Intralesional cryotherapy versus excision with corticosteroid injections or brachytherapy for keloid treatment: Randomised controlled trials

Effect of Keloid Properties on Treatment Efficacy, a Systematic Review

BACKGROUND

The efficacy of keloid treatment in randomized studies is highly variable. However, no systematic review has been performed to evaluate the effect of different keloid properties on treatment efficacy.

OBJECTIVE

To identify clinically relevant keloid properties that may influence treatment efficacy.

MATERIALS AND METHODS

An electronic database search was conducted. Two reviewers independently selected randomized controlled trials (RCTs) and performed a methodologic quality assessment using the Cochrane risk-of-bias 2.0 tool.

RESULTS

One thousand five hundred twenty studies were screened, and 16 RCTs, involving 1,113 patients, were included. The authors found lower efficacy in older keloids ( n = 3), keloids located on the chest, extremities, pinna, and shoulder ( n = 3), larger keloids ( n = 2), lower baseline Vancouver Scar Scale score ( n = 1), and keloids with history of recurrence ( n = 1). Overall, most studies had a high risk of bias.

CONCLUSION

Only a minority of studies specifically addressed keloid properties, which makes comparisons between studies challenging. The authors' results suggest that keloid location, duration prior to treatment, size, history of recurrence, and severity are clinically relevant keloid properties that affect treatment efficacy. Further studies are crucial to corroborate the authors' findings, establish a clinically relevant keloid classification, and ultimately develop an evidence-based treatment algorithm that takes these properties into account.

Pharmacotherapy for Keloids and Hypertrophic Scars

Keloids (KD) and hypertrophic scars (HTS), which are quite raised and pigmented and have increased vascularization and cellularity, are formed due to the impaired healing process of cutaneous injuries in some individuals having family history and genetic factors. These scars decrease the quality of life (QOL) of patients greatly, due to the pain, itching, contracture, cosmetic problems, and so on, depending on the location of the scars. Treatment/prevention that will satisfy patients' QOL is still under development. In this article, we review pharmacotherapy for treating KD and HTS, including the prevention of postsurgical recurrence (especially KD). Pharmacotherapy involves monotherapy using a single drug and combination pharmacotherapy using multiple drugs, where drugs are administered orally, topically and/or through intralesional injection. In addition, pharmacotherapy for KD/HTS is sometimes combined with surgical excision and/or with physical therapy such as cryotherapy, laser therapy, radiotherapy including brachytherapy, and silicone gel/sheeting. The results regarding the clinical effectiveness of each mono-pharmacotherapy for KD/HTS are not always consistent but rather scattered among researchers. Multimodal combination pharmacotherapy that targets multiple sites simultaneously is more effective than mono-pharmacotherapy. The literature was searched using PubMed, Google Scholar, and Online search engines.

Recurrence and Complications of Peri-operative Steroid Injection of Keloids: A Systematic Review and Meta-analysis

Keloid scars are a particularly challenging fibroproliferative wound healing disorder with a variety of proposed management approaches including concurrent surgery and intralesional steroid injection. We aimed to identify the optimum time for triamcinolone injection of keloids, by comparing the recurrence and complication occurrence in patients who received pre-, intra- or post-operative injection. Studies reporting on the rate of recurrence and complication occurrence following treatment of keloid scarring with concurrent surgical excision and intralesional steroid injection were identified from the PubMed, Web of science and Embase databases. The I-squared (I2) statistic was used to quantify the variability in study estimates due to heterogeneity and to determine whether the fixed or random effect models will be employed. Publication bias was visualized through funnel plots and tested with the Egger's test. We found that the recurrence rate was significantly lower with post-operative injection compared to intra-operative injection (p < 0.001) and pre-operative injection (p = 0.009). A significant difference between intra-operative and pre-operative injection was not found (p = 0.46). In conclusion, post-operative steroid injection after surgical excision results in lower keloid recurrence compared to pre- and intra-operative injection.Level of Evidence IV "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Analysis of subsets and localization of macrophages in skin lesions and peripheral blood of patients with keloids

Keloids are a type of abnormal fibrous proliferation disease of the skin, characterized by local inflammation that lacks clear pathogenesis and satisfactory treatment. The phenomenon of distinct phenotypes, including M1 and M2 macrophages, is called macrophage polarization. Recently, macrophage polarization has been suggested to play a role in keloid formation. This study aimed to evaluate the relation between macrophage polarization and keloids and identify novel effective treatments for keloids. Differentially expressed genes were identified via RNA sequencing of the skin tissue of healthy controls and patients with keloids and validated using quantitative PCR. Multiplex immunofluorescence microscopy was used to detect different phenotypes of macrophages in keloid tissues. Finally, quantitative PCR validation of differentially expressed genes and flow cytometry were used to analyze macrophages in the peripheral blood of healthy controls and patients with keloids. Total and M2 macrophages were significantly increased in the local skin tissue and peripheral blood of patients with keloids compared with healthy controls. In addition, inflammation- and macrophage polarization-related differentially expressed genes in keloid tissue showed similar expression patterns in the peripheral blood. This study highlighted an increased frequency of total macrophages and M2 polarization in the local skin tissue and peripheral blood of patients with keloids. This systematic macrophage polarization tendency also indicates a potential genetic predisposition to keloids. These findings suggest the possibility of developing new diagnostic and therapeutic indicators for keloids focusing on macrophages.

Efficacy of surgical resection and ultra-reduced tension suture combined with superficial radiation in keloid treatment

BACKGROUND

There are many available treatment options for keloid; however, single treatments are usually less effective. Therefore, more scientifically rational and effective combined treatment methods should be sought to solve the pain associated with keloids.

AIM

To explore the efficacy and safety of surgical resection and ultra-reduced tension suture combined with superficial radiation as keloid treatment.

METHODS

Fifteen keloid patients admitted to Qingdao Eighth People's Hospital from June 2020 to January 2022 were enrolled in this retrospective analysis. All patients underwent a comprehensive treatment approach comprising surgical resection, ultra-reduced tension suture incision, and superficial radiation therapy within 24 h postoperatively. The modified Vancouver Scar Scale (mVSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to evaluate the treatment effect, whereas the efficacy, adverse effects, and recurrence rate were observed according to the 12-mo follow-up after treatment.

RESULTS

The mVSS and POSAS scores at 1 and 6 mo after combination treatment decreased compared to before treatment (P < 0.001), and the overall response rate was 93.3%. Only one case recurred, yielding a 6.7% recurrence rate. The incidence of local chromour sedimentation rate in 1-3 mo after radiotherapy was 33.3% (5 patients), all subsiding after 6-9 mo, without complications, such as delayed wound healing or dermatitis.

CONCLUSION

Surgical resection, super subtraction sutures, and superficial radiotherapy are treatment methods with short courses, low recurrence rates, and good safety profiles.

Revealing the roles of glycosphingolipid metabolism pathway in the development of keloid: a conjoint analysis of single-cell and machine learning

Keloid is a pathological scar formed by abnormal wound healing, characterized by the persistence of local inflammation and excessive collagen deposition, where the intensity of inflammation is positively correlated with the size of the scar formation. The pathophysiological mechanisms underlying keloid formation are unclear, and keloid remains a therapeutic challenge in clinical practice. This study is the first to investigate the role of glycosphingolipid (GSL) metabolism pathway in the development of keloid. Single cell sequencing and microarray data were applied to systematically analyze and screen the glycosphingolipid metabolism related genes using differential gene analysis and machine learning algorithms (random forest and support vector machine), and a set of genes, including ARSA,GBA2,SUMF2,GLTP,GALC and HEXB, were finally identified, for which keloid diagnostic model was constructed and immune infiltration profiles were analyzed, demonstrating that this set of genes could serve as a new therapeutic target for keloid. Further unsupervised clustering was performed by using expression profiles of glycosphingolipid metabolism genes to discover keloid subgroups, immune cells, inflammatory factor differences and the main pathways of enrichment between different subgroups were calculated. The single-cell resolution transcriptome landscape concentrated on fibroblasts. By calculating the activity of the GSL metabolism pathway for each fibroblast, we investigated the activity changes of GSL metabolism pathway in fibroblasts using pseudotime trajectory analysis and found that the increased activity of the GSL metabolism pathway was associated with fibroblast differentiation. Subsequent analysis of the cellular communication network revealed the existence of a fibroblast-centered communication regulatory network in keloids and that the activity of the GSL metabolism pathway in fibroblasts has an impact on cellular communication. This contributes to the further understanding of the pathogenesis of keloids. Overall, we provide new insights into the pathophysiological mechanisms of keloids, and our results may provide new ideas for the diagnosis and treatment of keloids.

Ear Keloids Treated with Postoperative Electrons: A Case Series

Introduction Multiple modalities exist for treating keloids ranging from surgical, medical, chemotherapeutic, and radiation therapy. Different techniques of radiation therapy have been used to treat keloids as an adjuvant to surgical excision. With this case series, we report our experience of using electron beam radiation therapy in this setting.

Materials and Methods We retrospectively analyzed 16 ear keloids treated in 10 patients from January 2013 to October 2015 with surgical excision followed by electron beam to a dose of 10 Gy in two fractions over two consecutive days in immediate postoperative period. Patients were evaluated for recurrent lesions, cosmesis, and adverse effects.

Results With a median follow-up of 78 months (range: 67–100 months), recurrent lesion was seen in five cases; a local control rate of 68.75% was seen. Median recurrence-free period was 67 months (range: 12–100 months). Acceptable cosmesis was seen in all cases and no acute or chronic adverse effects were seen.

Conclusion The large follow-up period in our series establishes the role of electron beam radiation therapy in attaining long-term control in keloid patients. The lower total dose with higher dose per fraction used in our patients has acceptable control along with good cosmesis and absent adverse effects.

Single-Cell Sequencing Analysis and Weighted Co-Expression Network Analysis Based on Public Databases Identified That TNC Is a Novel Biomarker for Keloid

Background

The pathophysiology of keloid formation is not yet understood, so the identification of biomarkers for kelod can be one step towards designing new targeting therapies which will improve outcomes for patients with keloids or at risk of developing keloids.

Methods

In this study, we performed single-cell RNA sequencing analysis, weighted co-expression network analysis, and differential expression analysis of keloids based on public databases. And 3 RNA sequencing data from keloid patients in our center were used for validation. Besides, we performed QRT-PCR on keloid tissue and adjacent normal tissues from 16 patients for further verification.

Results

We identified the sensitive biomarker of keloid: Tenascin-C (TNC). Then, Pseudotime analysis found that the expression level of TNC decreased first, then stabilized and finally increased with fibroblast differentiation, suggesting that TNC may play an potential role in fibroblast differentiation. In addition, there were differences in the infiltration level of macrophages M0 between the TNC-high group and the TNC-low group. Macrophages M0 had a higher infiltration level in low TNC- group (P<0.05).

Conclusion

Our results can provide a new idea for the diagnosis and treatment of keloid.

Combined versus single treatment regimens for keloid therapy using serial intralesional corticosteroid injections, surgical excision, silicone- and/or cryotherapy

Efficacy comparison of several regimens in treating keloids as combined or standalone therapies could provide essential information for selecting appropriate therapy. This study retrospectively evaluated the treatment efficacy of corticosteroid injections, excision, silicone, cryotherapy, or combinations of these for treating keloids. Additionally, the use of corticosteroid injection schemes and combined cryotherapy regimens were analysed.

Retrospective chart analysis was performed on 204 keloids treated patients at the plastic surgery department of the Máxima Medical Centre between 2009 and 2018. The patient's age, gender, treatment, anatomic location, scar aetiology, previous therapy, scar recurrence, additional therapy, and follow-up duration were retrieved. Treatment efficacy was assessed through treatment failure, defined by the recurrence or lack of response. Kaplan–Meier and Cox survival analyses were performed to compare treatment efficacy between the different regimens.

Monotherapies exhibited a significantly higher chance of treatment failure (HR 2.4, 95% CI 1.4–4.2, p<0.05) when compared to combined therapies.

Sporadic corticosteroid injections demonstrated more treatment failure overall (HR 3.5 95% CI 1,6–7,3; p=0.001), but did not differ significantly from injection schemes.

Combined cryotherapy efficacy did not differ significantly from the other combined regimens (HR 1,6 95% CI 0,5–5,1; p=0.401).

Combined therapies exhibited clear superiority over monotherapies. Sporadic corticosteroid injections demonstrated inferior results compared to all other therapies. Combined cryotherapy cases were insufficient, and more data are required for proper assessment. Future prospective assessments of corticosteroid injection schemes and combined regimens are warranted.

Suppurative keloids: a complication of severe keloid disease

BACKGROUND

Some keloids show cystic cavities that give rise to acute inflammatory flares and oozing. These suppurative keloids (SK) have rarely been systematically studied. We conducted a retrospective cohort study to evaluate SK frequency and its risk factors. We also reviewed microbiological analyses as well as the histological features of removed SKs.

METHODS

Between July 1, 2015, and September 30, 2016, all adult patients attending a specialized keloid clinic were asked to participate. Clinical information and microbiological results were extracted from each patient's file. Histological features were observed and interpreted.

RESULTS

In this study, we observed an SK rate of 26% for a mean keloid history of 17.2 years. Male gender, African ancestry, and a family history of keloids were significantly associated with suppuration. Microbiological examination revealed commensal skin flora 7/9 (77.8%), Staphylococcus aureus 1/9 (11.1%), and Enterococcus faecalis 1/9 (11.1%).

CONCLUSION

Suppuration is a common complication of keloids occurring in patients with severe keloid disease and may arise from pilosebaceous occlusion and aseptic inflammation.

Scoping Review of Therapeutic Strategies for Keloids and Hypertrophic Scars

Background:

Keloids are an abnormal proliferation of scars that can involve large areas of tissue beyond the original injury site. Hypertrophic scars are similar clinically, but do not exceed the original scar limits. These scarring abnormalities can cause noxious symptoms such as pain, tenderness, itching, and ulcerations. The aim of this review is to discuss current therapies for both types of abnormal scarring, and to determine if guidelines can be provided for excisional treatment with adjuvant therapies versus non-excisional methods.

Methods:

A systematic literature search was performed through the Web of Science database. The search revolved around keywords such as “keloid,” “hypertrophic scars,” and “treatment.” Articles were reviewed and screened for inclusion and exclusion criteria. The review focuses on an analysis and summarization of randomized control trials regarding keloid or hypertrophic scar treatments.

Results:

The original searches produced 1161 and 1275 articles for keloid and hypertrophic scars, respectively. In total, 316 duplicates were found. After accounting for 2014–2019 publication time, 655 keloid and 893 hypertrophic scar articles were reviewed. This resulted in 15 articles that pertained to treatment and randomized control trials.

Conclusions:

Keloids and hypertrophic scars present a clinical challenge. Based on qualitative review of recurrence, neither excision plus adjuvant therapy or nonsurgical treatments can be recommended preferentially at this time. More research is needed to determine if recurrence rate bias exists between the treatment regimens, as excisional treatment plus adjuvant therapy is reserved for refractory scars.

The Efficacy of Surgical Excision Plus Adjuvant Multimodal Therapies in the Treatment of Keloids: A Systematic Review and Meta-Analysis

BACKGROUND

Research evaluating the efficacy of multimodal therapy for the treatment of keloids has reported combination regimens are most effective.

OBJECTIVE

To compare recurrence rates for keloids treated with surgery plus one adjuvant intervention (dual therapy) versus surgery plus 2 or more adjuvant interventions (triple therapy).

MATERIALS AND METHODS

Systematic literature review and meta-analysis of combination treatment for keloids.

RESULTS

After full-text review, we included 60 articles representing 5,547 keloids: 5,243 received dual therapy, 259 received triple therapy, and 45 received quadruple therapy (the latter 2 groups were combined for analysis). The difference in recurrence rates between dual (19%) and triple therapy (11.2%) was not significant (p = .343). However, the difference in recurrence rates between dual therapy using surgery and radiation (18.7%) and triple therapy using surgery, radiation, and a third intervention (7.7%) was significant (p = .002). The differences for surgery and intralesional triamcinolone (TAC) showed trends toward significance, because keloids treated with dual therapy (21.7%) had a higher recurrence rate than those treated with triple therapy comprised of surgery, TAC, and another intervention (13.7%; p = .099).

CONCLUSION

Triple therapy using surgery plus radiation and/or TAC as one of the adjuvant treatment modalities may achieve the lowest recurrence rates for keloids.

Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy

INTRODUCTION

We evaluate a single center's, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT).

STUDY DESIGN

Patients undergoing keloid treatment were identified (2008-2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications.

RESULTS

284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1-53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6-30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE + RT group.

CONCLUSIONS

MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.

A Review of Current Keloid Management: Mainstay Monotherapies and Emerging Approaches

Commonly affecting those with skin of color, keloids are an aberrant wound response that leads to wound tissue expanding above and beyond the original cutaneous injury. Keloids are notoriously and particularly difficult to treat because of their tendency to recur after excision. The current standard of care is intralesional steroid (triamcinolone acetonide). However, because no therapy has yet proven to be fully curative, keloid treatments have expanded to include a number of options, from injections to multimodal approaches. This review details current treatment of keloids with injections (bleomycin, verapamil, hyaluronic acid and hyaluronidase, botulinum toxin, and collagenase), cryotherapy, laser, radiofrequency ablation, radiation, extracorporeal shockwave therapy, pentoxifylline, and dupilumab.

Combined surgical excision and electron external beam radiation improves the treatment of keloids: A descriptive study

Keloids are firm, fibrous nodules that form on an individual's skin and are associated with difficult symptoms as well as high recurrence rates. This study aims to improve the surgical techniques that reduce local tension after surgical excision of keloids as well as applying adjuvant radiotherapy to suppress scar formation. A total of 58 patients aged between 21 and 76 years received surgical incision of keloid and immediate postoperation low-dose radiotherapy. All patient follow-ups were performed at the out-patient department. Any sign of a keloid at the incision site was defined as treatment failure or keloid recurrence, regardless of the size. At a median follow-up of 22 months, the overall recurrence for all lesions was 8.6%, which is improved compared with previous study. In addition, all incisions performed during surgeries were healed and no signs of necrosis or the development of ulcers was observed. Our study suggests that this combined therapy provides excellent local control of keloids and shows promise for future therapy.

A novel experimental model for studying efficacy of cryosurgery in keloids

BACKGROUND

Intralesional cryosurgery is effective in the treatment of keloids; however, clinical studies have presented diversified results.

OBJECTIVE

A novel, reproducible model for biophysical studies on intralesional cryosurgery of keloids is presented.

METHODS

Triplicate studies with a cryosurgical needle on 37°C-heated potatoes, which exhibit identical specific heat and similar heat conductivity with human skin, were performed.

RESULTS

No complete potato freezing resulted through a cryosurgical needle. The limited tissue damage achieved had a double concave form. The needle induced lower temperature and stronger tissue damage at the distal exit than the proximal entrance site. The concave form of tissue damage flattened with time at the area under the needle. Needle freezing with puncture distances of 0.5, 1.0 and 1.5 cm from the potato surface only revealed freezing temperatures within the 0.5 cm range. At any needle depth, tissue damage was detected at only an area to about 1 cm under the needle.

CONCLUSION

Clinical extrapolation of these experimental findings indicates a proper needle positioning towards the keloid basis, shows keloid volume freezing limitations by a single needle and corroborates the observations of minor epidermal and deep dermal damage induced by intralesional cryosurgery.

[Focused ultrasound therapy for reducing recurrence of vulvar lichen simplex chronicus in rats: efficacy and mechanism]

OBJECTIVE

To explore the changes of collagen fibrosis in the vulva skin of SD rats with lichen simplex chronicus (LSC) after focused ultrasound therapy and explore the mechanism by which focused ultrasound reduces the recurrence of vulvar LSC.

METHODS

Fifty female SD rat models of vulvar LSC were established and randomly divided into the treatment group and the control group (n=25) for treatment with focused ultrasound and sham treatment, respectively. Before and after the treatment, vulvar skin tissues were sampled to observe the pathological changes with HE staining and assess the density of collagen fibers using Masson staining. The ultrastructure of the collagen fibers in the superficial dermis was observed using transmission electron microscopy. The expressions of notch1 and c-fos in the vulvar tissue were detected by immunohistochemistry and Western blotting.

RESULTS

After 4 weeks of focused ultrasound therapy, 16% (4/25) of the rats in the treatment group showed lesion progression to LSIL, 4% (1/25) still had LSC, and 80% (20/25) showed normal vulvar skin. In the control group, progression to LSIL occurred in 19 (76%) rats, 3 (12%) rats still showed LSC, and only 3 (12%) had normal vulvar skin. The difference in the cure rate differed significantly between the two groups (P < 0.05). The density of collagen fibers in the superficial dermis and the expressions of notch1 and c-fos in the vulvar skin were significantly lower in the treatment group than in the control group (P < 0.05).

CONCLUSIONS

Focused ultrasound therapy can inhibit superficial collagen fibrosis of the dermis by lowering the expressions of notch1 and c-fos in the vulvar skin to reduce the recurrence of vulvar LSC in rats.

AMF siRNA treatment of keloid through inhibition signaling pathway of RhoA/ROCK1

A keloid (KD) is a benign dermal fibrotic tumor. Treatment of KDs is challenging and the recurrence rate is high; thus, there is an unmet need to explore new target sites and new treatment methods. As a tumor-associated cytokine, autocrine motility factor (AMF) can effectively stimulate the random and directional movement of cells. We first found that AMF was overexpressed in keloid fibroblasts (KFs) and the proliferation and migration of KFs were promoted by AMF stimulation. After treatment with Y-27632, RhoA kinase inhibitor, the proliferation and migration capacity of KFs declined significantly, and type I collagen protein, active RhoA and ROCK1 also were downregulated. In addition, a KD transplantation model was established under the skin of nude mice, with KD intramural injection AMF siRNA, we found that the weight of the KD was smaller than in the control group (P < 0.05), KD tissue sections stained by HE and Masson showed that fibers became loose and the blood vessels were visibly reduced. In conclusion, AMF siRNA is expected to be a novel strategy to treat KD by inhibiting signaling pathway of RhoA/ROCK1.