From the Physician’s Desk … Weekly Blog!
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Keloids and hypertrophic scars are conditions that may require treatment if symptomatic. Pain, pruritus (itching), hyperhidrosis (sweating too much), functional impairment, and cosmetic disfigurement are examples of comorbidities. Although multiple medical and surgical therapies have been used for the treatment of keloids and hypertrophic scars, none of these treatments has been adequately evaluated in high-quality studies and there is no universally accepted treatment approach.
Patient evaluation and counseling — The evaluation of the patient with a symptomatic scar involves a detailed scar history, family history of keloids, and scar assessment. The scar location, size, contour, color, pliability, and presence of subjective symptoms such as pain and itching should be recorded. Baseline photographs may be useful for comparison after treatment completion.
Patients should let their physicians know their perception about the scar and subjective symptoms (your account of what you are feeling – pain, itching, shame, sensitivities, etc.,), as these will be documented as reasons for chosing a particular type of treatment and what expectations are from treatments.
Patients should know that there is a high recurrence risk associated with all treatment options and that repeated treatments or multiple treatment combinations may be necessary to achieve satisfactory results.
Goals of therapy — A frank discussion with your physician will determine the goals of therapy should be based on the patient’s complaints and desire for treatment. They may include one or more of the following:
- Relief of symptoms (eg, pain, pruritus)
- Reduction of the scar volume
- Functional improvement
- Cosmetic improvement
Patient AND Physician should accept their “pre-established” definition of success. For example, for conservative treatments volume reduction by 30% to 50%, symptom reduction by >50%, and may be acceptable after three to six treatments or after three to six months
An overall recommendation for the treatment of keloids based on size is first listed, followed by explanation of each treatment modality. Please note the “warnings” and possible side effects of each, especially as it pertains to Radiation Therapy (though highly effective, the long term side effects warrants consideration). Intralesional = injection of medication directly into the keloid
- For linear or small hypertrophic scars resulting from surgery or trauma, silicone gel sheeting may be used as initial treatment. Pressure therapy, if feasible and tolerated by the patient, may be an alternative first-line treatment. Second-line therapies include intralesional corticosteroids, laser therapy, and surgical excision.
- For minor keloids (<0.5 cm), intralesional corticosteroids is suggested as the first-line therapy. Silicone gel sheeting or pressure therapy may be used as adjunctive therapies. Second-line therapies include intralesional corticosteroids in combination with intralesional 5-FU, contact or intralesional cryotherapy, or laser therapy.
- For major keloids (>0.5 cm), intralesional triamcinolone acetonide is the first-line therapy to control pruritus (itching) and pain, increase scar pliability, and reduce volume. Adjunctive (follow-up) treatments include intralesional 5-FU and contact or intralesional cryotherapy. For large earlobe keloids that cause considerable cosmetic disfigurement, the initial treatment is often surgical excision in combination with perioperative intralesional corticosteroids, compression, or radiation therapy.
- For linear or small hypertrophic scars resulting from surgery or trauma, silicone gel sheeting may be used as initial treatment. Pressure therapy, if feasible and tolerated by the patient, may be an alternative first-line treatment. Second-line therapies include intralesional corticosteroids, laser therapy, and surgical excision
Description of each treatment modality
Intralesional corticosteroids (injection directly into the keloid) – Intralesional triamcinolone acetonide is the most commonly used treatment for hypertrophic scars and keloids. Corticosteroids soften and flatten the scar. Treatment is usually repeated several times at four to six-week intervals, but the optimal concentration and number of treatments has not been determined. Intralesional corticosteroid injections are painful. Other adverse effects include dermal atrophy, skin ulceration, hypo- or hyperpigmentation, and development of telangiectasias.
Intralesional 5-fluorouracil (5-FU is also used a chemotherapy agent to treat cancer) — Intralesional 5-fluorouracil (5-FU) has been used for scars that do not respond to intralesional corticosteroids. Adverse effects of this treatment include pain and hyperpigmentation (darkening spots). Intralesional 5-FU can be used in combination with intralesional corticosteroids.
Silicone gel sheets — Silicone gel sheeting is frequently used for the treatment and prevention of hypertrophic scars and keloids. The mechanism by which silicone gel sheeting might exert an anti-scarring effect is unknown. Evidence showed that silicone gel sheeting may reduce the thickness and improve the appearance of hypertrophic scars and keloids.
Pressure therapy — Pressure therapy is usually performed with pressure garments, bandages, or special devices for certain locations such as the ear. A type of pressure earrings for earlobe keloids called Zimmer splints can be molded to the appropriate size and cosmetically altered to appear as earrings. Other devices using magnets with or without silicone sheeting have also been used as post-surgery adjuvant therapy for ear keloids. Observational studies of patients with ear keloids have shown that custom-made pressure devices may be beneficial to reduce the risk of recurrence after surgical excision.
Cryotherapy (see video below) — Cryotherapy is most useful in combination with other treatments for keloids, although up to 50% of patients may respond to cryotherapy alone. A 10- to 30-second freeze-thaw cycle is used and can be repeated up to three times per treatment session. Treatment is repeated at intervals of four to six weeks until response occurs. The major side effects are pain and permanent hypo-pigmentation (lightening of the skin), the latter of which limits its use in patients with darker skin.
Intralesional cryotherapy is a newer technique that allows the focused destruction of keloid scar tissue with minimal surface damage. Delivery of liquid nitrogen to the scar tissue is performed under local anesthesia using a special cryosurgery needle probe. Treatments can be repeated at two- to three-week intervals. In contrast with conventional cryotherapy, postinflammatory hypopigmentation is infrequent after intralesional cryotherapy.
Laser therapy — Pulsed dye laser (PDL) and neodymium-yttrium-aluminum-garnet (Nd:YAG) laser treatment has been reported to be beneficial for hypertrophic scars and keloids. The underlying mechanism of laser therapy involves the destruction of small blood vessels, which leads to improved scar color, height, pliability, and texture.
Evidence from high-quality studies to support the use of lasers for the treatment of hypertrophic scars and keloids is limited. Therefore, the efficacy of laser treatment for hypertrophic scars remains uncertain.
Surgery/Excision — Surgical excision of hypertrophic scars and keloids may be indicated if conservative therapies alone are unsuccessful or unlikely to result in significant improvement. Surgical excision of keloids is associated with recurrence rates of up to 100%. (Surgery SHOULD be combined with other treatments). The combination of surgery with other types of treatments previously mentioned, may significantly lower the risk of recurrence:
- Intralesional corticosteroids
- Intralesional 5-fluorouracil (5-FU)
- Radiation therapy– Brachytherapy or external beam radiotherapy administered after surgical excision appear to be highly effective in reducing keloid recurrence.
Radiation therapy after surgery — Several studies have found radiation therapy to be highly effective in reducing keloid recurrence when administered immediately after surgical excision. A variety of techniques, doses, and schedules of radiation have been used in the treatment of keloids.
The control of keloids using postoperative radiation is illustrated by several studies with recurrent rates of 4% in 18months, 3% at 34 months, another report of 1/45 pt recurring at 2yrs, and yet another study with use of brachytherapy that showed recurrence of 12% at 61 month follow-up. Radiation therapy may occasionally be indicated for lesions that are not amenable to resection.
Though these results are GREAT when compared to 50-100% likelihood of recurrence, please note: “Concerns regarding the potential long-term risks associated with the use of radiation therapy limit its utilization for these lesions. Several cases of malignancy that may have been associated with radiation therapy for keloids have been reported. Although causation cannot be confirmed in these cases, caution should still be used when prescribing adjuvant radiation therapy for keloids, particularly when treating younger patients.”
Combination treatments — Recalcitrant (hard to treat) keloids that do not respond to intralesional corticosteroids alone may be treated with a combination of intralesional triamcinolone acetonide and 5-FU.
Limited evidence from small retrospective studies supports the use of pulsed dye laser (PDL) or fractional ablative laser treatment in combination with postoperative intralesional triamcinolone.
SURGERY – Interview with patient
VERY GRAPHIC! Intralesional corticosteroids and cryotherapy
Patients are encouraged to discuss these treatment options with their primary care, and when indicated, a consultation with another specialty is highly encouraged!
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