By Gary M. White, MD
A keloid represents a nodular growth of scar tissue. In contrast to hypertrophic scars, keloids extend beyond the area of injury. The chest, shoulders, ears and upper back are common sites. There is no preference among the sexes. Darker-skinned patients are predisposed.
A firm, rubbery papule, nodule, or plaque develops at the site of trauma/injury. Over time, it grows to extend beyond the area of injury. Keloids are more common on the chest, upper back, shoulders, and ear lobes. On the chest, horizontal dermal plaques are typical.
The patient should accept the fact that therapy is designed to reduce the size of the keloid, but there will always be some sort of scar in the area ("Once a scar, always a scar."). Also, any inciting disease or trauma must be eliminated. Acne is the most common culprit here.
In a recent review of TMC (triamcinolone) and 5-FU (5-fluorouracil) treatment of keloids [Acta Derm Venereol 2015; 95: 778–782], the authors recommended "4:45 mg/ml TAC:5-FU combination therapy, injected intralesionally, until a satisfactory response is reached. It is likely that approximately 8 injections are needed." Most studies perform the injections weekly although varying the frequency of injections has not been formally studied. The above recommendation may be achieved using TAC 4 mg (0.1 ml of 40 mg/ml TAC) mixed with 5-FU 45 mg (0.9 ml of 50 mg/ml 5-FU) administered once weekly for a total of eight sessions.
IL injection with TMC is perhaps the most common treatment modality used. Concentrations of 20-40 mg/cc are needed. Injecting every 3-4 weeks is usually done. Anesthetizing the area with lidocaine beforehand greatly lessens pain. Buffer the lidocaine. Use a 30-gauge needle. Inject slowly underneath the keloid going around it in a ring block. If possible, inject underneath. Then wait 5 minutes.
When injecting keloids, inject into the papillary dermis where collagenase is produced. Check after each injection to make sure the needle isn't clogged. The standard intervention is triamcinolone 40 mg/cc every month and tapered as able. Some have recommended limiting to triamcinolone 40 mg per month, but this is equivalent to prednisone 50 mg so others use up to 80 mg in one setting. Even keloids on the face may need the maximum, TMC 40 mg/cc, but be cautious of atrophy. Try not to get into surrounding skin. Intralesional injection of keloids can be quite painful therefore pretreatment with EMLA or Ametop followed by ring block with injected lidocaine is recommended (or just do ring block).
IL 5-FU is commonly used to treat keloids. Most experts find better results with weekly or every other week injections [Dermatol Reports. 2015; 7: 5880]. Various studies show it as either equal or more effective than IL TMC. However, when injected weekly, side effects such as pain, ulceration, and hyperpigmentation may be more common [Indian J Surg 2012;74;326]. One study found the 5-FU/TMC mixture more effective than TMC alone [Clin Exp Dermatol. 2009;34:219] see above. As with IL TMC, ring block with lidocaine beforehand is recommended to reduce the pain. 5-FU comes 500 mg in 10 cc = 50 mg/cc--limit 2 cc per session. The patient must understand and agree to the fact that this is all off-label use of 5-FU. Patients must not be pregnant or lactating.
Postsurgery adjunctive therapy may take the form of radiation therapy which has the lowest recurrence rate postexcision, e.g., 2-10%. Radiation therapy may be started within a day of excision. In one study of surgery followed by radiation therapy of chest keloids with a low recurrence rate, XRT was given on the first and seventh days postoperation [Medicine (Baltimore) 2016 Aug; 95(35): e4684].
The one drawback to radiation therapy is the concern over the development of malignant tumors. Ogawa et al [Plast Reconstr Surg 2009;124:1196–1201] reported carcinogenesis attributable to the use of radiotherapy in a small percentage of cases. They concluded that radiotherapy is safe with adequate preventive measures, which are particularly crucial in delicate tissues such as the neck and mammary glands. Lundell et al [Radiat Res 1996;145:225–230] conducted a study of thousands of adults irradiated in childhood for infantile hemangiomas and found a greater incidence of thyroid and mammary gland cancer.
If surgery is considered, the following should be remembered. First, any excision, either by blade or laser, should remove the entire keloid, leaving only normal tissue. Second, any excision should be followed up by some adjunctive therapy, e.g., intralesional TMC, 5-FU, or radiation therapy as the recurrence rate after surgery alone is 70%. Finally, recurrences after surgery tend to be worse than the initial keloid and harder to treat. The keloids most amenable to surgery are either pedunculated or have a relatively small base and are older. Removal by either blade or laser has similar success rates. The resultant wound should either be closed with minimal tension or allowed to heal by secondary intention. Intralesional TMC may be injected every 2-4 weeks for 2-4 months postsurgery. In one review, IL 5-FU was more effective at preventing recurrences postexcision compared to IL triamcinolone [J Oral Maxillofac Surg. 2016 May;74(5):1055-60].
One study of shave excision of smaller keloids followed by imiquimod yielded a recurrence rate of 15%.
Compression bandages are useful but hard to use on most sites except the ears. Compression earrings are quite useful as they can be both attractive and apply significant pressure (e.g., Padgett Instruments, 800-842-1029). Another approach being investigated with good results so far is intralesional cryotherapy. A probe is attached to the cryotherapy device and the keloid is frozen from the inside. This helps to minimize surface skin changes. Topical imiquimod has not been shown in any well-controlled trial to prevent keloids although some clinicians still use it along with injection.
The mid chest is a very common location for excessive scarring.
Keloid resistant to multiple injections of TMC 40 and 5-FU.
Before and after shave biopsy.
Here is a stylish pressure earring being worn post shave biopsy of a keloid.
The side of the foot is a very unusual location for a keloid (biopsy proven).
Injecting a steroid can flatten out the keloid, but does not necessarily fix the color. Deposition of steroid powder as shown here (white) may sometimes occur.
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