Radiation therapy modalities for keloid management: a critical review

Combining Steroid Plus 5-Fluorouracil Injection with Radiotherapy Versus Injection Alone for Keloids: A 4-Year Retrospective Study

BACKGROUND

Keloid management has been debated for decades due to unsatisfactory outcomes and high recurrence rates. Intralesional injection and radiotherapy are prominent nonsurgical interventions for keloids. However, monotherapies for keloids usually yield poor efficacy and cause patient burden due to additional treatment sessions and side effects, affecting adherence. The study aimed to evaluate the safety and efficacy of combining intralesional triamcinolone acetonide (TAC) + 5-fluorouracil (5-FU) injection with electron beam radiotherapy or brachytherapy compared to intralesional TAC+5-FU injection alone.

METHODS

We retrospectively reviewed patients who were initially treated between 2019 and 2022 and followed for more than 12 months. The baseline condition, the Vancouver Scar Scale (VSS), recurrence, symptoms, follow-up period, and patient self-assessment were recorded.

RESULTS

The study included a cohort of 100 eligible patients with a total of 111 keloids. Seventy-one of patients received the combined therapy and 29 received TAC+5-FU injection only. The results revealed that combining injection with radiotherapy reduced the recurrence rate and improved symptoms such as pruritus and pain while posing minimal extra risk of side effects. Moreover, patients receiving combined therapy assessed treatment outcomes more positively than those solely receiving injection therapy. Other factors that related to increased risk of recurrence included a higher VSS score at the end of treatment and the presence of keloid family history.

CONCLUSIONS

The combined schedule of intralesional TAC+5-FU injection with radiotherapy could effectively reduce the recurrence rate and alleviate symptoms of keloids.

LEVEL OF EVIDENCE IV

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Altered Arginine Metabolism Affects Proliferation and Radiosensitivity of Keloids

Keloid is characterised by the reprogramming of cellular metabolism, wherein keloid cells adapt their metabolic pathways to meet the demands for energy and biosynthetic precursors. Investigating the intricate relationship between cellular metabolism and the biological behaviour of keloid holds the potential to yield novel therapeutic strategies for keloid. To elucidate the molecular alterations and potential underlying regulatory mechanisms in keloids, we created comprehensive metabolic profiling at the pathway level by analysing metabolomic, transcriptomic and single-cell RNA-sequencing data from keloids and adjacent skin. Viability assay and clonogenic assay were performed to validate the function of the metabolic pathway(s) in primary keloid fibroblast cells. Integrated analysis revealed an upregulation of arginine and proline metabolism in keloids. According to single-cell RNA-seq data, elevated expression of genes related to arginine and proline metabolism, such as P4HA3, P4HA2, P4HA1, PYCR1, OAT and ASS1, was predominately highly expressed in fibroblast-2. Fibroblast-2 displayed more obvious phenotypes of mesenchymal fibroblast. Critical genes from integrated analysis including P4HA3, P4HA2, P4HA1, PYCR1 and AZIN2, and metabolites including fumaric acid and 2-oxo-5-amino-pentanoic acid showed prognostic relevance with disease-free survival of keloid. Additionally, an In vitro study showed that arginine deprivation therapy (ADT) inhibited and radiosensitised the proliferation of keloid-derived fibroblasts. In conclusion, our thorough multiomics study deepens our understanding of the link between arginine and proline metabolism and keloid proliferation and radiosensitivity. Elevated activity of arginine and proline metabolism in mesenchymal fibroblasts may be a potential therapeutic pathway for keloid.

Experimental Study of Ultra-Pulsed CO 2 Fractional Laser Combined With Recombinant Human Epidermal Growth Factor Gel in the Treatment of Eyelid Keloid

PURPOSE

Keloid (KD) and hypertrophic scars are prevalent and result from excessive growth of dermal tissue after skin damage. This review focused on the clinical application of the ultra-pulsed CO 2 fractional laser combined with recombinant human epidermal growth factor (rHEGF) gel in patients with eyelid KD.

METHODS

Patients (N = 98) with KD who underwent surgery were randomly divided into a study group (ultra-pulsed CO 2 fractional laser combined with rHEGF gel therapy, N = 49) and a control group (ultra-pulsed CO 2 fractional laser therapy, N = 49). Besides, 5 cases dropped out of the study, including 2 cases in the study group and 3 cases in the control group. Finally, 47 cases of the study group and 46 cases of the study group were included in the analysis. The clinical baseline data such as sex, age, body mass index, scar area, etiology, Vancouver Scar Scale score, Patient and Observer Scar Assessment Scale score, four-item itch questionnaire score, serum interleukin-6 (IL-6), IL-10, and tumor necrosis factor-α level expression were recorded in the study group (N = 47) and the control group (N = 46).

RESULTS

There was no significant difference in gender, age, body mass index, scar area, etiology, Vancouver Scar Scale score, Patient and Observer Scar Assessment Scale score, 4-item itch questionnaire score, IL-6, IL-10, and tumor necrosis factor-α levels between the patients treated with ultra-pulse CO 2 fractional laser + rHEGF gel and those only treated with ultra-pulse CO 2 fractional laser ( p > 0.05). Vancouver Scar Scale scores, Patient and Observer Scar Assessment Scale scores, and four-item itch questionnaire scores of patients with eyelid KD decreased to a greater extent than those treated with ultra-pulsed CO 2 fractional laser combined with rHEGF gel ( p <0.01). Compared with ultra-pulsed CO 2 fractional laser treatment, ultra-pulsed CO 2 fractional laser combined with rHEGF gel was more efficacious in treating patients with eyelid KD, with a lower incidence of adverse effects and a 1-year recurrence rate.

CONCLUSIONS

Ultra-pulsed CO 2 fractional laser combined with rHEGF gel can significantly improve the scar status and scar itching in patients with eyelid KD, with an obvious therapeutic effect, a low incidence of adverse effects, a 1-year recurrence rate, and high safety, which is worthy of popularization and application.

The efficacy of sequentially comprehensive treatment based on surgery in the treatment of keloids: a retrospective study

Purpose

The objective of this study is to investigate the clinical efficacy of sequentially comprehensive treatment based on surgery and to furnish clinical evidence for the management of keloids.

Patients and methods

The patients with keloids were retrospectively analyzed who underwent surgery-based sequentially comprehensive treatment at the Plastic Surgery Department of Shandong Provincial Hospital from January 2018 to August 2021. The recurrence rate and incidence of adverse reactions were explored for all the included patients. For patients who were followed up for more than 1 year, the clinical response rate was calculated, and the chi-square test was used to analyze which factors could influence clinical effectiveness. Binary logistic analysis was performed on the factors with statistical differences. For patients with a follow-up time of less than 1-year, paired t-test was used to evaluate their Vancouver Scar Scale (VSS) before and after treatment.

Results

A total of 67 patients with 80 keloids were included. The clinical response rate was 81.5% (44/54), the recurrence rate was 15.0% (12/80) and the adverse reaction rate was 4.5% (3/67). The clinical response rate of tumor-type keloids (95.8%) was higher than that of inflammatory-type (70.0%) with a significant difference (P = 0.040). After treatment, the color, blood vessel distribution, softness, thickness, and VSS score were all decreased, and the difference was statistically significant (P < 0.001).

Conclusion

The sequentially comprehensive treatment based on surgery has a significant curative effect, as well as a low recurrence rate and a low adverse effect rate. The type of keloid has a statistically significant effect on clinical efficacy, and tumor-type keloids are more suitable for sequentially comprehensive treatment based on surgery.

The Pathophysiology and Management of Pathologic Scarring-a Contemporary Review

Significance: Pathologic scarring occurs secondary to imbalances in the cellular mechanisms of wound healing and affects millions of people annually. This review article aims to provide a concise overview of the pathophysiology and management of pathologic scarring for clinicians and scientists alike. Recent Advances: Contemporary research in the field has identified aberrations in transforming growth factor-β/small mothers against decapentaplegic (TGF-β/SMAD) signaling pathways as key drivers of pathologic scar formation; indeed, this pathway is targeted by many treatment modalities and translational investigations currently underway. Although intralesional injection of corticosteroids has been the gold standard in the treatment of pathologic scarring, studies show greater treatment efficacy with the use of combination injections such as triamcinolone/5-fluorouracil and triamcinolone/botulinum toxin. Adjunctive therapies including ablative fractional carbon dioxide/erbium-doped yttrium aluminum garnet and non-ablative pulsed-dye lasers, microneedling, and carboxytherapy have shown encouraging results in small cohort studies. Translational investigations involving the use of nanogels, RNA interference, and small molecules targeting TGF-β/SMAD pathways are also currently underway and hold promise for the future. Critical Issues: The heterogeneous nature of hypertrophic scars and keloids poses significant challenges in formulating standardized treatment and assessment protocols, thereby limiting the conclusions that can be drawn. Future Directions: Rigorous clinical trials into the individual and synergistic effects of these therapies would be ideal before any definitive conclusions or evidence-based treatment recommendations can be made. Owing to the heterogeneity of the pathology and patient population, well-conducted cohort studies may be the next best option.

The role of apoptosis, immunogenic cell death, and macrophage polarization in carbon ion radiotherapy for keloids: Targeting the TGF-β1/SMADs signaling pathway

Keloids, characterized by excessive extracellular matrix (ECM) deposition and aberrant fibrous tissue proliferation, present significant therapeutic challenges due to their recalcitrant and recurrent nature. This study explores the efficacy of Carbon Ion Radiotherapy (CIRT) as a novel therapeutic approach for keloids, focusing on its impact on fibroblast proliferation, apoptosis induction, immunogenic cell death (ICD), macrophage polarization, and the TGF-β/SMAD signaling pathway. Utilizing a murine model of keloid formed by subcutaneous injection of zeocin in C57BL/6 mice, we demonstrated that CIRT effectively reduces collagenous fiber synthesis and collagen production in keloid tissues. Further, CIRT was shown to inhibit keloid fibroblast proliferation and to induce apoptosis, as evidenced by increased expression of apoptosis-related proteins and confirmed through flow cytometry and TUNEL assay. Notably, CIRT induced mitochondrial stress, leading to enhanced immunogenicity of cell death, characterized by increased expression of ICD markers and secretion of interferon-γ. Additionally, CIRT promoted a shift from M2 to M1 macrophage polarization, potentially reducing TGF-β release and mitigating ECM deposition. Our findings suggest that CIRT mediates its therapeutic effects through the inhibition of the TGF-β/SMAD signaling pathway, thereby attenuating ECM formation and offering a promising avenue for keloid treatment. This study underscores the potential of CIRT as an innovative strategy for managing keloids, highlighting its multifaceted impact on key cellular processes involved in keloid pathogenesis.

Disabling Plantar Keloids Treated with Brachytherapy and Free Flap Reconstruction: A Case Report

Introduction

Keloids result from a disorganized fibroproliferative collagen response that extends beyond the original wound margins and fails to regress. They are associated with a high recurrence rate despite various treatment options. Keloids on the sole of the foot are exceedingly rare and pose significant challenges for both patients and surgeons. To date, only 15 cases of plantar keloids have been described in the English literature. Management options for this region include observation with custom-made footwear, steroid injections, surgery alone, or surgery followed by multimodal therapy. This report presents the first documented case of a plantar keloid treated with surgical excision, brachytherapy, and free flap reconstruction.

Case Presentation

We describe the case of a plantar keloid treated with surgical excision followed by high-dose-rate brachytherapy and free flap reconstruction. At 18 months postoperatively, the patient was ambulating independently without crutches, though hypersensitivity persisted. The scars at the donor site and the medial ankle exhibited keloids, but all scars subjected to brachytherapy were normal.

Conclusion

The free flap approach may not be the optimal reconstruction method for plantar keloids, as skin grafts appear to have better outcomes, according to the literature. Also, in our patient, brachytherapy has proven its effectiveness in preventing further keloid formation as shown in the literature.

Electron radiation therapy: Back to the future?

Electron radiotherapy has long been preferred to photons for the treatment of superficial lesions because of its physical characteristics (high dose at the surface, rapid decrease in depth). Other characteristics (penumbra, heterogeneity on an oblique or irregular surface) make them difficult to use. In most indications (skin cancers, head and neck, medulloblastoma), with technical progress, in some cases they have been replaced by intensity-modulated conformal radiotherapy, brachytherapy and contact therapy. Other indications (drainage of mesotheliomas or irradiation of benign lesions) have disappeared. The low frequency of use leads to problems of safety and cost-effectiveness. However, modern photon radiotherapy techniques are still less effective than electrons in specific indications such as total skin irradiation (mycosis fungoides) or certain thin chest wall irradiations after total mastectomy, reirradiation or paediatric treatments without protons. Flash therapy, initiated by electrons, has been developed over the last 10 years, providing high-dose irradiation in an extremely short time. Initial results show good efficacy, with fewer side effects than with conventional radiotherapy. These results are leading to clinical technological developments on a larger scale. Although it has been replaced in most indications by more modern techniques, electron radiotherapy remains essential for targeted indications in specialised centres. The emergence of flash therapy will lead to new indications, on machines equipped with this new technology, which have yet to be defined and are currently the responsibility of specialised teams.

Effectiveness of postoperative superficial radiotherapy following the keloid-cross-flap surgery for auricular keloid: A prospective cohort study

BACKGROUND AND PURPOSE

Retaining partial keloid skin to make cross flaps (keloid-cross-flap surgery) is a modification of the core excision. This study aimed to compare the effectiveness of superficial radiotherapy versus compression therapy after keloid-cross-flap surgery.

MATERIALS AND METHODS

In this prospective cohort study, auricular keloid patients were consecutively screened from January 2019 to December 2021. They underwent keloid-cross-flap surgery and then enter either the superficial radiotherapy or the compression treatment group. The primary outcome was the one-year keloid recurrence rate. Secondary outcomes included: non-completion rate of adjuvant treatment; Patient and Observer Scar Assessment Scale (POSAS) scores and auricular aesthetics scores, evaluated by a four-point Likert scale (1 = poor to 4 = excellent) of non-recurring patients. Propensity score matching (PSM) was used to eliminate potential confounding factors.

RESULTS

123 patients were included in the superficial radiotherapy group and 128 in the compression treatment group. Non-completion rate was significantly higher in the compression treatment group (17.97 %), while the loss rate was comparable between the two groups. Overall, 13 patients (13.54 %) relapsed in superficial radiotherapy group, while 22 patients (25.58 %) in compression group (p < 0.05). After PSM, 59 patients in each group were analyzed, and the recurrence rate was lower in the superficial radiotherapy group (13.56 %). Of relapse-free patients, no significant difference was found in PSAS scores, OSAS scores or aesthetic scores between the two groups.

CONCLUSION

Keloid-cross-flap surgery could provide favorable morphologic repair of the auricular keloid, and postoperative superficial radiotherapy shows higher compliance and lower recurrence rate comparing to compression treatment.

Clinical Effect of Dermatologic Trephination Combined With Radiotherapy in the Treatment of Keloids

BACKGROUND

Keloids are excessive formations of scar tissue that develop at the site of a skin injury. Due to their invasive nature, they have a negative impact on the skin's appearance and are prone to recurrence, making them a challenging condition to treat with regard to skin aesthetics.

OBJECTIVES

The objective of this article was to compare the long-term effects of dermatologic trephination with nonsurgical treatments for scars and evaluate the clinical value of the treatments.

METHODS

A retrospective analysis was conducted of 48 patients who received keloid treatment in the Department of Dermatology and Department of Thoracic Surgery at our hospital from January 2021 to October 2023. Twenty-four patients received dermatologic trephination, and 24 patients received nonsurgical treatment. Outcome measures included scar appearance, scar healing time, pain and itching levels, and patient satisfaction.

RESULTS

The healing time of patients receiving dermatologic trephination was significantly shorter than that of patients in the nonsurgical group. The degree of itching in patients undergoing dermatologic trephination was significantly lower than that of patients in the nonsurgical group. The satisfaction of patients who received dermatologic trephination was significantly higher than that of patients in the nonsurgical group.

CONCLUSIONS

In this study we demonstrated that trephination achieves better long-term results in keloid revision, including improved keloid appearance, itching symptoms, and patient satisfaction.

LEVEL OF EVIDENCE: 3

Investigation of the impact of copper nanoparticles coated with ocimum bassilicum at chemoradiotherapy of colon carcinoma

Background

Colon carcinoma poses a significant health challenge globally, particularly in developed nations where sedentary lifestyles, poor dietary choices, and genetic factors play a crucial role in its prevalence. Chemotherapy, the primary treatment method, carries severe side effects that can jeopardize patients' lives. Herbal extracts such as Ocimum Basillicum extract have shown effectiveness against cancer cells. Additionally, nanoparticles can significantly enhance drug delivery efficacy in these scenarios.

Aim

This article aims to investigate the impact of copper nanoparticles coated with Ocimum Bassilicum at chemoradiotherapy of Colon Carcinoma to hopefully create new treatment options with fewer side effects for patients.

Methodology

CuO bio-NPs were produced by the addition of 15 mL of extract dropwise to 80 mL of a 5 mM Cu (OAc)2 aqueous solution, which was then refluxed for 2 h at 100 °C. The mixture gradually became darker brown in color as a result of the heating procedure. The production of CuO NPs and the hydrogen-donating activity of antioxidant phenols within the plant are signaled by surface plasmon resonance excitation, which is the cause of this. In the cell culture, LS174t colon cancer cells were treated with OB extract, CuNPs, and OB-coated CuNPs with and without different radiation levels in order to assess cell viability, through the MTT assay, and the pro-apoptotic BAX and anti-apoptotic BCL2 expressions, through qPCR assay.

Results

The results demonstrate a decrease in cell viability and the expression of BCL2 and an increase in the expression of BAX especially when treated with OB-coated CuNPs and even furthermore when paired with radiation therapy.

Conclusions

After doing the clinical trial studies, the recent nanoparticles can be used for the treatment of Colorectal carcinoma.

Comprehensive Insights into Keloid Pathogenesis and Advanced Therapeutic Strategies

Keloid scars, characterized by abnormal fibroproliferation and excessive extracellular matrix (ECM) production that extends beyond the original wound, often cause pruritus, pain, and hyperpigmentation, significantly impacting the quality of life. Keloid pathogenesis is multifactorial, involving genetic predisposition, immune response dysregulation, and aberrant wound-healing processes. Central molecular pathways such as TGF-β/Smad and JAK/STAT are important in keloid formation by sustaining fibroblast activation and ECM deposition. Conventional treatments, including surgical excision, radiation, laser therapies, and intralesional injections, yield variable success but are limited by high recurrence rates and potential adverse effects. Emerging therapies targeting specific immune pathways, small molecule inhibitors, RNA interference, and mesenchymal stem cells show promise in disrupting the underlying mechanisms of keloid pathogenesis, potentially offering more effective and lasting treatment outcomes. Despite advancements, further research is essential to fully elucidate the precise mechanisms of keloid formation and to develop targeted therapies. Ongoing clinical trials and research efforts are vital for translating these scientific insights into practical treatments that can markedly enhance the quality of life for individuals affected by keloid scars.

Massive facial keloid precipitated by chronic suppuration and mechanical skin traction: A case report

Keloids are benign fibroproliferative tumours with a high recurrence rate of 20%-100%, therefore, multimodal treatment is recommended. We report the case of an exceptionally large facial keloid precipitated by a vicious cycle of chronic inflammation and mechanical skin traction and discuss the management challenges in a low resource setting. A 67-year-old man presented with a 10-year history of a facial keloid that rapidly enlarged to 2,800 g in 2 years causing difficulties eating, speaking, dressing, head movements and breathing. He had multiple other smaller keloids, hypertension, HIV, and a keloid family history. Surgical excision of the keloid including the multiple sinuses and cysts of enclosed skin with growing hair found inside was performed. A posterior skin flap was used to achieve tension free closure and monthly triamcinolone injections commenced. Histology showed keloidal collagen bundles in a fibrotic background, foci of a lymphoplasmacytic infiltrate and multinucleated foreign body type giant cells consistent with chronic inflammation. CD34 and S100 immunohistochemistry were both negative, ruling out the differential diagnoses that included dermatofibroma. Recovery was uneventful and the patient was discharged after 2 weeks. Notably, radiotherapy was not available in our country. We report this unique case of an extremely large keloid to demonstrate the role of suppurative chronic inflammation and high skin tension in accelerated keloid growth. This case also highlights the severe global disparity in the availability of effective keloid treatment and the urgent need for access to radiotherapy services especially in Africa where keloid prevalence is highest.

Post-Excision Soft X-Ray Radiotherapy for Keloids: Experience in a Tertiary Referral Center

INTRODUCTION

Keloid is an abnormal proliferation of scar tissue that grows beyond the original margins of the injury. Even after complete resection, recurrences are common and pose a poorly understood challenge in dermatology. There is lack of large prospective clinical trials; thus, treatment recommendations are based on retrospective analyses and small cohort studies. Superficial radiotherapy is recommended in recurrent keloids; however, the successful treatment rates vary greatly. The aim of this study was to evaluate the keloid recurrence rate after post-excision soft X-ray radiotherapy and the associated factors.

METHODS

We reviewed retrospective data of all patients, treated with adjuvant post-excision soft X-ray radiotherapy with 12 Gy in 6 sessions at the tertiary referral center, Department of Dermatology, University Hospital Zurich, Switzerland, between 2005 and 2018. We analyzed individual keloids as separate cases. Successful treatment was defined as no sign of recurrence within 2 years.

RESULTS

Of the 200 identified patients, 90 met the inclusion criteria and were included in the final analysis. In 90 patients, 104 cases of treated keloids were analyzed. Keloids were mainly located on the trunk (49%) and were mostly caused by previous surgery (52.2%). 50% of the keloids did not relapse within 2 years after therapy. A significant factor leading to recurrence was the presence of previous therapy, with prior topical therapies, such as steroid injections or 5-fluorouracil, leading to most relapses. 69.2% of keloid cases who relapsed were pretreated. Soft X-ray radiotherapy was well tolerated, with posttreatment hyperpigmentation noted in 34% of patients, particularly in patients with non-Caucasian origin (61.3%).

CONCLUSION

Treatment of refractory keloids is difficult. Post-excision radiotherapy is an established adjuvant treatment option; nevertheless, recurrence rates are high, especially in pretreated keloids. Prospective studies determining the exact dosage and fraction of post-excisional radiotherapy are needed to determine the optimal radiation parameters.

A Novel Method for Patients With Ear Keloid: Enucleation and Fat Grafting

BACKGROUND

Keloid is a dermal fibroproliferative disease unique to humans. Due to the ambiguity in its pathophysiology and the frequent recurrence of keloid, there is no clear consensus on the treatment of keloid and there are many treatment methods defined. In order to benefit from the positive effects of fat grafting on pathological scars, we applied fat grafting to patients who underwent keloid enucleation.

METHODS

Fifteen ear keloid patients included in the study. All patients underwent the same surgical procedure by the same surgeon. Routine follow-ups and examinations were performed to evaluate the results and in addition, the Patient and Observer Scar Assessment Scale (POSAS) survey was used.

RESULTS

In the study, 15 patients were followed for a median (IQR) period of 21 (13-28) months. No recurrence was observed in any patient during follow-up, which occurred for a median of 21 (13-28) months. In the questionnaire filled out by the patients, the preoperative median value was found to be 48 (IQR: 12), whereas the postoperative median value was found to be 14 (IQR: 8). According to the patients, there was a statistically significant ( P < 0.05) positive improvement after surgery.

CONCLUSIONS

Historically, surgical procedures were avoided because the surgical recurrence rate was very high, but today, recurrence rates are decreasing with combined treatments. These treatment combinations may require more than one intervention and require frequent clinical follow-ups. With our technique of fat grafting after enucleation, the treatment was completed with a single operation and no additional intervention was required.

Low-Dose Irradiation and Rotating-Hinge Revision for the Treatment of Severe Idiopathic Arthrofibrosis Following Total Knee Arthroplasty: A Review of 60 Patients With a Mean 6-Year Follow-Up

BACKGROUND

Severe idiopathic arthrofibrosis after total knee arthroplasty (TKA) is a challenging problem to treat. Low-dose irradiation may decrease fibro-osseous proliferation, while rotating-hinge (RH) revision allows for distal femur shortening and collateral ligament sacrifice. This study reports the clinical outcomes and implant survivorship in patients treated with low-dose irradiation and RH revision for severe idiopathic arthrofibrosis following TKA.

METHODS

A retrospective review was performed on 60 consecutive patients. Patients who had greater than 80° arc of knee motion or less than 15° flexion contracture were excluded. Mean follow-up was 6 years (range, 2 to 14). Kaplan-Meier survivorship analyses were performed, and logistic regressions were used to determine associations between preoperative patient characteristics and clinical outcomes.

RESULTS

Median flexion contracture and median terminal flexion at presentation were 20 and 70°, respectively; at final follow-up, 59 of 60 patients (98%) had ≤10° flexion contracture and 49 of 60 patients (82%) had ≥90° of flexion. The 10-year survivorship free from reoperation for any reason, revision for any reason, and revision for aseptic loosening were 63, 87, and 97%, respectively. There were 27% percent of patients who underwent a manipulation under anesthesia postoperatively, which was the most common reason for return to the operating room. A greater number of prior surgeries was significantly associated with worse range of motion at the final follow-up (P = .004). There were no known radiation-associated complications.

CONCLUSIONS

Patients with severe idiopathic arthrofibrosis following TKA treated with low-dose irradiation and RH revision maintained a gain in knee range of motion of 60° with reliable flexion contracture correction at a mean 6-year follow-up. A manipulation under anesthesia was common in the postoperative period. Survivorship free from revision for aseptic loosening was excellent at 10 years.

A Triple Combination Therapy Using 2-mm Biopsy Punch for the Treatment of Multifocal Keloids

BACKGROUND

Keloid treatment is challenging. The surgical approach can be divided into complete excision versus partial excision.

OBJECTIVE

The current study aims to introduce our novel surgical approach of partial excision using a 2-mm punch biopsy device to treat refractory multifocal keloids in the trunk.

MATERIALS AND METHODS

This is a case series of 30 patients with refractory multifocal keloids treated with a triple combination therapy consisting of a punch-assisted partial excision and intralesional triamcinolone injections followed by immediate single fractional electron beam radiotherapy within 8 hours, postoperatively. The follow-up period was 12 months. The primary outcome was recorded as recurrence versus nonrecurrence or aggravation versus remission . The secondary outcome was patient satisfaction as assessed by the POSAS.

RESULTS

The recurrence or aggravation of keloid was not found without complications. Scores obtained from the POSAS patient scale showed that pain, itchiness, color, stiffness, thickness, and irregularity significantly improved.

CONCLUSION

Our novel surgical approach using a 2-mm punch biopsy device effectively treats refractory multifocal keloids once considered intractable. Triple combination therapy of partial excision using a 2-mm punch biopsy device, intralesional triamcinolone injections, followed by immediate single fractional electron beam radiotherapy, is a safe, efficacious, and more convenient protocol to treat this condition.

The Role of Radiation Therapy in Adult and Pediatric Keloid Management: A National Survey of Radiation Oncologists

INTRODUCTION

Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians because of concern surrounding the risk of radiation-induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management.

AIM

The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers.

METHODS

An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed.

RESULTS

A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults, whereas only 54.9% supported radiation therapy for pediatric patients. Of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied 3 fraction regimens (54.4%), and delivered radiation within 24 hours postexcision (45.5%). In pediatric patients, only 42 providers reported treating at least 1 patient. The majority used electron beam radiation (76.2%), applied 3 faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%).

CONCLUSION

Although radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted because of concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.

Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies

Hypertrophic scars and keloids can have significant detrimental effects on patients both psychosocially and functionally. A careful identification of patient risk factors and a comprehensive management plan are necessary to optimize outcomes. Patients with a history of dystrophic scarring should avoid unnecessary procedures and enhance the wound-healing process using various preventive strategies. As there is no single, fully efficacious treatment modality, prevention remains the best approach in reducing aberrant scar formation. When prevention therapies fail, keloids have been shown to be respond to a variety of therapies including topical and injectable corticosteroids, 5-fluorouracil, radiotherapy, lasers, and surgical excision, all with varying efficacies. As such, management should be tailored to the individual patient's risk factors with the use of combination therapies to reduce recurrence rates. Still, keloid and hypertrophic scar therapies are widely diverse with novel treatment modalities providing alternatives for recurring lesions. Laser-assisted drug delivery, skin priming, and novel topical therapies may provide alternative options for the management of hypertrophic scars and keloids.

Current advances in the selection of adjuvant radiotherapy regimens for keloid

Keloid is a common benign skin tumor in the outpatient department, and patients are often accompanied by itching and pain. Since the pathogenesis is unknown, the effect of single method treatment is unsatisfactory, and therefore the recurrence rate is high. Therefore, comprehensive treatment is mostly used in clinical treatment. Adjuvant radiotherapy is currently one of the most effective treatments for keloid. After long-term clinical practice, brachytherapy and electron beam radiotherapy has increasingly become the gold standard of treatment, because brachytherapy provides more focused radiation treatment to focal tissue to significantly reduce recurrence rate, and better preserve normal tissue. With the development of new radiotherapy techniques, more options for the treatment of keloid. Currently, adjuvant radiotherapy has been widely recognized, but there is no consensus on the optimal protocol for adjuvant radiotherapy for keloids. This review provides a review of published treatment options and new radiotherapy techniques for adjuvant radiotherapy of keloids and gives a comprehensive evaluation for clinical treatment.