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BACKGROUND Conservative and nonconservative treatments are available for keloids. However, few studies have explored the effectiveness of punch excision in keloid treatment. OBJECTIVE This study aimed to investigate the efficacy and safety of punch excision combined with intralesional steroid injection for keloid treatment. METHODS In this prospective, randomized, controlled trial, 81 patients were randomly divided into 2 groups. The patients in the treatment group were initially treated with punch excision combined with intralesional steroid injection, followed by injection treatment alone. The patients in the control group received intralesional steroid injection alone. The keloid thickness before and after the punch excision was evaluated; the keloid scores at different time points and the number of injection treatments required in both groups were compared, and adverse reactions were observed. RESULTS The mean thickness after punch excision was lower (p < .05), injection treatments were fewer (p < .05), keloid scores were significantly lower (p < .05), and incidence rate of long-term adverse effects was lower in the treatment group than in the control group (p < .05). CONCLUSION The combination of punch excision and intralesional steroid injection has a notable therapeutic effect on keloids, shortening the treatment course without evident adverse reactions.