Keloids, hypertrophic scars: re-examining treatment options

San Diego - Preventing and treating hypertrophic scars and keloid formation has always been a difficult task for dermatologists and cosmetic surgeons.

Recent advances in aesthetic medicine though, have borne hope for patients who have the propensity to develop these lesions.

Males and females are equally affected by these scars, which occur in 0.9 percent to 6 percent of the general population; darker skin people are two to 19 times more likely to develop keloids than lighter-complected people.

Today there are a multitude of therapy options for keloids, some more effective than others, depending on location and age of the lesion. The advent of lasers as well as steroids, surgery, cryotherapy, silicone products, radiation, pressure, immune response modifiers and 5-fluroruracil, as well as combination therapies, can all be used to combat keloids, with varying degrees of success.

Corticosteroids

According to Dr. Baldwin, intralesional corticosteroids are one of the cornerstones of keloid therapy.

Any treatment failures are most probably due to inadequate concentrations of the steroid injected. Treatment consists of monthly intralesional injections of triamcinolone 10 to 40 mg/cc.

"Corticosteroids are best used for sessile lesions, which are a high surgical risk," Dr. Baldwin says. "Corticosteroid treatment in pedunculated keloids will turn the lesion into a 'deflated balloon.' I have had good results in younger, softer lesions when starting the treatment on one pole and working over to the other. For optimal results in the harder, more mature keloids it is important to use a large bore needle, making multiple horizontal tracts without angling down. Here, I either advance the needle or push the needle, but not both, to avoid dumping steroids into the subcutaneous tissue."

For postoperative prevention of the occurrence and recurrence of keloids, Dr. Baldwin likes to inject 40 mg/cc into the base and walls of the excision site immediately post-op, with repeated injections every two weeks for two months, regardless of clinical appearance. She then follows up with monthly injections for six months, determining the dose and concentration according to the appearance of the lesion.

She says that the side effects of this treatment modality include expected hypopigmentation (which may last from six to 12 months), atrophy, telangiectasias (which vascular lasers can eradicate) and suppression of the adrenal axis if the monthly treatment dosage exceeds 40 mg. Also, the patient should understand that the treated area will never look normal, regardless of treatment received.

Surgery

Dr. Baldwin tells Dermatology Times that surgical techniques vary according to keloid size, location and shape.

Pedunculated lesions or those located in highly mobile skin are most amenable to surgical removal. Sessile lesions, on the other hand, are much more difficult and have a tendency to recur. If possible, dermatologists should seek other avenues of therapy in these cases.

Statistics show that with surgery as a monotherapy 50 percent to 100 percent and 39 percent to 42 percent of body and earlobe keloids, respectively, will recur. This number is reduced to 1 percent to 3 percent recurrence on the earlobe if the surgery is combined with the implementation of intralesional corticosteroids.

Lasers

Dr. Baldwin says that, theoretically, superpulsed CO₂ and Nd:YAG lasers decrease fibroblast proliferation and growth factor production in vitro, and vascular lasers act by coagulating enlarged vessels, potentially reducing lesion growth and improving erythema and symptoms.

Unfortunately though, these lasers have shown disappointing in vivo results, except for palliation.

Radiation therapy

The mode of action of radiation therapy (X-ray, electron beam and interstitial) is to inhibit fibroblasts and alter the vasculature.