Painless steroid injections for hypertrophic scars and keloids

KECORT Study: An International e-Delphi Study on the Treatment of KEloids Using Intralesional CORTicosteroids in Clinical Practice

BACKGROUND

Intralesional corticosteroid administration (ICA) is a first-line keloid treatment. However, it faces significant variability in current clinical and scientific practice, which hinders comparability of treatment results.

OBJECTIVES

The aim of the study was to reach consensus on different aspects of ICA using hypodermic needles in keloids among an international group of dermatologists and plastic surgeons specialized in keloid treatment to provide consensus-based clinical treatment recommendations for all physicians treating keloids.

METHODS

The keloid expert panel of 12 dermatologists and 11 plastic surgeons rated 30 statements. Two online e-Delphi rounds were held, both with a response rate of 100%. Fifteen (65%) keloid experts participated in the final consensus meetings. Consensus was defined as ≥ 75% of the participants choosing agree or strongly agree on a 7-point Likert scale.

RESULTS

Consensus was reached on treatment goals, indication for ICA, triamcinolone acetonide (TAC) 40 mg/mL as the preferred corticosteroid administered at a maximum of 80 mg per month and at intervals of 4 weeks, minimizing pain during ICA, the use of 1 mL syringes and 25 or 27 Gauge needles, blanching as endpoint of successful infiltration, caution of not injecting subcutaneously, and the option of making multiple passes in very firm keloids prior to infiltration. Consensus could not be reached on TAC dosing, methods of prior local anesthesia, and location of injection.

CONCLUSIONS

This e-Delphi study provides important clinical treatment recommendations on essential aspects of ICA in keloids. By implementing these recommendations, uniformity of ICA in keloid treatment will increase and better treatment results may be achieved.

Topical Anesthetic versus Lidocaine Mixture for Pain Relief During Keloid Treatment: A Prospective, Split Study

BACKGROUND

The most common typical symptoms of keloids can be pain and itchiness. Intralesional corticosteroid administration is generally the first-line conservative treatment. Minimizing pain during intralesional corticosteroid injections into keloids should be aimed, as the treatment is often painful. There has yet to be a report on which local anesthetic technique is superior in keloid treatment between topical anesthetic versus lidocaine mixture injection.

METHODS

This was a single-center prospective study. The study included 100 patients with painful multiple/multifocal keloids aged 18 to 85 years and was performed between May 2021 and December 2022. Among multiple keloid lesions in a single patient, we assigned the keloids pretreated with topical cream application versus local injection. Then, subjects received 40 mg of intralesional corticosteroid injections into the keloids with a 26G needle to treat keloids. Patients rated the pain intensity of each lesion pretreated with two different anesthetic techniques on an 11-point numeric rating scale. A separate direct question of "Which technique would you recommend if you had to be injected again?" was given.

RESULTS

One-hundred patients with painful multiple/multifocal keloids were included in the study. Data on pain intensity numeric rating scale (NRS) revealed that injection techniques relieved the pain statistically significantly more than topical creams. ( P <0.001) 63% of the participants (n=63) preferred the injection technique, while 25% preferred topical anesthetics. In total, 12% of patients responded that there was no difference between the two techniques.

CONCLUSION

When comparing with topical lidocaine/prilocaine (EMLA) cream, a 1:1 mixture of 1% lidocaine and epinephrine significantly alleviated pain during and after the corticosteroid injection.

A Topical Anesthetic and Lidocaine Mixture for Pain Relief During Keloid Treatment: A Double-Blind, Randomized Controlled Trial

BACKGROUND

Keloids are abnormal overgrowth of collagen fibers, and the first-line treatment includes intralesional injection of triamcinolone acetonide (TA), which is associated with pain.

OBJECTIVE

To study the benefit of applying topical anesthetics or a 1:1 mixture of 1% lidocaine and TA at the TA injection site to alleviate pain during keloid treatment.

METHODS AND MATERIALS

A double-blind, randomized controlled trial was conducted. Four TA injection methods were tested: control, lidocaine, topical, and combined. A visual analog scale (VAS) was used to assess needle-stick and injection pain. Data on pain duration after injection were also collected.

RESULTS

Forty patients were enrolled (mean age, 37.1 years). The VAS scores of needle-stick pain in the control, lidocaine, topical, and combined groups were 4.18 ± 2.12, 3.82 ± 2.48, 2.03 ± 2.02, and 2.20 ± 1.99, respectively. Pain statistically decreased in the topical and combined groups. Intralesional injection pain (VAS) scores in the control, lidocaine, topical, and combined groups were similar as follows: 4.97 ± 2.50, 4.97 ± 2.79, 4.10 ± 2.80, and 4.43 ± 2.68, respectively.

CONCLUSION

Application of topical anesthetics significantly relieved needle-stick pain, especially at sternum and auricular keloids; administration of a lidocaine mixture did not alleviate pain during injection.

Development of a porcine incisional wound model and novel scarring scales

A major goal of wound management is to reduce scarring. Prior to evaluating novel anti-scarring therapies, we developed a porcine incisional wound model and scarring outcome measures. Forty-eight full-thickness incisions (3 cm in length) and excisional wounds (3 x 0.5 cm) were created on two animals and closed with sutures (n=24) or tissue adhesive (n=24). Scars were evaluated using two validated clinical scar scales and a novel scale developed for animals. Full-thickness biopsies were obtained at 5 and 8 weeks for determination of scar morphology using H&E and Congo red staining with and without polarized light. Scar tissue was classified based on the collagen fiber morphology and "redness" ratio, which is a measure of the relative distribution of collagen fiber in all three spatial dimensions. The clinical cosmetic scales were highly reliable, yet nondiscriminatory. The novel gross cosmetic and histomorphological scores were both highly reliable (0.75 and 0.70, respectively), yet poorly correlated with each other (0.17). The "redness" ratio and cross-sectional surface area measurements were also highly reliable (r=0.96 and 0.99, respectively) but unrelated to cosmetic outcomes. However, the "redness ratio" did correlate with the histomorphologic appearance of the scars, with poorer appearing clinical scars receiving lower ratios (ANOVA p=0.001). Significant differences in cosmetic scores were noted between excisional and incisional wounds favoring incisions (p=0.0019). We describe a novel porcine model for incisional and excisional wounds. The new clinical and histomorphologic outcomes were highly reliable yet poorly correlated. In general, incisional wounds healed with less apparent scarring than excisional wounds.