Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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Brian Berman, Ran Huo and Martha Viera
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Keloids are dermal hyperproliferative growths with excessive accumulation of dense fibrous tissue that may appear in areas of trauma. By definition, keloids are scars that extend beyond the borders of the original wound and do not regress spontaneously. In addition to the cosmetic disfigurement and negative psychological impact that keloids may cause the patient, these scars can often present with intense pain and pruritus.
The therapeutic options for keloids are numerous; however, there is no one modality that is considered to be universally safe and effective. Prevention of recurrence should be the main determinant in treatment selection. The initial rule of treatment involves prevention and patient education. It is of the utmost importance to close wounds with minimal tension and inflammation. Non-essential cosmetic surgery should be avoided in patients predisposed to developing keloids. These scars commonly develop in high-tension areas of the body. Incision sites in the skin of the mid-chest and skin overlying joints should be avoided, and surgical wounds should parallel skin creases.
Common therapeutic modalities include occlusive dressings, compression therapy, intralesional corticosteroid injections, intralesional interferon injections, intralesional 5-fluorouracil injections, cryosurgery, surgical excision, radiation therapy, and laser therapy. As no single therapy is vastly superior or universally efficacious, combination therapies have led to the best success rates.
Intralesional corticosteroids have been the mainstay of treatment for keloids. The most commonly used is triamcinolone acetonide in concentrations of 10–40 mg/mL administered intralesionally with a 25–27-gauge needle at 4- to 6-week intervals. Topical corticosteroids and topically applied corticosteroid-impregnated tape are also used frequently; the basis for the latter involves recent data demonstrating that occlusion enhances percutaneous penetration of steroid by the formation of a drug reservoir within the stratum corneum. Silicone gel sheets and silicone occlusive dressings have anti-keloidal effects, which appear to be a result of hydration.
Pressure devices are thought to induce local tissue hypoxia and have been shown to have a thinning effect on keloids. A novel idea in the treatment of keloids and hypertrophic scars is the use of intralesional interferon-α2b, which has been used successfully to reduce scar height and postoperative recurrences, via a mechanism of collagen synthesis inhibition. Interferon-γ has also been evaluated in the treatment of keloids, with modest results.
Cryotherapy can be used as monotherapy or in conjunction with other treatment modalities, most commonly triamcinolone, with reported efficacy. Its mechanism of action involves the induction of vascular damage and tissue anoxia that ultimately leads to necrosis. However, some reported side effects have included hypopigmentation and postoperative pain. A specialized intralesional needle cryoprobe method has been recently reported to result in better efficacy and fewer side effects.
Radiation therapy has been used as monotherapy or as an adjuvant to surgical excision. The carcinogenesis risks of radiotherapy are extremely small; however, the concept of using potentially harmful radiation to treat benign lesions is a persistent and important issue.
Surgical excision alone yields widely varying results with high (55–100%) recurrence rates. The combination of surgical excision with other modalities, such as intralesional corticosteroids or with pressure dressing, X-ray therapy, interstitial radiation, and brachytherapy, reduces recurrence rates to a range of 10–50%.
CO2 and argon lasers have been used in the past in the treatment of keloids, but have recently been replaced by the Nd:YAG and 585 nm pulsed dye laser because of their better efficacy and fewer adverse effects. Intralesional injection of 5-fluorouracil has been beneficial for hypertrophic scars and for keloids. Bleomycin, retinoic acid, intralesional verapamil, and mitomycin C have all been reported to have good efficacy in small clinical trials, but more clinical experience with these agents is needed.
Skin biopsy
Aiba S, Tabata N, Ishii H, Ootani H, Tagami H. Br J Dermatol 1992; 127: 79–84.
Dermatofibrosarcoma protuberans can be easily misdiagnosed as a keloid. Histopathology may help differentiate the two, but expression of CD34 by tumor cells occurs only in dermatofibrosarcoma protuberans.
Hayashi T, Furukawa H, Oyama A, Funayama E, Saito A, et al. Dermatol Surg 2012; 38: 893–7.
Twenty-one keloids were treated with surgical excision, then corticosteroid injections after removal of the sutures and every 2 weeks (for five more times) thereafter. In addition, all postsurgical wounds received self-administered steroid ointment application twice daily for 6 months after suture removal. Recurrence occurred in three of the 21 keloid cases (14.3%) and one of the six hypertrophic scar cases (16.7%).
Kiil J, Scand J. Plast Reconstruct Surg 1977; 11: 169–72.
In a prospective clinical trial of 52 patients, intralesional injections of triamcinolone acetonide alone resulted in significant flattening and reduction of pruritus in 93% of the keloids. One-third had partial recurrence at 1 year, and at 5 years more than 50% had recurred. All recurrences were successfully treated with further triamcinolone acetonide injections.
Park TH, Seo SW, Kim JK, Chang CH. Plast Reconstr Surg 2011; 128: 431–9.
In this study, 1436 ear keloids in 883 patients were treated with surgical excision followed by pressure therapy using magnets. The overall recurrence-free rate was 89.4% after a follow-up period of 18 months. Keloid recurrence was significantly associated with the presence of prior treatment history, keloid low growth rate, and high patient body mass index.
Kim DY. Plast Reconstr Surg 2004; 113: 1668–74.
Surgical revision of keloids on earlobes followed by intradermal scaffold/linear surgical incision was performed in 19 subjects (26 earlobe keloids). At 12 months, the recurrence rate was 19.2%. There were no device-related adverse events.
Berman B, Flores F. Dermatol Surg 1999; 25: 484–6.
In this study of 32 keloid patients, 53% treated with silicone gel cushion and 36.3% treated with silicone gel sheeting had a reduction in keloid volume.
Signorini M, Clementoni MT. Aesthet Plast Surg 2007; 31: 183–7.
A prospective trial involving 160 patients that compared postoperative treatment with a self-drying transparent silicone gel with no treatment. Sixty-seven percent of patients in the treatment group had a significant improvement in scar quality.
Akoz T, Gideroglu K, Akan M. Aesthet Plast Surg 2002; 26: 184.
Nine patients were treated with surgical excision of their earlobe keloids, followed by triamcinolone acetonide injection and silicone gel sheets. No recurrences occurred in eight of the nine patients.
Hatamipour E, Mehrabi S, Hatamipour M, Ghafarian Shirazi HR. Acta Med Iran 2011; 49: 127–30.
Fifty patients with keloids were treated either with perilesional surgical excision combined with topical silicone, or with adjuvant treatment of intralesional 5-fluorouracil. The 5-fluorouracil group had superior results, with 75% keloid free, 21% partial improvement, and 4% recurrence. This is in comparison to 43%/35%/22%, respectively, in the silicone group. No serious side effects were observed.
Sadeghinia A, Sadeghinia S. Dermatol Surg 2012; 38: 104–9.
Forty patients were randomized to treatment with either intralesional triamcinolone acetonide injection or 5-fluorouracil tattooing every 4 weeks for 12 weeks. At 44-week follow-up, superior improvement was observed in the 5-fluorouracil group for lesion erythema, pruritus, height, surface, and induration. No side effect was detected in either of the groups.
Berman B, Flores F. J Am Acad Dermatol 1997; 37: 755–7.
There was a statistically significant reduction in the recurrence of 124 excised keloids with post-excision interferon-α2b (18.7% recurrence) versus excision alone (51.1%), and versus treatment with postoperative intralesional triamcinolone (58.4%).
Lee JH, Kim SE, Lee A-Y. Int J Dermatol 2008; 47: 183–6.
Forty keloid lesions from 19 patients were treated either with triamcinolone acetonide intralesional (TAIL) combined with interferon-α2b or with TAIL alone. Superior results were obtained with combination therapy, with more than 80% improvement in lesion depth and volume in most patients.
Rusciani L, Paradisi A, Alfano C, Chiummariello S, Rusciani A. J Drugs Dermatol 2006; 5: 591–5.
Of 135 patients with 166 keloids treated with cryotherapy between 1990 and 2004, 79.5% responded very well with a volume reduction of 80% or more after three treatments. Median follow-up time was 4 years. The most common adverse effects included atrophic depressed scars and, in 75% of cases, residual hypopigmentation.
Yosipovitch G, Widijanti Sugeng M, Goon A, Chan YH, Goh CL. J Dermatol Treat 2001; 12: 87–90.
Ten patients with 28 keloids were treated with cryotherapy alone, steroid injection alone, or cryotherapy and steroid injection. At 8 months’ follow-up the combination therapy was significantly better at reducing keloid thickness and pruritus than either treatment alone. None of the keloids treated with combination therapy recurred. No significant side effects were noted.
Malaker K, Zaidi M, Franka MR. Ann Plast Surg 2003; 52: 602–4.
Forty-seven patients were treated with postoperative telecobalt external beam radiation and 87.2% had no recurrence at the 6-month follow-up visit.
Yamawaki S, Naitoh M, Ishiko T, Muneuchi G, Suzuki S. Ann Plast Surg 2011; 67: 402–6.
The authors treated 91 keloids in total, with 51 keloids (56.0%) resolved completely by a combination of surgical excision and postoperative irradiation. Eighty-one keloids (89.0%) showed good results with additional treatment of intralesional steroid injections.
Ragoowansi R, Cornes PG, Moss AL, Glees JP. Plast Reconstruct Surg 2003; 111: 1853–9.
In a retrospective study of 80 patients treated with postoperative single-fraction radiotherapy, 9% of keloids relapsed after 1 year and 16% relapsed after 5 years.
Escarmant P, Zimmermann S, Amar A, Ratoanina JL, Moris A, Azaloux H, et al. Int J Radiat Oncol Biol Phys 1993; 26: 245–51.
There was a recurrence rate of 21% after at least 1 year follow-up in 783 treated keloids.
Malaker K, Vijayraghavan K, Hodson I, Al Yafi T. Clin Oncol J Roy Coll Radiol 2004; 16: 290–8.
In this retrospective study involving 86 keloids in 64 patients, 97% of keloids showed significant regression after completing radiotherapy with either kilovoltage X-rays or electron beams, without significant side effects. The patients were treated with a total of 3750 cGy administered in five once-weekly fractions.
Veen RE, Kal HB. Int J Radiat Oncol Biol Phys 2007; 69: 1205–8.
Postoperative 192Ir brachytherapy showed better cosmetic results at higher dosages, with only one keloid recurrence out of 38 observed after a once-administered 6 Gy and twice-administered 4 Gy regimen.
Kuribayashi S, Miyashita T, Ozawa Y, Iwano M, Ogawa R, et al. J Radiat Res 2011; 52: 365–8.
A total of 36 keloids were treated with high-dose-rate superficial brachytherapy after keloidectomy. A dose evaluation point was established below 2 mm from skin surface, and 20 Gy was delivered in three or four daily fractions to keloidectomy scars. The median follow-up period was 18 months (range 9 to 29 months). Only three keloids (9.7%) showed local recurrence.
Kassab AN, El Kharbotly A. Eur Arch Otorhinolaryngol 2012; 269: 419–23.
Twelve patients with a total of 16 lobule keloids were treated with 980 nm diode laser and subsequent intralesional triamcinolone acetonide injection. Between two to five treatment sessions led to 75% of patients with more than 75% reduction of keloid size, with no recurrence past 12 months.
Manuskiatti W, Wanitphakdeedecha R, Fitzpatrick RE. Dermatol Surg 2007; 33: 152–61.
In 19 patients with keloidal or hypertrophic median sternotomy scars, pulsed dye laser with pulse width of 0.45 ms was significantly effective in reducing scar volume and improving elasticity. However, the reported reduction in scar volume was only 24.4% after three treatments.
Norris JEC. Plast Reconstruct Surg 1991; 87: 44–9.
In this retrospective study, 23 patients had adequate follow-up. One had no recurrence, nine required corticosteroids to suppress recurrence, and 13 were considered to be treatment failures.
Berman B, Kaufman J. J Am Acad Dermatol 2002; 47: S209–11.
Thirteen keloids were treated with excision and imiquimod 5% cream every night for 8 weeks. Ten patients with 11 keloids completed the 6-month study, and there were no recurrences.
Gupta M, Narang T. J Laryngol Otol 2011; 125: 297–300.
Twenty patients with 26 earlobe keloids were treated with surgical shave excision and topical mitomycin C. No recurrences were noted after 24 months.
Larrabee WF, East CA, Jaffe HS, Stephenson C, Peterson KE. Arch Otolaryngol Head Neck Surg 1990; 116: 1159–62.
Five of the 10 study patients had a reduction in their scar size by at least 50% in linear dimensions. The treatment protocol was one treatment per week for 10 weeks. Up to 0.05 mg of interferon-γ was injected weekly.
Janssen de Limpens AMP. Br J Dermatol 1980; 103: 319–23.
There was a reduction in keloid size and symptoms in 77% of 28 intractable keloids treated with topical retinoic acid.
Aggarwal H, Saxena A, Lubana PS, Mathur RK, Jain DK. J Cosmet Dermatol 2008; 7: 43–9.
Over 3 months, four courses of bleomycin were administered through a multiple superficial puncture technique in 50 patients with keloids and hypertrophic scars. Forty-four percent of patients experienced complete flattening of lesions, and 22% showed more than 75% lesion regression.
Margaret Shanthi FX, Ernest K, Dhanraj P. Indian J Dermatol Venereol Leprol 2008; 74: 343–8.
In this randomized, single-blind, parallel group study in which 54 patients were allocated to receive either verapamil (2.5 mg) or triamcinolone (40 mg) every 3 weeks up to 6 months, there was a reduction in vascularity, pliability, height, and width of the scar with both the drugs after 3 weeks of treatment. Triamcinolone had a faster reduction rate, while verapamil had a lower rate of hypopigmentation.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Intralesional corticosteroids
Compression
Occlusive dressing
Intralesional 5-fluorouracil
Intralesional interferon-α2b
Cryosurgery
Radiation
Laser surgery
Imiquimod
Mitomycin C
Intralesional interferon-γ
Topical retinoic acid
Intralesional bleomycin
Verapamil
Surgery
