ASAP revisited: The Brazilian sequential algorithm for treating keloids and hypertrophic scars

Treatment of keloids and hypertrophic scars poses a significant challenge. Several treatments are beneficial, including surgery, technologies such as lasers, medication injections (eg, triamcinolone and antineoplastic drugs), cryotherapy, and radiation, but recurrence rates are high after all of these procedures. The ASAP algorithm is a rational, sequential, nonsurgical approach to treating keloids and hypertrophic scars, described by the authors several years ago; after applying it, recurrence rates are very low. ASAP stands for the following steps: A, assessment of the keloid or hypertrophic scar; S, soften the lesion using occlusive dressings; A, approach the scar or keloid utilizing a combination of technologies and injectable antifibrosant drugs; and finally, P, pigmentary alteration treatment. This algorithm was initially popularized in Brazil and has been adopted at several centers; however, with the advent of new technologies and drugs to treat keloids and hypertrophic scars, it has undergone significant improvement. This overview offers an updated perspective on the ASAP sequential algorithm. New research data, including the benefits of microneedling and medications such as verapamil and botulinum toxin, as well as the improvement of hyperpigmentation with picosecond laser, have been incorporated into the ASAP protocol. The importance of integrating diverse therapeutic modalities is highlighted. This sequential stepwise approach promotes gradual clinical improvement while minimizing the likelihood of recurrence.