Clinical Efficacy of the ASAP Algorithm: A prospective cohort study of 354 keloids in 280 patients
Débora Barbosa Rocha Ribas, MS1, Maria Eduarda Barbieri Orta, MS2, Sofia de Carvalho Leal, MS3, Luciana Nacif da Costa Valle, MD4 , Gisele Viana de Oliveira, PhD5
BACKGROUND
The ASAP algorithm is a rational, sequential and multi-modal nonsurgical treatment specifically designed for the management of hypertrophic scars and keloids. The acronym ASAP refers to: A, assessment of the lesion; S, soften using occlusive dressings; A, approach the scar or keloid with synergistic combination of advanced energy-based technologies and intralesional injectable antifibrosant drugs; and finally, P, pigmentary alteration treatment. Also, its revisited version, published in 2026, includes the benefits of microneedling and pharmacotherapy (exemplified by verapamil and botulinum toxin), along with picosecond laser to improve hyperpigmentation.
CONCLUSION
The findings suggest that the laser is a critical component in the treatment of keloids (OR=4.01), such that those treated have a 4 times higher odds of flattening. Furthermore, the paradoxical superior response in chronic, mature keloids may be explained by three primary hypotheses: old lesions are biologically more stable and exhibit diminished inflammatory activity, facilitating flattening; furthermore, patients with chronic lesions often demonstrate higher psychological motivation and consistent long-term adherence; and the therapeutic initiation timing is secondary to treatment duration. Finally, it is important to highlight that a minimum period of seven months is crucial, given that the treatment of keloid disorder is complex and long-term. The data reveal that the flattening rate varies drastically with the duration of therapy, presenting a therapeutic inflection point of response at seven months, when the majority of patients begin to achieve the expected results.
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