Management Of Keloids Research Articles

Pediatric keloids: A 6-year retrospective review.

Keloids are reportedly rare at the extremes of life. We sought to describe the epidemiology of pediatric keloids seen at the plastic surgery outpatient department of the University College Hospital, Ibadan. We retrospectively reviewed all children younger than 19 years who presented with nonburn keloids between 2008 and 2014. Data were obtained on age; duration, size, and location of the keloid; family history; mode of treatment; and outcome. Outcome variables were recurrence and wound complications. Data were analyzed using the Pearson chi-square test for discreet variables and the independent-sample t test for continuous variables. P < .05 was taken as statistically significant. Within the review period, 304 patients presented with keloids, of whom 40 (13.1%) were younger than 19 years. There was a female preponderance (n = 23, 57.5%). The mean age at onset of the keloid was 9.3 years (range 3 months-18 years). Thirty (75%) patients had keloids in the head and neck region. Keloids were sporadic in 31 (77.5%) patients. Nineteen (47.5%) patients had multimodal treatment for keloid. The recurrence rate was 20%. Recurrence was significantly associated with the size of the lesion (P = .003). Keloids during childhood are not rare. More attention should be paid to the management of keloids in this age group.

Advancing Keloid Treatment: A Novel Multimodal Approach to Ear Keloids.

Management of keloids of the pinna, in particular, those located in the helix and antihelix and lobule that occur as complications of ear piercing. Retrospective analysis of 49 patients treated with extralesional surgical excision of keloids localized to the ear followed by the application of autologous platelet-rich plasma (PRP) to wound site and postoperative in-office superficial radiation therapy (SRT). Radiation protocol consisted of 1 to 3 fractions, with cumulative dosage ranging from 1,300 to 1,800 cGy. Average follow-up was 24 months to assess for evidence of recurrence and adverse side effects. Fifty ear keloids were treated with this method, age from 15 to 66 (mean = 32, SD = 16) of which 14 were male and 35 female. Almost 30% (n = 14) of patients acknowledged the source of injury that led to the development of the keloid was ear piercing. Treatment protocol achieved a 94% success rate with 3 patients who reported recurrence. Surgical excision combined with intraoperative PRP, adjuvant postoperative in-office SRT achieved a 94% nonrecurrence rate on follow-up over a 2-year period. Outcomes provide preliminary, albeit, strong evidence to support this multimodal method as a viable alternative in the management of keloids localized to the ear.

MiR-141-3p inhibits fibroblast proliferation and migration by targeting GAB1 in keloids

Keloids are benign dermal fibroproliferative tumors that develop as a result of several dysregulated processes. Emerging evidence has revealed that miRNAs contribute to keloid formation. However, the molecular mechanisms of keloid pathogenesis remain unclear. In our study, we found that miR-141-3p in keloid tissues and keloid fibroblasts was significantly decreased compared with the levels in normal tissues and normal skin fibroblasts, respectively. miR-141-3p overexpression resulted in significantly decreased proliferation and migration and the promotion of apoptosis in keloid fibroblasts, whereas miR-141-3p knockdown in keloid fibroblasts yielded the opposite results. Growth factor receptor binding 2-associated binding protein 1 (GAB1) was identified and confirmed as a direct target of miR-141-3p. The expression of GAB1 was up-regulated in keloid tissues, and the restoration of GAB1 partially reversed the inhibitory effects of miR-141-3p on the proliferation and migration of keloid fibroblasts. All data suggested that miR-141-3p decreased the proliferation and migration of keloid fibroblasts by repressing GAB1 expression, providing a useful target for keloid management.

A new treatment of hypertrophic and keloid scars with combined triamcinolone and verapamil: a retrospective study

BackgroundSince the management of keloid and hypertrophic scars still remains a difficult clinical problem, there is need for adequate, effective therapy. In this study, we explored for the first time the efficacy and the potential synergetic effect of combined triamcinolone and verapamil for the treatment of hypertrophic and keloid scars. The objective was to assess the efficacy of combined intralesional triamcinolone and verapamil therapy for hypertrophic and keloid scars.MethodsFifty-eight patients with hypertrophic scars (n = 31) and keloid scars (n = 27) were included. A specific injection therapy scheme was applied. Five follow-up moments were chosen, with a maximum follow-up of nearly 2 years. The effects of combination therapy on scar pliability, thickness, relief, vascularization, surface area, pain, and pruritus were examined by means of the Patient and Observer Scar Assessment Scale (POSAS).ResultsOur results reveal a fast and abiding improvement of both keloid and hypertrophic scars after treatment with the combination therapy. All POSAS components showed a reduction in scar score, while scar relief, pain, itchiness, and surface area improved significantly (P < 0.05) in keloids. Significant improvement in hypertrophic scars was found in scar pigmentation, vascularization, pliability, thickness, pain, and surface area. Overall POSAS scores revealed statistically significant decreases between baseline and 3–4 months, 4–6 months, and >12 months after start of therapy in both keloids and hypertrophic scars.ConclusionsThis study reveals that combined therapy of triamcinolone and verapamil results in overall significant scar improvement with a long-term stable result.Level of evidence: Level IV, therapeutic study.

Association of surgical excision and brachytherapy for the management of keloids.

Many techniques have been described to prevent the appearance and relapse of keloids but most of them have an efficacy lower than 50%. Our objective is to describe our standardized management of keloids by associated surgery and brachytherapy. Surgery-brachytherapy is usually given only when less invasive treatments failed. Both a surgeon and a radiotherapist are involved. Forty-eight hours of hospitalization in a surgery unit are required. The extra-lesional excision is performed and a brachytherapy sheath is placed in the dermis plane. An iridium source with an initial activity of 300GBq is used to deliver high dose rate brachytherapy. The brachytherapy sessions are held in a lead-shielded room in a radiotherapy unit: the first session at 6h after surgical excision, while the second and third on the following day. The total dose administered is 18Gy. A surgical workup is scheduled at 10days. The patient is followed-up closely by the radiotherapist for an 18-month period. The recurrence rate after 2years is 8 to 12%. The main complaints are dyschromia, telangiectasia and skin atrophy.

Asiaticoside hinders the invasive growth of keloid fibroblasts through inhibition of the GDF-9/MAPK/Smad pathway.

Higher expression of growth differentiation factor-9 (GDF-9) in keloids compared with hypertrophic scars and normal skin tissues has been reported recently. The present study was performed to investigate the role of GDF-9 in keloid pathogenesis, and to elucidate its implication for asiaticoside in the keloid management. The data showed that GDF-9 could enhance the proliferation, migration, and invasion of keloid fibroblasts (KFs), while it only slightly elevated collagen expression, indicating that the effect of GDF-9 was opposite to that of TGF-β1. The bioactivity difference between GDF-9 and TGF-β1 could be explained by the different phosphorylated sites on the downstream Smad2/3. Moreover, asiaticoside could inhibit GDF-9-induced activation of MAPKs and Smad pathway in KFs. In conclusion, GDF-9 enhanced the invasive growth of KFs, which was achieved by phosphorylation of Smad 2/3 at the linker region through activation of MAPKs pathway. Asiaticoside hindered the invasive growth of KFs by inhibiting the GDF-9/MAPK/Smad pathway.

Triamcinolone Acetonide and 5-Fluorouracil Intralesional Combination Injection in Keloid Treatment

Objective: To evaluate the effectiveness of steroid and 5-fluorouracil (5-FU) injection combination for keloid management. Methods: A 22-year-old female patient was presented with recurrent skin lesions. The skin lesions first appeared 10 years prior to consultation, had been surgically excised, and were given triamcinolone acetonide injection. However, no improvement was observed. A decision was made to use and evaluate treatment using an intralesional 4 mg (0.1 ml of 40 mg/ml) triamcinolone acetonide and 45 mg (0.9 ml of 50 mg/ml ) 5-FU injection combination for 5 weeks. Results: Clinical improvements were observed in the third week as the lesions softened and pruritic sensation dinimished. At the end of the fifth week, improvements in the form of keloid lesion flattening and size reduction were observed. Conclusions: Intralesional injection using a combination of triamcinolone acetonide and 5-fluorouracil is effective for keloid lesion treatment. Keywords: 5-fluorouracil, intralesional injection, keloid, triamcinolone acetonide DOI: 10.15850/ijihs.v5n1.959

Treatment of Keloids With Excision and Adjuvant Radiation: A Single Center Experience and Review of the Literature.

Management of keloids has remained a conundrum, because an optimum treatment regimen has yet to be elucidated. Currently, treatment varies widely between more conservative measures, such as steroid injections, topical medications, and silicone sheeting, to more aggressive options, such as surgery and postoperative radiation. The latter combination has been touted to have superior results, with the lowest rates of pathologic scar recurrence. We performed a retrospective review to critically evaluate the effectiveness of surgical excision and radiation treatment in patients with keloids. Surgical resection of surgeon-selected keloids, combined with state-of-the-art postoperative cutaneous radiation therapy, was used at a major tertiary referral center. For patients with poor follow-up, phone calls were made to determine recurrence. In addition, we present a review of the current literature to provide a comprehensive synopsis of current keloid treatment. A total of 69 patients' records were reviewed. There were a total of 84 keloids upon pathology review. The overall recurrence rate for all keloids was 27%, and in those followed greater than 1 year, recurrence for keloids was 74%. About half the patients with more than 1 year of follow-up experienced recurrence more than 1 year after treatment. At this time, the evidence supporting surgery and radiation for the treatment of keloids remains equivocal, and randomized controlled studies are needed to determine the efficacy of this treatment protocol. Most importantly, our data reinforce the need for long-term follow-up in this patient population.

Fractional carbon dioxide, long pulse Nd:YAG and pulsed dye laser in the management of keloids

Background:Keloids are abnormal wound responses characterised by excessive deposition of collagen and glycoprotein. They are both aesthetically and symptomatically distressing for most of the patients. There are reports of keloid management with pulsed dye laser (PDL), fractional carbon dioxide (CO2) laser and neodymium-doped yttrium aluminium garnet (Nd:YAG) laser individually and also in combination of CO2 with PDL and CO2 with Nd:YAG. Here, we discuss a combination of all the 3 lasers as a therapy for keloids.Aim:This study aims to assess the efficacy of fractional CO2 laser, long pulse Nd:YAG laser and PDL in the management of keloids.Materials and Methods:Fifteen patients with keloids were treated by fractional CO2 laser, followed by PDL and long pulse Nd:YAG laser at monthly intervals. Four patients discontinued the study and were lost for follow-up. Photographs were taken at the beginning of the treatment and at the end of five sessions. Clinical improvement was analysed based on a visual analogue scale graded by three blinded observers after assessing the clinical photographs for the improvement in size, colour and aesthetic impression.Results:Of the 11 patients, one patient had excellent improvement, one patient had good improvement, four patients had moderate improvement, two patients had mild improvement and three had no improvement.Conclusion:Lasers may have a synergistic effect when combined with other modalities of treatment but cannot be used as monotherapy in the treatment of keloids.

Postoperative radiotherapy in the management of keloids.

BackgroundThe high recurrence rate following keloid resection has generated interest in adjuvant treatments for this disease.ObjectiveThis study assesses keloid recurrence when treated with surgery and adjuvant radiotherapy.MethodsRetrospective analysis of resected keloids in patients referred to a Chilean radiation oncology centre between 2006 and 2013. Local recurrence was defined as new tissue growth on the surgical scar margin.ResultsAround103 keloids were analysed in 63 patients treated with 15 Gy in three fraction radiotherapy which was initiated on the same day as the surgery (75% of cases). The median keloid diameter was 6 cm; the most common site was thoracic (22%); the most common cause was prior surgery (35%); 37% caused symptoms, and several (47%) had received prior treatment with corticosteroids (32%), or surgery (30%). The median follow-up was three years, and 94% of recurrences occurred during the first year following treatment. Uni and multivariate analyses showed that an absence of symptoms was a protective factor for recurrence (OR: 0.24), while the time interval from onset to treatment with surgery plus radiotherapy >4.2 years was a risk factor (OR: 2.23). The first year recurrence rate was 32% and stabilised at 32% by the second year with no recurrences after 15 months.ConclusionsThe combination of surgery and radiotherapy proved to be a good therapeutic alternative in the management of keloids. Our results are similar to those described in the literature for a dose of 15 Gy. Given these results, our centre will implement a new dose escalation protocol to improve future outcomes.

Strategy for Successful Management of Facial Keloid Using Triamcinolone Injection as Adjunct to Surgery.

The literature on keloids is replete with authors expressing frustration with treatment results. Triamcinolone is effective in shrinking keloids and preventing their recurrence following excision, if delivered successfully. Strategies for effective delivery of drug are presented: recommended needle size, use of metal syringe, slow injection to avoid skin rupture, and delayed withdrawal of needle after injection. The futility of expecting pedunculated keloids to be completely flattened by steroid injection alone is mentioned.

Abstract: Principles and Algorithm for the Microsurgical Treatment of Unstable Keloids on the Trunk after Burn Injury

INTRODUCTION: Unstable keloids are one of the most frustrating clinical problems in wound healing and the pathogeneses remains largely unknown.1 To date, little is known in the literature about the microsurgical management of unstable and middle-sized keloids on the trunk, and a clear consensus is lacking.2 Perforator flaps are thin and pliable, have a robust blood supply, potentially release the scar-site tension effectively and may provide an outcome with well-matched color, thickness, and texture.3,4 In this study, we provide a versatile algorithm by using various pedicled and free perforator flaps for the treatment of keloids on the trunk. MATERIALS AND METHODS: Patients with a history of multiple treatments of middle-sized keloids on various regions of the trunk were included. Color Doppler ultrasound (CDU) and multidetector-row computed tomographic angiography (MDCTA) were performed preoperatively. Depending on the location of the keloid, the following flaps were used: superficial circumflex iliac artery perforator (SCIP) flap, internal mammary artery perforator (IMAP) flap, superior epigastric artery perforator (SEAP) flap, anterior intercostal artery perforator (AICAP) flap, deep inferior epigastric artery perforator (DIEP) flap and anterolateral thigh (ALT) flap. RESULTS: Between June 2013 to June 2015, 29 patients (15 male and 14 females) with a mean age of 41 ± 15years were treated. Totally, we performed 5 free SCIP flaps, 2 pedicled SCIP flaps, 8 IMAP flaps, 6 SEAP flaps, 3 AICAP flaps, 4 DIEP flaps and 1 ALT flap. The mean flap size was 83 ± 36cm2 and the mean flap thickness was 14.8 ± 5mm. One partial distal necrosis occurred after a pedicled AICAP reconstruction, which healed conservatively. After a mean follow-up of 5 ± 3months, all surviving flaps showed excellent thickness, texture and color match. Importantly, there was no need for secondary debulking surgery. The donor site healed well after primary closure in all patients. CONCLUSION: We successfully applied various free and pedicled perforator flaps for the treatment of unstable keloids on the trunk. Based on our experience, we provide a useful and reliable algorithm in order to achieve the best possible outcome. No disclosures REFERENCES: 1. Ogawa R, Chin MS. Animal models of keloids and hypertrophic scars. J Burn Care Res 2008;29(6):1016–1017 2. Wang J, Min P, Grassetti L, et al. Preliminary Outcomes of Distal IMAP and SEAP Flaps for the Treatment of Unstable Keloids Subject to Recurrent Inflammation and Infections in the Lower Sternal and Upper Abdominal Areas. J Reconstr Microsurg 2015 3. Hong JP, Choi DH, Suh H, et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014;30(7):491–496 4. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42(6):645–648

Advances in scar management: prevention and management of hypertrophic scars and keloids.

Abnormal scarring remains a poorly understood but functional and aesthetic consequence of surgical and traumatic wounds. The purpose of this review is to describe the current state of the science behind the prevention and management of these scars. A recent update in the International Clinical Recommendations on Scar Management provides a wealth of information on new and revised treatments for hypertrophic scars and keloids. Silicone-based products continue to be the premier option for prevention and initial treatment of hypertrophic and keloid scars. There is growing evidence demonstrating the efficacy of intralesional corticosteroids and 5-fluorouracil. Laser therapy remains a second-line treatment option, with low-level evidence supporting the use of pulse dye lasers and ablative fractional lasers. Although there remains no 'gold standard' for the prevention and treatment of hypertrophic scars and keloids, silicone gel products and microporous paper tape present the best conservative options. A stepwise algorithm for the treatment of hypertrophic scars or keloids based on the characteristics and responsiveness of the scar presents the best management strategy. Combination therapy (including steroid injections, 5-fluorouracil, and pulse dye laser) proves to be the strongest option for the nonsurgical management of severe hypertrophic scars and keloids.

Keloid Management: A Retrospective Case Review on a New Approach Using Surgical Excision, Platelet-Rich Plasma, and In-office Superficial Photon X-ray Radiation Therapy.

ABSTRACTOBJECTIVE:The objective of this retrospective study was to evaluate the efficacy of the authors’ combination therapy protocol for keloid treatment.DESIGN:Retrospective.SETTING:Plastic surgery office-based outpatient setting in New York City.PATIENTS:Forty patients with 44 keloid scars requiring surgical excision.INTERVENTIONS:Keloid scars were treated using surgical excision, platelet-rich plasma, and postoperative in-office superficial photon X-ray radiation therapy. Intralesional triamcinolone injections were administered once to 4 patients with poor results on scar scale assessment. Patient follow-up visits ranged from 3 to 11 months to assess for evidence of recurrence and adverse effects.MAIN OUTCOME MEASURE(S):For the purpose of this study, recurrence was defined as any sign of extraordinary erythema, induration, and hypertrophy beyond the site of excision.MAIN RESULTS:In the 16 keloids treated with 2 fractions, there was no evidence of recurrence. One of 25 keloids treated with 3 fractions demonstrated evidence of recurrence. One of 3 keloids treated with a single fraction displayed signs of recurrence. Postirradiation hyperpigmentation was noted in all patients.CONCLUSIONS:Surgical excision combined with platelet-rich plasma and postoperative in-office superficial radiation therapy achieved a 95.5% nonrecurrence rate at 1- to 3-month follow-up. This protocol appears to be a safe and viable option in the management of keloids and merits further randomized controlled study of its comparative efficacy.

Management of Keloid By Hirudo Therapy

Management of Keloid By Hirudo Therapy

Perioperative Interstitial High-Dose-Rate Brachytherapy for the Treatment of Recurrent Keloids: Feasibility and Early Results

To prospectively evaluate high-dose-rate brachytherapy in the treatment of therapy-resistant keloids and report first results, with emphasis on feasibility and early treatment outcome. From 2009 to 2014, 24 patients with 32 recurrent keloids were treated with immediate perioperative high-dose-rate brachytherapy; 3 patients had been previously treated with adjuvant external beam radiation therapy and presented with recurrences in the pretreated areas. Two or more different treatment modalities had been tried in all patients and had failed to achieve remission. After (re-)excision of the keloids, a single brachytherapy tube was placed subcutaneously before closing the wound. The target volume covered the scar in total length. Brachytherapy was given in 3 fractions with a single dose of 6 Gy in 5 mm tissue depth. The first fraction was given within 6 hours after surgery, the other 2 fractions on the first postoperative day. Thus, a total dose of 18 Gy in 3 fractions was administered within 36 hours after the resection. The treatment was feasible in all patients. No procedure-related complications (eg, secondary infections) occurred. Nineteen patients had keloid-related symptoms before treatment like pain and pruritus; disappearance of symptoms was noticed in all patients after treatment. After a median follow-up of 29.4 months (range, 7.9-72.4 months), 2 keloid recurrences and 2 mildly hypertrophied scars were observed. The local control rate was 94%. Pigmentary abnormalities were detected in 3 patients, and an additional 6 patients had a mild delay in the wound-healing process. The early results of this study prove the feasibility and the efficacy of brachytherapy for the prevention of keloids. The results also suggest that brachytherapy may be advantageous in the management of high-risk keloids or as salvage treatment for failure after external beam therapy.

The role of Bleomycin in management of hypertrophic scars and keloids – A clinical trial

The role of Bleomycin in management of hypertrophic scars and keloids – A clinical trial

Post-operative radiotherapy of keloids. A 10-years experience of kilovoltage irradiation

Background: Keloids are benign fibrous dermal tumors originang from skin injury aer surgery, piercing or others wounds. Materials and Methods: Sixty -two paents with keloids were treated postoperavely using orthovoltage irradiaon. The total dose delivered was 12 Gy in three consecuve days, 4Gy per fracon. Treatment started 24 h aer surgery. The median follow-up was 44.5 months. Results: Grade 1 erythema was observed in 48% of paents (30/62); 20/62 paents (32%) showed telangiectasia and altered skin pigmentaon as late toxicies. In 10/62 (16%) a clinical relapse was observed. Conclusion: The postoperave orthovoltage radiotherapy for keloids is a valid and tolerated method that reduces the risk of recurrence. Aims: evaluate the role of post-operave superficial orthovoltage radiotherapy in the management of keloids.

Role of verapamil in preventing and treating hypertrophic scars and keloids.

Keloid and hypertrophic scars are difficult to manage and remain a therapeutic challenge. Verapamil has shown a great potential in the management of keloid and hypertrophic scars. Comparing with conventional corticosteroid injections, verapamil could improve the appearance of keloid and hypertrophic scars, and is associated with a lower incidence of adverse effects. Is verapamil an effective alternative modality in the prevention and treatment of keloid and hypertrophic scars? The aim of this study was to assess the effectiveness of verapamil in preventing and treating keloid and hypertrophic scars. Searches were conducted in Medline, EMbase and Cochrane databases from 1974 to January 2015. The selection of articles was limited to human subjects. Five randomised controlled trials (RCTs) or cluster-randomised trials or controlled clinical trials (CCTs) comparing the efficacy of verapamil with conventional treatments were identified. The results showed that verapamil could improve keloid and hypertrophic scars, and was not significantly different from conventional corticosteroid injections. Few adverse effects were observed. However, this result should be considered carefully, as most of the included studies have a high risk of bias because of issues with randomization, allocation concealment, blinding, incomplete outcomes and selective reporting. In conclusion, verapamil could act as an effective alternative modality in the prevention and treatment of keloid and hypertrophic scars. More high-quality, multiple-centre, large-sample (RCTs) are required to define the role of verapamil in preventing and treating keloid and hypertrophic scars.

The use of triamcinolone combined with surgery in major ear keloid treatment: a personal two stages approach

Background Keloid is a fibroproliferative disorder characterized by an abnormal deposition of collagen within a wound. Despite an increased understanding of wound healing and collagen metabolism, the exact cause, the clinical behavior, and gold standard of treatment for keloids remain an enigma. There is no one right way of treatment, the results are variable, and the management of ear keloids can be difficult and frustrating both for patients and physicians. Traditional techniques include intralesional steroids, topical applications of silicone, vitamins, and segmental excision by lasers or surgery. The purposes of this article are to review the literature concerning the current therapies as well as to present the authors’ experience in the treatment of major ear keloids.