Effect of the combination of photobiomodulation therapy and the intralesional administration of corticoid in the preoperative and postoperative periods of keloid surgery: A randomized, controlled, double-blind trial protocol study

Keloid scars are characterized by the excessive proliferation of fibroblasts and an imbalance between the production and degradation of collagen, leading to its buildup in the dermis. There is no “gold standard” treatment for this condition, and the recurrence is frequent after surgical procedures removal. In vitro studies have demonstrated that photobiomodulation (PBM) using the blue wavelength reduces the proliferation speed and the number of fibroblasts as well as the expression of TGF-β. There are no protocols studied and established for the treatment of keloids with blue LED. Therefore, the purpose of this study is to determine the effects of the combination of PBM with blue light and the intralesional administration of the corticoid triamcinolone hexacetonide on the quality of the remaining scar by Vancouver Scar Scale in the postoperative period of keloid surgery. A randomized, controlled, double-blind, clinical trial will be conducted involving two groups: 1) Sham (n = 29): intralesional administration of corticoid (IAC) and sham PBM in the preoperative and postoperative periods of keloid removal surgery; and 2) active PBM combined with IAC (n = 29) in the preoperative and postoperative periods of keloid removal surgery. Transcutaneous PBM will be performed on the keloid region in the preoperative period and on the remaining scar in the postoperative period using blue LED (470 nm, 400 mW, 4J per point on 10 linear points). The patients will answer two questionnaires: one for the assessment of quality of life (Qualifibro-UNIFESP) and one for the assessment of satisfaction with the scar (PSAQ). The team of five plastic surgeons will answer the Vancouver Scar Scale (VSS). All questionnaires will be administered one, three, six, and twelve months postoperatively. The keloids will be molded in silicone prior to the onset of treatment and prior to excision to assess pre-treatment and post-treatment size. The same will be performed for the remaining scar at one, three, six, and twelve months postoperatively. The removed keloid will be submitted to histopathological analysis for the determination of the quantity of fibroblasts, the organization and distribution of collagen (picrosirius staining), and the genic expression of TGF-β (qPCR). All data will be submitted to statistical analysis.

Trial registration: This study is registered in ClinicalTrials.gov (ID: NCT04824612).

Burden of Keloid Disease: A Cross-sectional Health-related Quality of Life Assessment

Keloid scars may be painful, itch severely and be cosmetically disturbing. The burden of keloid disease, however, has not yet been determined. This study evaluated the association of keloid disease with health-related quality of life (HRQL) and identified indicators of burden using a cross-sectional survey study, with one disease-specific HRQL measure (Skindex-29) and 2 generic HRQL measures (SF-36 and EQ-5D-5L). A total of 106 keloid patients with no other skin diseases participated in the study. Having keloid disease was associated with a considerable impairment of emotional wellbeing, with most impairment on the emotional and mental HRQL. Pain and itch were the strongest indicators of HRQL impairment in keloid patients. Having painful or itchy keloids was related to low mental and emotional HRQL, implying that patients with keloids require access to effective treatment aimed at alleviating physical symptoms.

[The surgical treatment of scars]

Scars can be functionally or socially disabling. Many patients affected therefore request corrective surgery. The list of surgical techniques is long and the most frequently-used solutions are well-known.

Combination of Surgery and Intralesional Verapamil Injection in the Treatment of the Keloid

Keloid scars are one of the most challenging problems for physicians and surgeons. These scars have been treated in many ways, with varying success. Verapamil is a widely used calcium channel antagonist, and it has been shown that calcium channel blockers inhibit the synthesis/secretion of extracellular matrix molecules, including collagen, glycosaminoglycans, and fibronectin, and increase collagenase. In this study, we performed total keloid excision in combination with reconstruction with W-plasty or skin grafting and injection of verapamil hydrochloride into the lesions of 21 patients with keloids. Patients were followed for minimum of 2 years, and the treatment outcome was evaluated based on the cosmetic appearances, symptomatic improvements, and the results of microscopic examinations. Also, patient satisfaction was scored with a visual analog scale. Two years after the operations, two patients had keloid in lesser diameter than the original lesions, two patients had lesions that were hypertrophic scars in appearance, and four patients had pruritus. One patient had keloid on the donor site. The rate of patient satisfaction was 6.4 on a scale of 1 to 10. We reviewed the treatment of keloid in this study and obtained one of the lower rates of complication in the literature. We believe that surgical excision with W-plasty or skin grafting and intralesional verapamil injection may be a good alternative in the treatment of keloid.