Superficial x-ray therapy in keloid management: a retrospective study of 24 cases and literature review

Scar-centered dilation in the treatment of large keloids

BACKGROUND

Hypertrophic scars and keloid treatment is a major problem in plastic surgery. While small keloids can be treated with resection followed by radiotherapy, large keloids require treatment with a tissue expander. Conventional methods increase the need for auxiliary incisions, causing new scar hyperplasia.

AIM

To introduce a new method for the treatment of keloids with an expander.

METHODS

Between 2018 and 2021, we performed surgeries to treat large keloids in nine patients with a two-stage approach. In the first stage, an intrascar incision was made in the keloid, and a customized expander was implanted under the keloid and the surrounding normal skin. A period of 3-6 mo was allowed for skin expansion. In the second stage, after the initial incision healed, a follow-up surgery was performed to remove the expander, resect the keloid, and repair the expanded skin flap. To accomplish this, an incision was made along the scar boundary to avoid making a new surgical incision and creating new scars. Superficial radiotherapy was then performed postoperatively.

RESULTS

Two patients had anterior chest keloids. After treatment, the anterior chest incision was broken repeatedly and then sutured again after debridement. It healed smoothly without scar hyperplasia. Keloids were successfully removed in 7 patients without recurrence.

CONCLUSION

This method was performed through a keloid incision and with a custom expander embedded. After full expansion, the keloid was directly resected using a linear suture, which avoids new surgical incisions and scars and can successfully remove large-area keloids. The treatment is effective, providing new insights and strategies for the treatment of similar large-area keloid and hypertrophic scar cases in the future.

Radiation induced mucoepidermoid carcinoma of the parotid gland following post-operative radiotherapy to the earlobe for keloid prophylaxis

Radiation-induced malignancies (RIMs) are rare but well-documented late toxicities associated with exposure to radiation or radiotherapy. A keloid scar is a common benign proliferation of scar tissue which commonly develops at the site of an injury, such as on the earlobe after ear-piercing. While typically reserved for management of malignancies, radiotherapy is often utilized in the management of some benign conditions, including keloids. Given the benign nature of keloids, any theoretical late toxicity from radiotherapy, particularly a life-threatening toxicity such as a RIM, is particularly concerning. Here, we report a case of a 34-year-old male who presented with a radiation induced mucoepidermoid carcinoma of the parotid gland which developed in a previously irradiated field ten years after the patient received electron radiotherapy for a keloid of the earlobe. Using available literature, we estimate the risk of a RIM of the parotid gland from a typical course of radiotherapy to the earlobe as 0.007% per year.

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago

BACKGROUND

In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.

METHODS

All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.

RESULTS

Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.

CONCLUSIONS

Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.

Efficacy of Surgical Excision and Adjuvant High-dose Rate Brachytherapy in Treatment of Keloid: Our Experience

Background

Keloids are dermal tumors that are due to increased production of collagen caused by abnormal and prolonged wound healing. The incidence of recurrence is extremely high if only conservative measures are used. This study was conducted to evaluate the feasibility and efficacy surgery and high dose rate brachytherapy as an adjuvant therapy for treatment of keloids.

Materials and Methods

50 patients with clinically diagnosed 71 keloids were treated with excision of keloid and post-operative high-dose rate brachytherapy were studied. Complete excision of the keloid till the healthy skin margin was excised. The wound were closed in 2 layers. Subcutaneous tissue closed using absorbable suture, over which a 6F flexible polyethylene tube was placed. High dose rate cobalt-60 brachytherapy was administered. Total of 15 Gy in divided dose, 5 Gy in 3 fractions were administered.

Results

50 patients with 71 keloids were studied. Out of the 50 patients, 12 were male (24%) and 38 were females (76%). Age of the patients ranged between 14 and 71 years. Recurrence rate was 2% with 2 keloids recurring at 5 months interval. 4 patients scored the results as unacceptable, remaining 45 patients rated their results as excellent during their follow up at 10 days, 3 months and 6 months.

Conclusion

Treatment of keloids in the plastic surgeon's practice even today is still challenging. Many therapies have been described, but recurrence rate is high with mono-therapy. Combination therapy especially surgical excision with postoperative radiotherapy is best in preventing recurrence.

Systemic Fibrocyte Levels and Keloid Expression of the Chemoattractant CXCL12 Are Upregulated Compared With Patients With Normal Scar

BACKGROUND

Fibrocytes are bone marrow mesenchymal precursors with a surface phenotype compatible with leukocytes, fibroblasts, and hematopoietic progenitors that have been shown to traffic to wound healing sites in response to described chemokine pathways. Keloids are focal fibrotic responses to cutaneous trauma characterized by disordered collagen, which may be associated with elevated systemic fibrocyte levels and/or wound bed chemokine expression.

METHODS

Blood specimens from patients with longstanding keloids and those who form grossly normal scars were assayed by fluorescence activated cell sorting analysis for fibrocytes (CD45+, Col I+). The expression of the fibrocyte chemotactic cell surface marker CXCR4, intracellular markers of fibroblast differentiation (pSMAD2/3), and plasma levels of the CXCR4 cognate CXCL12 were compared. Keloid specimens and grossly normal scars were excised, and local expression of CXCL12 was assayed.

RESULTS

Keloid-forming patients demonstrated a significantly greater number of circulating fibrocytes (17.4 × 105 cells/mL) than control patients (1.01 × 105 cells/mL, P = 0.004). The absolute number of fibrocytes expressing CXCR4 was significantly greater (P = 0.012) in keloid-forming patients. Systemic CXCL12 levels were insignificantly greater in keloid-forming patients than controls. Keloid specimens had significantly greater CXCL12 expression (529.3 pg/mL) than normal scar (undetectable).

CONCLUSIONS

Systemic fibrocyte levels and the CXCR4/CXCL12 biologic axis responsible for fibrocyte trafficking to areas of regional fibrosis were both upregulated in patients who form keloids compared with controls. Keloids persistently expressed CXLC12, which serves both as the main chemoattractant for fibrocytes and a downstream mediator for local inflammation, suggesting a role for this biologic axis in keloid formation and possibly recurrence.

Assessing keloid recurrence following surgical excision and radiation

Keloids are a fibroproliferative disorder that can result from a cutaneous injury to the reticular dermis. Recurrence rates as high as 100% have been reported following surgical excision alone. Consequently, a variety of post-surgical techniques have been employed to prevent keloid recurrence, including the use of radiation. Although numerous studies have shown post-excisional X-rays, electron beam, lasers and brachytherapy can reduce the rate of keloid recurrence, numerous inconsistencies, including a wide range of definitions for keloid recurrence, make it difficult to compare study outcomes. The review aims to examine the various means for defining keloid recurrence in clinical trials involving the use of radiation therapy. Searches of the Cochrane Library and PubMed were performed to identify the available information for post-surgical keloid recurrence following radiation therapy. Each identified study was reviewed for patient follow-up and criteria used to define keloid recurrence. The search results included clinical studies with external beam radiation, brachytherapy and superficial radiation therapy. Many studies did not include a definition of keloid recurrence, or defined recurrence only as the return of scar tissue. Other studies defined keloid recurrence based on patient self-assessment questionnaires, symptoms and scar elevation and changes in Kyoto Scar Scale, Japan Scar Workshop Scale and Vancouver Scar Scale scores. The results of this review indicate keloidectomy followed by radiation therapy provide satisfactory recurrence rates; however, clinical studies evaluating these treatments do not describe treatment outcomes or use different definitions of keloid recurrence. Consequently, recurrence rates vary widely, making comparisons across studies difficult. Keloid recurrence should be clearly defined using both objective and subjective measures.

Interstitial high-dose-rate brachytherapy in the treatment of keloids: Moving toward a volumetric approach

PURPOSE

Brachytherapy (BT) after surgical resection of keloids reduces the risk of local recurrence, but standardization of dose/technique is lacking. Typical keloid BT treatment utilizes a single-channel source prescribed to 5-mm depth. We investigated the dosimetry of a volume-based target definition for interstitial high-dose-rate BT treatment of keloids.

METHODS AND MATERIALS

We retrospectively identified consecutive 14 patients who had a total of 20 keloids treated with interstitial high-dose-rate BT for keloids at our institution between 2004 and 2014. Keloids were treated with a single 8 Gy fraction prescribed to 5 mm beneath the scar within 36 h of surgery. Retrospectively, a 3-mm skin high-risk clinical target volume (HR-CTV) was contoured under the scar for volume-based dose calculations.

RESULTS

Mean (SD) HR-CTV was 3.91 cm³ (3.1) and mean (SD) HR-CTV dose was 11.3 Gy (3.6). Mean D₉₀ (SD) was 62.9% (25.8) and mean V₁₀₀ (SD) was 56.5% (26.4). The mean V₁₅₀ (SD), V₂₀₀ (SD), and V₃₀₀ (SD) were as follows: 37.6% (19.9), 25.1% (14.4), and 11.3% (6.5), respectively. No local failures were reported at 9 months median followup. There were no Grade 2 or higher late toxicities.

CONCLUSIONS

Using a volume-based target definition, a wide range of target coverage was observed. This is likely a consequence of the curvature of the skin and the challenges of keeping the catheter equidistant from the skin across the target. Additional data are needed to define the potential clinical impact on outcomes/toxicities of dosimetric correlates with single-catheter BT keloid treatment.

Nonsurgical Management of Hypertrophic Scars: Evidence-Based Therapies, Standard Practices, and Emerging Methods

Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.

Fat Injection for Cases of Severe Burn Outcomes: A New Perspective of Scar Remodeling and Reduction

BACKGROUND

Despite civilization and progress, burns occur frequently in the world. Remarkable discoveries of wound healing mechanisms have been reported. On the other hand, long-term outcomes from burn injuries represent a barrier to improvement of patients' social, functional, and psychological condition. Lipofilling, described since the 1980s, currently is used for several clinical applications. This study aimed to verify whether lipofilling could ameliorate scar remodeling in three clinical cases.

METHODS

Three adult patients with hemifacial hypertrophic scars and keloids resulting from severe burns 2 to 13 years previously were selected. The patients were treated by injection of adipose tissue harvested from abdominal subcutaneous fat and processed according to Coleman's technique. Two injections (with a 13-month interval between) were administered at the dermohypodermal junction. Histologic examination of scar tissue punch biopsies (hematoxylin-eosin staining) before and after the treatment was performed as well as magnetic resonance scan with contrast.

RESULTS

The clinical appearance and subjective patient feelings after a 6-month follow-up period suggest considerable improvement in the mimic features, skin texture, and thickness. Histologic examination shows patterns of new collagen deposition, local hypervascularity, and dermal hyperplasia in the context of new tissue, with high correspondence to the original.

CONCLUSIONS

The preliminary results show that lipofilling improves scar quality and suggest a tissue regeneration enhancing process.

Effect of Botulinum Toxin A on Scar Healing after Thyroidectomy: A Prospective Double-blind Randomized Controlled Trial

The persistence of neck scarring is a common concern among patients undergoing thyroidectomy. Botulinum toxin A (BTA (Botox)) has been shown to suppress scar enlargement at the incision site. The objective of this study was to evaluate the effect of intraoperative Botox administration on neck scarring after thyroidectomy. A prospective double-blind randomized clinical trial was performed in patients undergoing conventional thyroidectomy. Forty patients were randomly allocated to a Botox or a control group (both, n = 20). The wound was closed after injection into the platysma muscle of 50 U of Botox diluted in 1 mL of normal saline or 1 mL of saline alone. Skin scars were assessed using the modified Stony Brook Scar Evaluation Scale (SBSES) and Manchester Scar Scale (MSS) at 1, 12, and 24 weeks postoperatively. The SBSES and MSS scores of the Botox group were significantly better than those of the control group (p = 0.034 and p = 0.039). At 24 weeks postoperatively, the SBSES and MSS scores were significantly better in the Botox group (p = 0.006 and p = 0.030). BTA injected into the incision site can suppress postoperative scar formation and thereby improve the cosmetic outcome.

Keloid treatment: what about adjuvant radiotherapy?

Background: Keloids are debilitating fibrous skin proliferations with a high recurrence rate after surgical treatment. Postoperative radiotherapy (PORT) is a well-tolerated adjuvant treatment to reduce the risk of recurrence, but the optimal regimen for this combined treatment remains unknown. The aim of this study is to evaluate the efficacy of combining surgical excision and immediate PORT.

Methods: We retrospectively reviewed the records of patients with keloid lesions treated with adjuvant PORT in the period 2005–2014 at Geneva University Hospitals. Main outcomes were the rates of complications and recurrence in patients with a minimal follow-up of 1 year, including the Patient and Observer Scar Assessment Scale satisfaction scores.

Results: 10 patients with 16 keloids were eligible (mean follow-up, 37 months). Only one recurrence was reported (6%). In 12.5% of cases, mild erythema appeared in the early postoperative period. No major complications were observed. The overall patient and observer satisfaction rate was excellent.

Conclusion: Surgical excision combined with immediate PORT is an effective and easy treatment with good esthetic results and an acceptable recurrence rate. It should be considered for patients with persistent keloid formation after failure of other treatments and those at high risk of relapse.

Radiation Therapy in Keloids Treatment: History, Strategy, Effectiveness, and Complication

Objective:

Radiation therapy combined with surgical excision was considered as one of the most effective treatment plans for keloid lesions. However, there was no unanimity found over present literatures regarding the issue on optimized treatment strategy for keloids. We here provide a comprehensive review over this issue and emphasize on the influencing factors.

Data Sources:

The data analyzed in this review were searched from articles included in PubMed and EMBASE databases.

Study Selection:

The original articles and critical reviews discussing the application of radiation therapy in keloids treatment were selected for this review.

Results:

The application of radiation therapy has transitioned from simple superficial X-ray irradiation to brachytherapy. Furthermore, several factors including radiation type, dose, fraction, interval, and complications were reviewed, and the results revealed that these factors were significant toward clinical outcome at various levels.

Conclusions:

Both past and present evidence support the idea that combination therapy of radiation and surgical therapy is safe and feasible. However, the optimization of treatment strategy was based on different radiation types and should take dose, fractions, interval, and complications into consideration, which will then decrease the rate of recurrence and increase the level of satisfaction.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Keloids and Hypertrophic Scars Can Now Be Cured Completely: Recent Progress in Our Understanding of the Pathogenesis of Keloids and Hypertrophic Scars and the Most Promising Current Therapeutic Strategy

Keloids and hypertrophic scars are fibroproliferative disorders of the skin that are caused by abnormal healing of injured or irritated skin. It is possible that they are both manifestations of the same fibroproliferative skin disorder and just differ in terms of the intensity and duration of inflammation. These features may in turn be influenced by genetic, systemic, and local risk factors. Genetic factors may include single nucleotide polymorphisms, while systemic factors may include hypertension, pregnancy, hormones, and cytokines. The most important local factor is tension on the scar. Over the past 10 years, our understanding of the pathogenesis of keloids and hypertrophic scars has improved markedly. As a result, these previously intractable scars are now regarded as being treatable. There are many therapeutic options, including surgery, radiation, corticosteroids, 5-fluorouracil, cryotherapy, laser therapy, anti-allergy agents, anti-inflammatory agents, bleaching creams and make-up therapies. However, at present, we believe that the following combination of three therapies most reliably achieves a complete cure: surgery, followed by radiation and the use of steroid tape/plaster.

Surgical Excision and Adjuvant Brachytherapy vs External Beam Radiation for the Effective Treatment of Keloids: 10-Year Institutional Retrospective Analysis

BACKGROUND

Surgically excised keloids reportedly recur at a rate of >45%. Post-excision radiation (RT) has been delivered via external beam radiotherapy (EBRT) or interstitial high dose rate (HDR) brachytherapy. Despite historical data showing 10% to 20% keloid recurrences with post-excision RT, there is a paucity of high-quality evidence comparing keloid recurrences between the two RT modalities.

OBJECTIVES

We performed the largest single-institution case-control retrospective study (2004-2014) of keloid recurrence rates and complications between post-excision EBRT and HDR brachytherapy.

METHODS

One-hundred and twenty-eight patients, with 264 keloid lesions, were treated by excision alone (n = 28), post-excision EBRT (n = 197), or post-excision HDR brachytherapy (n = 39). Patient and keloid recurrence data were analyzed using mixed effect Cox regression modeling with a statistical threshold of P < .05.

RESULTS

Fifty-four percent of keloids recurred after surgical excision alone (9-month median follow up); 19% of keloids recurred with post-excision EBRT (42-month median follow up); 23% of keloids recurred with post-excision brachytherapy (12-month median follow up). Adjuvant EBRT and brachytherapy each showed significant control of keloid recurrence compared to excision alone (P < .01). EBRT significantly delayed the time of keloid recurrence over brachytherapy by a mean difference of 2.5 years (P < .01).

CONCLUSIONS

Post-excision RT shows significant reduction in keloid recurrence compared to excision alone. While the recurrence control rates are not statistically different between EBRT and brachytherapy, keloids treated with EBRT recurred significantly later than those treated by HDR brachytherapy by a mean of 2.5 years. Further workup with a randomized control study will help to refine optimal adjuvant RT treatment. LEVEL OF EVIDENCE 3.

Reconstruction after Anterior Chest Wall Keloid Resection Using Internal Mammary Artery Perforator Propeller Flaps

It is difficult to completely resect huge anterior chest wall keloids and then close the wound directly. We report here our retrospective analysis of our case series of patients with such keloids who underwent reconstruction with internal mammary artery perforator (IMAP) pedicled propeller flaps and then received postoperative high-dose-rate superficial brachytherapy.

Hypertrophie Scars and Keloids: An Overview of the Aetiology and Management

Hypertrophic scars and keloids are a common surgical problem. There is increasing knowledge of the pathology of this condition but the exact pathogenesis is yet unknown. Treatment remains difficult and is associated with high recurrence rates in certain forms. The psychological implications for the patient are enormous and have still to be fully defined. This article is a review of the current aetiology, pathology and management of hypertrophic scars and keloids. Various treatment options are discussed and psychological aspects have been emphasised.

Update on Postsurgical Scar Management

Postoperative scar appearance is often a significant concern among patients, with many seeking advice from their surgeons regarding scar minimization. Numerous products are available that claim to decrease postoperative scar formation and improve wound healing. These products attempt to create an ideal environment for wound healing by targeting the three phases of wound healing: inflammation, proliferation, and remodeling. With that said, preoperative interventions, such as lifestyle modifications and optimization of medical comorbidities, and intraoperative interventions, such as adherence to meticulous operative techniques, are equally important for ideal scarring. In this article, the authors review the available options in postoperative scar management, addressing the benefits of multimodal perioperative intervention. Although numerous treatments exist, no single modality has been proven superior over others. Therefore, each patient should receive a personalized treatment regimen to optimize scar management.

Surgical Excision with Adjuvant Irradiation for Treatment of Keloid Scars: A Systematic Review

Background:

Excision followed by adjuvant irradiation is considered safe and most efficacious for treatment of keloid scars. Recently, different authors published successful treatment protocols and recommended the following: (1) the use of high-dose-rate brachytherapy instead of low-dose-rate brachytherapy or external radiation; (2) a short-time interval between operation and irradiation; (3) single fraction instead of multifraction irradiation; and (4) a minimum of 12- to 24-month follow-up post treatment.

Methods:

This study evaluates the above recommendations with a systematic review of the English-language literature, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Both PubMed and EMBASE were searched. Studies were graded according to the American Society of Plastic Surgeons Rating Levels of Evidence.

Results:

Thirty-three studies were selected. Six studies were graded as level of evidence type II studies and 27 as type III. High-dose-rate brachytherapy showed lower recurrence rates compared with low-dose-rate brachytherapy and external radiation. A short-time (<7 hours) interval between scar excision and irradiation results in a lower recurrence rate compared with long-time intervals (>24 hours). Single-fraction irradiation showed promising results in terms of recurrence rate and patient convenience. Finally, scar recurrences were seen between 2 and 36 months, with a mean of 15 months.

Conclusions:

Based on this systematic review of the literature, the evidence confirms the recommendations stated by authors in the recent years. However, due to the lack of high-quality randomized studies, the quality of this evidence is limited. More randomized studies will generate stronger recommendations.

Strategic management of keloid disease in ethnic skin: a structured approach supported by the emerging literature

Keloid disease (KD) is a common, benign, dermal fibroproliferative growth of unknown aetiology. Lesions tend to grow over time; they often recur following therapy and do not regress spontaneously. KD causes considerable discomfort due to pain, pruritus and inflammation, and a significant psychosocial impact with reduced quality of life. It is unique to humans and occurrence is higher in individuals with dark, pigmented, ethnic skin. There is a strong familial heritability, with a high ethnic predisposition in individuals of African, Asian and Hispanic descent. High recurrence rates and unknown resolution rates present a major problem for both the patient and clinician. Many treatment modalities exist; however, there is no single advocated therapy. Therefore, the aim of this review was to explore the most current literature regarding the range of treatment options for KD and to offer a structured approach in the management of KD, based on evidence and experience, to aid clinicians in their current practice. A focused history involving careful evaluation of the patient's symptoms, signs, quality of life and psychosocial well-being should direct targeted therapy, complemented with regular follow-up and re-evaluation. Many treatment modalities, such as intralesional steroid injection, silicone gel application, cryotherapy, lasers, 5-fluorouracil and, relatively recently, photodynamic therapy, are currently being used in clinical practice for the management of KD. Combination therapies have also been shown to be beneficial. However, there is a lack of robust, randomized, level-one, evidence-controlled trials evaluating these treatment options. Management of KD in ethnic pigmented skin remains a clinical challenge. Thus, a strategic approach with structured assessment, targeted therapy and focus on prevention of recurrence is highly recommended. Quality evidence is essential in order to tailor treatment effectively for the ethnic patient presenting with KD.

Keloids can be forced into remission with surgical excision and radiation, followed by adjuvant therapy

We have treated keloids using a combination of surgical excision and postoperative irradiation. The objective of this study was to evaluate the results of our treatment over 12 years. From 1995 until 2006, we treated keloids using the aforementioned treatment. If we identified a sign of recurrence during the follow-up period, we started an intralesional injection of triamcinolone acetonide immediately. We selected 91 keloids for which we had more than 2 years of follow-up data for this study and assessed the results according to our original scale (Kyoto scar scale) based on objective and subjective symptoms. In all, 51 keloids (56.0%) were cured completely by a combination of surgical excision and postoperative irradiation without additional treatment, and finally 81 keloids (89.0%) showed good results with additional treatment. Keloids are a controllable condition when treated with combination therapy, involving surgical excision with postoperative irradiation and early conservative treatment after the detection of recurrence.

Surgery and perioperative intralesional corticosteroid injection for treating earlobe keloids: a korean experience

BACKGROUND

The aesthetic implications of ear keloids, which affect people of all races, are serious and the treatment of earlobe keloids is known to be difficult. The high rate of recurrence following excision alone has led to investigating various types of adjuvant therapy, including intralesional corticosteroid injection.

OBJECTIVE

We evaluated the efficacy of excision combined with perioperative intralesional triamcinolone acetonide injection for treating earlobe keloids of Korean patients.

METHODS

From 1997 to 2006, eighteen keloids on the earlobes of fifteen Korean patients were treated. The patient age ranged from 15 to 32 years (mean age: 24 years). All the patients were female and the keloids occurred after ear piercing. Preoperative intralesional triamcinolone acetonide (TA) injection was administered twice at a 1-month interval. Postoperative intralesional TA injections were given every 1 month for several months, depending on the patient's clinical progress.

RESULTS

The follow-up period ranged from 4 to 42 months (mean: 18.5 months). After the surgery, TA intralesional injections were given 2 to 13 times (mean: 5.2 times). Of the treated keloids, eleven showed good results (61.1%) and three recurred (16.6%). No complications from the TA intralesional injection were observed.

CONCLUSION

Among the various treatments for earlobe keloids, we suggest that excision with corticosteroid intralesional injection can be used as the first line therapy when considering its effect and economic advantage.

Keloids treated with postoperative Iridium 192* brachytherapy: a retrospective study

BACKGROUND

Post-excisional brachytherapy with Iridium 192 is a treatment of keloids scars (KS). Its indications and its parameters are not subject to any consensus.

OBJECTIVE

We wanted to assess the effectiveness and satisfaction of patients treated in our centre.

PATIENTS AND METHODS

This was a retrospective study conducted from November 2006 to November 2007. Patients with clinically and histologically proven KS treated between 1990 and 2005, were convened in consultation between September and October 2007. Clinical data and parameters of the brachytherapy have been collected.

RESULTS

Eighty-seven patients (138 KS) were treated. Eighty-two KS (46 patients) met the criteria for inclusion. Thirty-two patients (55 KS) have been seen in consultation. The average time between the onset of KS and treatment was 63.5 months. The brachytherapy has begun after a maximum of 7 hours posterior to surgery for all KS. The average dose was 17.9 Gy calculated at 5 mm. We observed 23.6% of recurrence after treatment. Seventy-nine per cent of itching and 87.5% of pain have totally disappeared. The phototypes 5 and 6 had an increased risk of recurrence.

DISCUSSION

This is the most important series of KS treated with Post-excisional brachytherapy presented so far. The technique is efficient in preventing keloid recurrence and in treating the functional signs, but at the expense of an unaesthetic result, of which patient must be warned about. A follow-up of at least two years after treatment is recommended.

Prevention and management of hypertrophic scars and keloids after burns in children

Hypertrophic scars and keloids are challenging to manage, particularly as sequelae of burns in children in whom the psychologic burden and skin characteristics differ substantially from adults. Prevention of hypertrophic scars and keloids after burns is currently the best strategy in their management to avoid permanent functional and aesthetical alterations. Several actions can be taken to prevent their occurrence, including parental and children education regarding handling sources of fire and flammable materials, among others. Combination of therapies is the mainstay of current burn scar management, including surgical reconstruction, pressure therapy, silicon gels and sheets, and temporary garments. Other adjuvant therapies such as topical imiquimod, tacrolimus, and retinoids, as well as intralesional corticosteroids, 5-fluorouracil, interferons, and bleomycin, have been used with relative success. Cryosurgery and lasers have also been reported as alternatives. Newer treatments aimed at molecular targets such as cytokines, growth factors, and gene therapy, currently in developing stages, are considered the future of the treatment of postburn hypertrophic scars and keloids in children.

Fat injection for cases of severe burn outcomes: a new perspective of scar remodeling and reduction

BACKGROUND

Despite civilization and progress, burns occur frequently in the world. Remarkable discoveries of wound healing mechanisms have been reported. On the other hand, long-term outcomes from burn injuries represent a barrier to improvement of patients' social, functional, and psychological condition. Lipofilling, described since the 1980s, currently is used for several clinical applications. This study aimed to verify whether lipofilling could ameliorate scar remodeling in three clinical cases.

METHODS

Three adult patients with hemifacial hypertrophic scars and keloids resulting from severe burns 2 to 13 years previously were selected. The patients were treated by injection of adipose tissue harvested from abdominal subcutaneous fat and processed according to Coleman's technique. Two injections (with a 13-month interval between) were administered at the dermohypodermal junction. Histologic examination of scar tissue punch biopsies (hematoxylin-eosin staining) before and after the treatment was performed as well as magnetic resonance scan with contrast.

RESULTS

The clinical appearance and subjective patient feelings after a 6-month follow-up period suggest considerable improvement in the mimic features, skin texture, and thickness. Histologic examination shows patterns of new collagen deposition, local hypervascularity, and dermal hyperplasia in the context of new tissue, with high correspondence to the original.

CONCLUSIONS

The preliminary results show that lipofilling improves scar quality and suggest a tissue regeneration enhancing process.

A case of unilateral keloid after bilateral breast reduction

Keloid scar is a manifestation of abnormal wound healing in predisposed individuals. Many treatment modalities have been tried with varying degrees of success. Radiotherapy is one such modality that is widely recognised. We present a case report and literature review based on a patient who developed unilateral keloid scarring following bilateral breast reduction surgery. Some 4 years previously, she had undergone breast conserving surgery followed by adjuvant radiotherapy for breast cancer. After her breast reduction surgery, she developed keloid scarring on the non-irradiated breast only. This case highlights a possible 'preventative' effect of radiotherapy in keloid formation.

A primary protocol for the management of ear keloids: results of excision combined with intraoperative and postoperative steroid injections

BACKGROUND

Keloids of the ear are a challenging problem, with many treatment modalities advocated. The primary determinant in choosing a treatment protocol should be a low recurrence rate. Most reports in the literature suffer from small numbers of patients and inadequate follow-up.

METHODS

This study presents a retrospective analysis of 64 patients representing 92 ear keloids treated between 1982 and 1997. The treatment protocol consisted of excision with an intraoperative and two postoperative steroid injections. All patients were treated by a single physician. Long-term follow-up was obtained at a minimum of 5 years.

RESULTS

Protocol success was achieved in 74 of 92 keloids (80 percent) excised. Prior excision of the keloid was significantly associated with protocol failure (p = 0.0068). Keloid recurrence was seen in 10 of 43 (23 percent). Statistically significant differences were noted in keloids that had undergone prior excision as compared with those presenting for initial treatment. These differences included growth rate (p = 0.0026), protocol failure (p = 0.0149), and total postoperative steroid injections administered (p = 0.0104).

CONCLUSIONS

The primary protocol presented for the treatment of ear keloids produces durable results, with an acceptably low recurrence rate. Stratification of keloids based on an assessment of aggressiveness may allow for a more informed choice in their optimal treatment.

Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods

Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.

Levels of evidence for the treatment of keloid disease

INTRODUCTION

Keloid disease presents a significant burden for patients and a significant therapeutic challenge for clinicians. Multiple treatments have been proposed, but with the increasing drive towards effective use of resources, therapeutic options need to be evaluated in terms of the levels of evidence supporting their use.

AIM

To retrieve and review the primary clinical studies evaluating keloid disease therapy over the last 25 years and assign levels of evidence for the treatment modalities evaluated.

METHOD

A Medline search was conducted to identify all primary clinical studies evaluating the treatment of keloid disease, published in English since 1980 (excluding single case reports). Studies were assigned a level of evidence (LOE-1, highest quality to LOE-5, lowest) adapted from the Oxford Centre for Evidence-based Medicine.

RESULTS

13 (12%) of 112 studies retrieved were assigned LOE-2, 99 (88%) assigned LOE-4. There were no LOE-1 studies. Ten of the LOE-2 studies evaluated silicone-based therapy or laser therapy. Most studies evaluating steroids, cryosurgery, laser therapy and post-surgical adjuvant therapy provide level 4 evidence.

CONCLUSION

High quality research in evaluating keloid therapy is lacking. There is a definite need for well designed and properly reported randomised controlled trials, to provide clinicians with a sound body of evidence on which to inform decision making.

The results of surgical excision and adjuvant irradiation for therapy-resistant keloids: a prospective clinical outcome study

BACKGROUND

There is no consensus on the best way to treat keloids, because adequate studies on this subject are sparse. Surgical excision in combination with radiotherapy is considered the most efficacious treatment available in severe keloids following the International Clinical Recommendations on Scar Management. Unfortunately, the recommendations are mainly based on retrospective studies that do not define recurrence.

METHODS

The authors evaluated the recurrence rate of therapy-resistant keloids treated with excision followed by radiotherapy (1200 Gy in three or four fractions). The minimum follow-up period was 12 months. The therapeutic outcome was judged as recurrence (elevation of the lesion not confined to the original wound area) or nonrecurrence. An evaluation of the outcome of the scars was obtained by using the Patient and Observer Scar Assessment Scale.

RESULTS

Twenty-one patients with 32 keloids were evaluated. The recurrence rate was 71.9 percent after a mean follow-up period of 19 months.

CONCLUSIONS

This high recurrence rate suggests that radiotherapy might be less efficacious than suggested by other studies. On the basis of the authors' results, surgical excision combined with radiotherapy should be reserved as a last resort in the treatment of therapy-resistant keloids.

Emerging new drugs for scar reduction

Hypertropic and keloid scars cause both functional and cosmetic problems for those afflicted. Although people of all ages suffer from these conditions, the patients are often young and otherwise healthy, and become burdened with an activity limiting lesion or psychosocial stresses associated with a perceived aesthetic defect. Currently available treatment modalities are often inconvenient, occasionally painful, and have unwanted side effects. Despite the highest standard of care, treatment protocols are prone to failure with high rates of scar recurrence. Hypertropic and keloid scars are the result of an abnormal healing response and may result from an extended inflammatory phase in the wound healing process. Regardless of the causes, which remain elusive, excessive collagen deposition occurs relative to normal wounds. This extracellular matrix collagen accumulation makes a logical target for pharmacological interventions, and researchers are attempting to modify collagen-synthetic and -degradative pathways. In addition, growth factors and cytokines have been implicated in scar formation, and these factors are targeted for potential therapeutic use in scar management. Cytotoxic agents are also being evaluated for their potential utility in the reduction of tissue bulk associated with these excessive scar states. Given the wide range of potential therapeutic agents, the future market for scar therapy remains highly promising.

Keloids - a frustrating hurdle in wound healing

A balance between collagen formation and degradation is essential for normal wound healing. Inadequate wound healing results in wound breakdown, and exaggeration results in hypertrophic scars and keloids. We look at the aetiological factors, the biochemical alterations and the treatment modalities for keloids, in this clinical challenge.

Wound Healing: An Overview

Understanding wound healing today involves much more than simply stating that there are three phases: inflammation, proliferation, and maturation. Wound healing is a complex series of reactions and interactions among cells and "mediators." Each year, new mediators are discovered and our understanding of inflammatory mediators and cellular interactions grows. This article will attempt to provide a concise overview on wound healing and wound management.

Keloid Pathogenesis and Treatment

BACKGROUND

Keloid management can be difficult and frustrating, and the mechanisms underlying keloid formation are only partially understood.

METHODS

Using original and current literature in this field, this comprehensive review presents the major concepts of keloid pathogenesis and the treatment options stemming from them.

RESULTS

Mechanisms for keloid formation include alterations in growth factors, collagen turnover, tension alignment, and genetic and immunologic contributions. Treatment strategies for keloids include established (e.g., surgery, steroid, radiation) and experimental (e.g., interferon, 5-fluorouracil, retinoid) regimens.

CONCLUSION

The scientific basis and empiric evidence supporting the use of various agents is presented. Combination therapy, using surgical excision followed by intradermal steroid or other adjuvant therapy, currently appears to be the most efficacious and safe current regimen for keloid management.

Ineffective Treatment of Keloids with Interferon Alpha-2b

BACKGROUND

Keloids are exuberant, disfiguring scars that result from an abnormal healing process. Current established treatment strategies include surgical resection, triamcinolone steroid injection, pressure therapy, silicone therapy, and radiotherapy. None of these therapies, either alone or in combination, offers consistent recurrence-free rates above 70 to 80 percent. The antiproliferative, antifibrotic cytokine, interferon alpha-2b, may be useful in keloid management because of its ability to interfere with collagen synthesis and fibroblast proliferation.

METHODS

To determine the efficacy of interferon alpha-2b in keloid management, the authors prospectively evaluated the effects of interferon alpha-2b as postexcisional adjuvant therapy for keloids. Thirty-nine keloids in 34 patients were photographed, measured, and surgically excised. The wound bed was injected twice with either interferon alpha-2b (treatment group; n = 13 keloids) or triamcinolone (control group; n = 26 keloids) at surgery and 1 week later. The patients were followed up in the plastic surgery clinic.

RESULTS

The trial protocol was terminated at midtrial surveillance. Among the 13 keloids that were treated with postoperative intralesional interferon alpha-2b, seven recurred (54 percent recurrence rate). In contrast, in the 26 keloids that received triamcinolone (control group), only four recurred (15 percent recurrence rate). Recurrence in either group did not correlate with location of the keloid or race.

CONCLUSION

Interferon does not appear to be effective in the clinical management of keloids.

Upregulation of the NNP-1 (novel nuclear protein-1, D21S2056E) gene in keloid tissue determined by cDNA microarray and in situ hybridization

BACKGROUND

A keloid results from excessive collagen deposition, the cause of which remains elusive. A thorough understanding of the pathophysiology of keloid tissue can help determine the most appropriate treatment strategy.

OBJECTIVES

To assess the differences in gene expression between keloids and adjacent normal skin in order to define the genes involved in keloid formation.

METHODS

Three Korean patients with keloids underwent excision of the keloid and adjacent normal skin, which was used as the control. We investigated expression patterns of genes in the keloids and the normal skin using cDNA microarray and in situ hybridization techniques.

RESULTS

Nine genes in the keloid tissue were consistently upregulated over the 2.0 ratio compared with the normal control from the cDNA microarray composed of 3063 clones: collagen type I alpha1 (NM_000088), DNA segment on chromosome 21 (unique) 2056 expressed sequence (D21S2056E, NNP-1, NM_003683), suppressor of Ty 5 homologue (NM_003169), phosphoglycerate dehydrogenase (NM_032692), adenosine triphosphate synthase beta (NM_001686), serine (or cysteine) proteinase inhibitor, clade H (heat shock protein 47, NM_001235), LIV-1 protein, oestrogen regulated (LIV-1, NM_012319), interleukin-11 receptor alpha (IL11RA, NM_004512) and carbonyl reductase 3 (CBR3, NM_001236). From the in situ hybridization study, the staining signals in the keloid tissue hybridized with anti sense probes of NNP-1 mRNA were stronger than signals in normal controls. Further, endothelial epithelium, but not the epidermis, expressed the signal equally in both keloid and normal control tissue.

CONCLUSIONS

We identified nine upregulated genes in keloid tissue using cDNA microarray. Of the nine, the NNP-1 gene was confirmed by topological information using the in situ hybridization technique. We conclude that these nine genes, especially NNP-1, probably contribute either directly or indirectly to keloid formation.