin healing. Beyond visible disfigurement, they may cause pruritus, pain, contractures, and motor dysfunction, with significant impact on self-esteem and mental health. These features highlight the importance of incorporating patient- reported outcomes into therapeutic assessment. This study evaluates the impact of keloids on physical, emotional, and social domains, as well as the risk of depressive symptoms. The A.S.A.P. protocol (Assessment, Softening, Application, and Protection) is a structured, non- surgical algorithm developed in Brazil to address high recurrence rates associated with isolated treatments such as surgery, corticosteroids, cryotherapy, laser, and radiotherapy. It integrates lesion assessment, tissue softening, combined use of technologies and antifibrotic agents, and management of pigmentary alterations. The protocol has been refined to include modalities such as microneedling, verapamil, botulinum toxin, and picosecond laser. This sequential approach aims to promote progressive clinical improvement while reducing recurrence.
CONCLUSION
A positive screen for depressive symptoms was identified in nearly 1 in 3 patients at the initial consultation, a prevalence 2.6 times higher than that of the general Brazilian population.
These findings suggest that structured dermatological treatment may be associated with improvement in quality of life and mood, in addition to cutaneous outcomes. Remission of positive screening in 62.5% of patients, concentrated in items of body perception, pruritus, and social stigma, is consistent with the hypothesis that mood improvement may be mediated by relief of physical and visual symptoms, rather than by a direct antidepressant effect. The absence of mood improvement in items of sadness or hopelessness further supports this hypothesis. These findings are consistent with a biopsychosocial impact of structured keloid treatment and
suggest two practical considerations: routine screening for depressive symptoms using the BDI as part of the initial dermatological evaluation; and institutional recognition that keloid treatment may offer mental health-related benefits: a consideration relevant to coverage policies in public and private health systems and to patient engagement during prolonged treatment.
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