Keloids

Management Strategy

The therapeutic options for keloids are numerous; however, there is no one modality that is considered to be universally safe and effective. Prevention of initial development and prevention of recurrence should be the main determinants in treatment selection. The initial rule of treatment involves prevention and patient education . It is of the utmost importance to close wounds with minimal tension and inflammation. Non-essential surgery, tattoos, and piercings should be avoided as keloids commonly develop in areas of high skin tension and incision sites in the mid-chest skin. Surgery overlying joints should be avoided, and surgical wounds should parallel skin creases. Areas of inflammatory skin diseases such as acne and folliculitis need to be treated.

Common therapeutic modalities include occlusive dressings, compression therapy, intralesional corticosteroid injections, intralesional interferon injections, intralesional 5-fluorouracil injections, cryosurgery, surgical excision, radiation therapy, and laser therapy. Because no single therapy is vastly superior or universally efficacious, combination therapies have led to the greater success rates. Radiation, occlusive dressings, topical imiquimod, and corticosteroid injections vary in effectiveness to reduce the high rate of keloid recurrence postsurgical excision (about 70%).

Intralesional corticosteroids have been the mainstay of treatment for keloids. The most commonly used is triamcinolone acetonide in concentrations of 10–40 mg/mL administered intralesionally with a 25- to 27-gauge needle at 4–6-week intervals. Topical corticosteroids and topically applied corticosteroid-impregnated tape are also used frequently; the basis for the latter involves recent data demonstrating that occlusion enhances percutaneous penetration of steroids by the formation of a drug reservoir within the stratum corneum. Silicone gel sheets and silicone occlusive dressings have anti-keloidal effects, which appear to be a result of hydration.

Pressure devices are thought to induce local tissue hypoxia and have been shown to have a thinning effect on keloids. A novel idea in the treatment of keloids and hypertrophic scars is the use of intralesional interferon -α _2b , which has been used successfully to reduce scar height and postoperative recurrences via a mechanism of collagen synthesis inhibition. Interferon -γ has also been evaluated in the treatment of keloids, with modest results.

Cryotherapy can be used as monotherapy or in conjunction with other treatment modalities, most commonly triamcinolone, with reported efficacy. Its mechanism of action involves the induction of vascular damage and tissue anoxia that ultimately leads to necrosis. However, some reported side effects have included hypopigmentation and postoperative pain. A specialized intralesional needle cryoprobe method has been recently reported to result in better efficacy and fewer side effects.

Radiation therapy has been used as monotherapy or as an adjuvant to surgical excision. The carcinogenesis risks of radiotherapy are extremely small; however, the concept of using potentially harmful radiation to treat benign lesions is a persistent and important issue.

Surgical excision alone yields widely varying results with high (55–100%) recurrence rates. The combination of surgical excision with other modalities, such as intralesional corticosteroids or with pressure dressings, X-ray therapy, interstitial radiation, and brachytherapy , reduces recurrence rates to a range of 10–50%.

CO ₂ and argon lasers were used in the treatment of keloids but have recently been replaced by the Nd:YAG and 585-nm pulsed-dye lasers because of their better efficacy and fewer adverse effects. Intralesional injection of 5-fluorouracil has been beneficial for hypertrophic scars and for keloids. Bleomycin , retinoic acid , intralesional verapamil , and mitomycin C have all been reported to have good efficacy in small clinical trials, but more clinical experience with these agents is needed.