BACKGROUND Keloids represent a troublesome condition that lacks a proper standard management protocol. Insulin and botulinum toxin A (BTX-A) both have evidence-based anti-scarring effects. Hence, their role in treating keloids needs to be investigated. OBJECTIVE To compare insulin’s efficacy versus BTX-A in treating keloids. PATIENTS AND METHODS Sixty-three patients with keloids were randomly allocated into 3 equal groups. Group A was treated with intralesional insulin, Group B with intralesional BTX-A, and Group C with intralesional corticosteroids, each for 4 monthly sessions. The results were assessed objectively and subjectively using the patient and observer scar assessment scale. RESULTS All 3 groups showed a statistically significant reduction in volume before and after therapy, with percent changes of 66.6%, 25.3%, and 75% for Groups A, B, and C, respectively. Insulin and corticosteroids were statistically superior to BTX-A in improving pigmentation, reducing thickness, and inducing relief in treated keloids. CONCLUSION Both insulin and BTX-A show a promising role in managing keloids, with insulin demonstrating better efficacy. Botulinum toxin A is better recommended as an adjuvant therapy alongside other mainstay treatment modalities. Larger-scale studies are needed to confirm their roles and establish guidelines for their useز