A comparative study of various modalities in the treatment of keloids

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.

Hyaluronidase: A New and Powerful Ally for Post-Rhinoplasty Fibrosis

Rhinoplasty outcome may depend on different factors: patient's selection, technique, surgeons' skills and patient's healing. Different surgical maneuvers can be performed in order to reduce post-operative risk of fibrosis such as dead spaces' closure, sub-perichondral and subperiosteal dissection and nasal ligaments preservation or reconstruction. However, in some patients, especially the ones with thick and sebaceous skin, these maneuvers may not be enough. Here we propose a new alternative to treat post-rhinoplasty fibrosis using a combination of Triamcinolone Acetonide and Hyaluronidase. LEVEL OF EVIDENCE V: 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 .

A Scoping Review of Hyaluronidase Use in Managing the Complications of Aesthetic Interventions

BACKGROUND

Hyaluronidase is used as an adjunct or main treatment to manage complications associated with cosmetic hyaluronic acid (HA) filler injections such as necrosis, blindness, hypersensitivity, delayed nodules, and poor aesthetic outcomes.

OBJECTIVE

To systematically map the available evidence and identify the gaps in knowledge on the effectiveness of hyaluronidase use in managing the aesthetic complications associated with HA injections (vascular occlusion, blindness, nodules, delayed hypersensivity, granuloma, poor aesthetic outcome).

METHODS

PubMed, Medline, Embase and Cochrane databases were used up to May 2022, to look for randomized clinical trials (RCTs), clinical trials, and retrospective case-control studies reporting on the use of hyaluronidase for managing the HA filler injection complications.

RESULTS

The database search yielded 395 studies; of those 5 RCTs (all carried out in the USA) were selected (53 subjects), indicating the effectiveness of hyaluronidase for removal of un-complicated injected HA nodules (forearm, upper arm, or back skin). The follow-ups ranged from 14 days to 4 years. The amount of HA filler injected into each site varied from 0.2 to 0.4 mL. A dose dependent response was observed for most HA fillers. No major adverse reactions were reported. Overall, for removal of every 0.1 mL of HA filler they injected 1.25-37.5 units of hyaluronidase (single injections). When 3 consecutive weekly hyaluronidase injection was used much lower doses of 0.375-2.25 unit was utilised. There was no evidence in a form of RCTs, clinical trials, and retrospective case-control studies on the removal/reversal of HA injections in the facial skin, or management of over-corrections, inflammatory nodules, or tissue ischemia/necrosis associated with HA filler injection.

CONCLUSION

Based on studies on the forearm, upper arm and back skin, hyaluronidase can be used for the reversal of uncomplicated HA filler injection nodule. However, further adequately powered studies are warranted to establish the ideal treatment protocol/dose of hyaluronidase for reversal of HA filler injections in the facial region or management of complications associated with aesthetic HA injection.

LEVEL OF EVIDENCE III

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 .

Combining scar-modulating agents for the treatment of hypertrophic scars and keloids: A systematic review

Injury to the skin can cause abnormal wound healing and continuous inflammation that leads to the formation of hypertrophic scars and keloids. These lesions often cause significant negative impact on a patient's life due to aesthetic, physical, social, and psychological consequences. Numerous treatment modalities exist for these hypertrophic scars and keloids, which include silicone sheeting, pressure garments, intralesional injection/topical application of scar-modulating agents, laser therapy, and surgical excision. Due to increased efficacy, an evolving treatment paradigm encourages the use of multiple treatment modalities instead of one treatment modality. However, no gold standard treatment exists for these lesions, leaving many people with unsatisfactory results. Adding scar-modulating agents such as 5-Fluorouracil, bleomycin, or Botulinum Toxin A to triamcinolone monotherapy has emerged as a potential drug combination for treating hypertrophic scars and keloids. We sought to critically analyze the evidence that exists for the use of more than one scar-modulating agent. This was done by conducting a systematic review to determine the efficacy of these combined drug regimens. We found that many of these combinations show evidence of increased efficacy and fewer/similar adverse events to triamcinolone monotherapy. Triamcinolone and 5-Fluorouracil showed the strongest and most consistent evidence out of all combinations. With this review, we intend to encourage more research into unique drug combinations that may improve outcomes for patients with symptomatic hypertrophic scars or keloids.

Natural History of Keloids: A Sociodemographic Analysis Using Structured and Unstructured Data

INTRODUCTION

Keloids are lesions characterized by the growth of dense fibrous tissue extending beyond original wound boundaries. Research into the natural history of keloids and potential differences by sociodemographic factors in the USA is limited. This real-world, retrospective cohort study aimed to characterize a population of patients with keloids compared with matched dermatology and general cohorts.

METHODS

Patients with ≥ 2 International Classification of Diseases codes for keloid ≥ 30 days apart and a confirmed keloid diagnosis from clinical notes enrolled in the OM1 Real-World Data Cloud between 1 January 2013 and 18 March 2022 were age- and sex-matched 1:1:1 to patients without keloids who visited dermatologists ("dermatology cohort") and those who did not ("general cohort"). Results are presented using descriptive statistics and analysis stratified by cohort, race, ethnicity, household income, and education.

RESULTS

Overall, 24,453 patients with keloids were matched to 23,936 dermatology and 24,088 general patients. A numerically higher proportion of patients with keloids were Asian or Black. Among available data for patients with keloids, 67.7% had 1 keloid lesion, and 68.3% had keloids sized 0.5 to < 3 cm. Black patients tended to have larger keloids. Asian and Black patients more frequently had > 1 keloid than did white patients (30.6% vs. 32.5% vs. 20.5%). Among all patients with keloids who had available data, 56.4% had major keloid severity, with major severity more frequent in Black patients. Progression was not significantly associated with race, ethnicity, income, or education level; 29%, 25%, and 20% of the dermatology, keloid, and general cohorts were in the highest income bracket (≥ US$75,000). The proportion of patients with income below the federal poverty line (< US$22,000) and patterns of education level were similar across cohorts.

CONCLUSION

A large population of patients in the USA with keloids was identified and characterized using structured/unstructured sources. A numerically higher proportion of patients with keloids were non-white; Black patients had larger, more severe keloids at diagnosis.

Comparative Efficacy of Drug Interventions for Keloids: A Network Meta-analysis

BACKGROUND

Keloids are common benign skin lesions originating from a disorganized fibroproliferative collagen response; these lesions often lead to both physical and psychological problems. The optimal treatment for keloids is yet to be standardized. Intralesional injection, which is simple and nontraumatic, is one of the most commonly used treatment modalities for these lesions. In this study, we compared 5 different drugs (intralesional injections) for the treatment of keloids in terms of efficacy.

METHODS

We systemically searched relevant studies on PubMed, EMBASE, and Cochrane Library. Randomized clinical trials on the safety and efficacy of triamcinolone acetonide (TAC), 5-fluorouracil (5-FU), botulinum toxin A (BTA), verapamil, and bleomycin were included in this study.

RESULTS

This network meta-analysis included a total of 1114 patients from 20 randomized controlled trials. Botulinum toxin A alone and TAC plus 5-FU exhibited significantly better efficacy than did 5-FU, TAC, and verapamil. No significant difference in efficacy between BTA alone and TAC combined with 5-FU was observed. No significant differences were noted in the adverse event rate between BTA, TAC plus 5-FU, 5-FU, and TAC. Furthermore, we performed surface under the cumulative ranking curve analyses to predict the rank of each intervention (by efficacy and adverse event rate). The predicted ranking by efficacy was as follows: TAC plus 5-FU, BTA, bleomycin, TAC, 5-FU, and verapamil; the predicted ranking by adverse events was as follows: TAC, 5-FU, TAC plus 5-FU, and BTA. Funnel plot analysis revealed no publication bias.

CONCLUSIONS

Botulinum toxin A and TAC plus 5-FU appear to have outstanding therapeutic efficacy for keloids. The rate of adverse events was similar among BTA, TAC, 5-FU, and TAC plus 5-FU. Nonetheless, additional reviews of rigorous, large-scale randomized controlled trials are warranted for further validation of our findings.

Recurrence rates in the treatment of keloids and hypertrophic scars with intralesional triamcinolone combined with other intralesional agents

Hypertrophic scars (HTS) and keloids are pathologic scars that are products of a wound healing pathway error attributed to genetic and inflammatory causes (Leventhal et al., Arch Facial Plast Surg 8(6):362-368. https://doi.org/10.1001/archfaci.8.6.362 , 2006). Methods of pathologic scar treatment include intralesional agents, cryotherapy, surgical excision, pressure dressings, topical agents, laser resurfacing, radiotherapy, and other investigational therapies (Leventhal et al. 2006). The recurrence of pathologic scar is high across all treatment modalities, including the use of intralesional agents (Trisliana Perdanasari et al., Arch Plast Surg 41(6):620-629. https://doi.org/10.5999/aps.2014.41.6.620 , 2014). In the treatment of pathologic scar, combination approaches using intralesional agents, such as triamcinolone (TAC), 5-fluorouracil (5FU), verapamil (VER), bleomycin (BLM), and botulinum toxin (BTX), are superior therapies when compared to monotherapy (Yosipovitch et al., J Dermatol Treat 12(2):87-90. https://doi.org/10.1080/095466301317085363 , 2001; Yang et al., Front Med 8:691628. https://doi.org/10.3389/fmed.2021.691628 , 2021; Sun et al., Aesthetic Plast Surg 45(2):791-805. https://doi.org/10.1007/s00266-019-01570-8 , 2021). This review assesses recurrence and the reporting of recurrence in pathologic scar after treatment with intralesional triamcinolone (TAC) in combination with another intralesional agent. A literature review was conducted using research journals from PubMed using the following search terms: [(keloid) AND (triamcinolone) AND (combination) AND (intralesional)], as well as [(keloid) AND (triamcinolone) AND (combination)]. Articles were reviewed and included if the article analyzed  or compared intralesional agents for pathologic scar treatment within the last 10 years. The average follow-up period of included articles (n = 14) that utilized combination intralesional therapy (TAC-X) was approximately 11 months (range 1-24 months). Consistent recurrence rate reporting across studies was lacking. The combination agent with the highest recurrence rate was TAC-5FU (23.3%). The range of reported recurrence rates was 7.5-23.3%. Six studies using various intralesional combination regimens reported 0% recurrence over the follow-up period (TAC-5FU, TAC-BTX, TAC-BLM, TAC-CRY). Three studies did not report recurrence rates. While the efficacy of combination therapy is typically assessed via scar scales, the assessment of recurrence across studies of combination therapy is inconsistent and inadequate, with truncated follow-up periods. While scar recurrence can take place during 1-year post-treatment, long-term follow-up (18-24 months) is needed to characterize recurrence in the treatment of pathologic scar using various intralesional agents. Long-term follow-up periods allow patients to receive accurate prognostic information regarding recurrence after combination intralesional therapy. There are limitations to this review in that comparisons were made across studies with varying outcome variables, including scar size, injection concentration and interval, and follow-up period. Standardized follow-up periods and recurrence rate reporting are integral to furthering the understanding of these therapies and enhancing patient care.

Comparing intralesional triamcinolone and verapamil-triamcinolone injections in keloids: A single-blinded randomised clinical trial

INTRODUCTION

In this clinical trial, we investigated the efficacy of two treatment methods for keloids resulting from surgical incisions: intralesional triamcinolone injections alone versus in combination with verapamil.

MATERIAL AND METHODS

Patients were divided into two groups: one received triamcinolone alone (Group T) and the other received a triamcinolone-verapamil blend (Group VT). Regular treatments were conducted until the keloids were nearly flat or for a maximum of eight sessions.

RESULTS

Both groups showed significant improvements, but Group VT saw quicker resolution of skin redness and needed fewer sessions. Though the Vancouver Scar Scale (VSS) scores were generally similar across both groups, Group VT exhibited greater improvements, leading to lower final scores. The VT group also attained normal scar flexibility faster than the T group.

CONCLUSION

These findings suggest that the combination of verapamil and triamcinolone provides a more effective treatment for keloids, thereby highlighting the potential of verapamil in scar reduction.

Clinical Features and the Outcome Evaluations of Keloid and Hypertrophic Scar Treatment with Triamcinolone Injection in Mekong Delta, Vietnam - A Cross-Sectional Study

Background

Excessive scarring is a common problem that can have significant cosmetic and psychological consequences for patients. Intralesional injection therapy, such as the use of triamcinolone, has emerged as an effective treatment option for hypertrophic scars. The objective of this study was to describe the morphological features of hypertrophic scars, categorize them, and evaluate the efficacy of triamcinolone injection therapy in treating these scars.

Materials and Methods

A cross-sectional descriptive study of 80 patients with hypertrophic scars treated with triamcinolone intralesional injection at Can Tho University of Medicine and Pharmacy Hospital from 5/2018 to 5/2021.

Results

There were 80 patients in all, with a male/female ratio of 1/1.05 and a median age of 15-35. There were 129 scars in all, with scar age >1 year accounting for 83%, keloid scars accounting for 64%, and hypertrophic scars accounting for the remaining 36%. Scars are most commonly seen on the trunk, accounting for 53.5% of all scars, particularly on the anterior chest wall. When the source of scars was discovered, trauma and acne accounted for 24% and 23%, respectively, while the rest were predominantly spontaneous scars, accounting for 49%. Scarring and discomfort of mild to moderate severity were common clinical symptoms; scars larger than 5cm in size had more symptoms than scars smaller than 5cm. Prior to the therapy, the mean Vancouver Score Scale-VSS was 6.55±2.13. After 24 weeks of the therapy, 96.7% of patients had entirely improved itching symptoms, 75% had completely improved pain, and 25% still had minimal pain. After therapy, the mean Vancouver Score Scale-VSS was 2.55±1.81 (p<0.05). At week 24, 3.75% of patients experienced skin shrinkage, 3.75% experienced depigmentation, and 13.75% experienced vasodilation.

Conclusion

Triamcinolone intralesional injection should be utilized as a first-line therapy for hypertrophic scarring.

Keloid treatments: an evidence-based systematic review of recent advances

BACKGROUND

Keloids are pathologic scars that pose a significant functional and cosmetic burden. They are challenging to treat, despite the multitude of treatment modalities currently available.

OBJECTIVE

The aim of this study was to conduct an evidence-based review of all prospective data regarding keloid treatments published between 2010 and 2020.

METHODS

A systematic literature search of PubMed (National Library of Medicine), Embase (Elsevier), and Cochrane Library (Wiley) was performed in November of 2020. Search strategies with the keywords "keloid" and "treatment" were performed by a medical librarian. The search was limited to prospective studies that were peer-reviewed, reported on clinical outcomes of keloid therapies, and were published in the English language between January 1, 2010, and November 24, 2020.

RESULTS

A total of 3462 unique citations were identified, of which 108 studies met inclusion criteria. Current literature supports silicone gel or sheeting with corticosteroid injections as first-line therapy for keloids. Adjuvant intralesional 5-fluorouracil (5-FU), bleomycin, or verapamil can be considered, although mixed results have been reported with each. Laser therapy can be used in combination with intralesional corticosteroids or topical steroids with occlusion to improve drug penetration. Excision of keloids with immediate post-excision radiation therapy is an effective option for recalcitrant lesions. Finally, silicone sheeting and pressure therapy have evidence for reducing keloid recurrence.

CONCLUSIONS

This review was limited by heterogeneity of subject characteristics and study outcome measures, small sample sizes, and inconsistent study designs. Larger and more robust controlled studies are necessary to further understand the variety of existing and emerging keloid treatments, including corticosteroids, cryotherapy, intralesional injections, lasers, photodynamic therapy, excision and radiation, pressure dressings, and others.

Hypertrophic Scars and Keloids: Advances in Treatment and Review of Established Therapies

Hypertrophic scars and keloids can have significant detrimental effects on patients both psychosocially and functionally. A careful identification of patient risk factors and a comprehensive management plan are necessary to optimize outcomes. Patients with a history of dystrophic scarring should avoid unnecessary procedures and enhance the wound-healing process using various preventive strategies. As there is no single, fully efficacious treatment modality, prevention remains the best approach in reducing aberrant scar formation. When prevention therapies fail, keloids have been shown to be respond to a variety of therapies including topical and injectable corticosteroids, 5-fluorouracil, radiotherapy, lasers, and surgical excision, all with varying efficacies. As such, management should be tailored to the individual patient's risk factors with the use of combination therapies to reduce recurrence rates. Still, keloid and hypertrophic scar therapies are widely diverse with novel treatment modalities providing alternatives for recurring lesions. Laser-assisted drug delivery, skin priming, and novel topical therapies may provide alternative options for the management of hypertrophic scars and keloids.

Efficacy and Safety of Verapamil Versus Triamcinolone Acetonide in Treating Keloids and Hypertrophic Scars: A Systematic Review and Meta-Analysis

BACKGROUND

Keloids and hypertrophic scars can affect the appearance and normal function of patients, and may severely affect patients' physical and mental health. Many methods have been used for the treatment of keloids and hypertrophic scars, there is no standardized method so far. The aim of this study was to compare the efficacy and safety of verapamil and triamcinolone acetonide (TAC) in treating keloids and hypertrophic scars.

METHODS

All studies from their inception date up to August 2022 were searched using four databases (PubMed, Cochrane Library, MEDLINE, and EMBASE). The weighted mean differences and the risk ratio were calculated for comparing continuous variables and dichotomous variables, respectively.

RESULTS

A total of nine randomized controlled trials involving 567 patients were identified. This meta-analysis indicated that TAC group showed significantly better effects compared with verapamil group in the reduction of height at 3 and 9 weeks, pliability at 3, 9, and 18 weeks, vascularity at 3, 6, 9, 12, 18, and 24 weeks, whereas verapamil group showed significantly better effects compared with TAC group in the reduction of pliability at 21 and 24 weeks. Verapamil group showed a significantly lower incidence of skin atrophy, telangiectasia, and hypopigmentation compared with TAC group. However, the incidence of burning sensation in verapamil group was higher than that in TAC group.

CONCLUSION

Concerning the treatment of keloids and hypertrophic scars, TAC was more effective than verapamil for improving vascularity; TAC was superior to verapamil in improving height within 9 weeks of treatment; TAC produced superior result for improving pliability within 18 weeks of treatment, whereas verapamil produced superior result between 18 and 24 weeks of treatment. Verapamil had fewer adverse events than TAC and can be used as a safer alternative for the treatment of keloids and hypertrophic scars.

LEVEL OF EVIDENCE II

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 .

Keloid Treatment Using Plasma Exeresis: A Pilot Trial Study

Introduction: Keloid scars and hypertrophic scars are more commonly seen after surgeries, suture placements, or other skin damages. Scars can be treated using a variety of methods, including topical compounds, surgery, and lasers. The aim of this study is to evaluate the effects of plasma exeresis on the treatment of keloid scars. Methods: This experimental study was conducted on patients with keloid scars, defined as a treatment-resistant subtype of scars with extension beyond the primary skin defect and cauliflower appearance, in different parts of the body. The patients were treated with 2-to-3-session plasma exeresis. Scars were examined based on the Vancouver scar scale (VSS) before and 5 months after the treatment. Results: A total number of 24 scars were enrolled in this study. The number of patients was 16. There was a decrease in the mean thickness of keloids from 2.20 to 0.54 (P=0.000). The mean pigmentation and pliability scores decreased from 1.54 and 2.16 to 0.375 and 0.541, respectively (P=0.001, 000). There was a significant reduction in the keloid scar vascularity score from 1.666 to 0.541 (P=0.000). There was a decrease from 0.708 to 0.00 (P=0.004) in the mean itchiness score. After the intervention, the mean pain score was 0.000, compared to 0.7500 before the intervention (P=0.003). There was a decrease in the total score from 8.958 to 2.000 (P=0.000). Conclusion: The plasma exeresis procedure is effective in destroying small keloid scars. Furthermore, results in less itching and pain, as well as no significant complications or recurrences.

Comparing the Efficacy of Multiple Drugs Injection for the Treatment of Hypertrophic Scars and Keloid: A Network Meta-Analysis

BACKGROUND

There is no consensus regarding the choice of injected drugs for pathological scars. Although the clinical efficacy of different drug treatments was shown in many randomized controlled trials, the efficacies of many drugs are inconsistent. Therefore, this study aimed to determine how different effective drugs are for treating pathological scars. It is anticipated that the study findings may serve as guidelines for plastic surgeons.

METHODS

Relevant literature was extracted from the following databases Cochrane Library, Embase, PubMed, Web of Science, CNKI, Weipu, and Wanfang until June 2022, such as randomized clinical trials (RCTs) evaluating different injected drugs for the treatment of pathological scars, including BTA, TAC, 5-Fu, VER, and BLE.

RESULTS

This network meta-analysis of 1539 patients from 23 articles revealed that the most effective treatment for a pathological scar was TAC + BTA. The effective rate of TAC + BTA combination therapy was significantly different from that of the BTA, TAC, 5-Fu, VER, and BLM monotherapies. TAC+5-FU was more effective than TAC, 5-FU, VER, or BLM alone, and BTA was more effective than both TAC and 5-Fu. The effectiveness of VER and BLM was the same, but both were better than TAC and 5-Fu. No big differences were found between any of the other local injection therapies.

CONCLUSIONS

According to this network meta-analysis, a combination of keloid and hypertrophic scar injection treatment is recommended, especially BTA+TAC. However, this network meta-analysis has some limitations and must be further verified by larger samples and higher quality RCTs.

LEVEL OF EVIDENCE III

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.

Microneedle delivery of botulinum toxin type A combined with hyaluronic acid for the synergetic management of multiple sternal keloids with oily skin: A retrospective clinical investigation

BACKGROUND

For the treatment of sternal keloids, corticosteroid therapy has side effects including abnormal sebum secretion and acne. Relapse of keloids is common after corticosteroid injection in patients with oily skin. To reduce side effects and keloid recurrence, we used a combination of botulinum toxin type A (BTX-A) and hyaluronic acid (HA) as synergetic management for multiple sternal keloids in patients with oily skin.

METHODS

In total, 58 patients with multiple sternal keloids who received monthly steroid injections were retrospectively included. Thirty-two patients in the intervention group received an additional injection of BTX-A/HA on the same day as the first injection of the steroid, while the remaining 26 patients were treated as the control group. At baseline and follow-up visits, sebum production and transepidermal water loss (TEWL) were assessed as primary outcomes, and the Vancouver Scar Scale (VSS) score, keloid recurrence, visual analog scale (VAS) score, and patient satisfaction were assessed as secondary outcomes.

RESULTS

In the control group, average sebum production and TEWL were increased to 132% and 104% of baseline, respectively, at the 24-week follow-up. In the intervention group, average sebum production and TEWL reached nadir at the 8-week follow-up and then increased to 96% and 91% of baseline, respectively, at the 24-week follow-up. Sternal keloid relapse was observed in 88.5% of the patients in the control group and none of the patients in the intervention group. The total VSS score at 24 weeks was 11.04 ± 0.14 and 8.93 ± 0.26 (p < 0.001) in the control group and intervention group, respectively, and the VAS score was 75 ± 5.10 and 19.14 ± 3.80 (p < 0.001) in the control group and intervention group, respectively. Higher patient satisfaction was reported in the intervention group.

CONCLUSIONS

Microneedle delivery of BTX-A/HA decreases sebum production while improving skin barrier function. Thus, this combined therapy can relieve the side effects of corticosteroid therapy and reduce keloid recurrence.

Treatment of Keloids: A Meta-analysis of Intralesional Triamcinolone, Verapamil, and Their Combination

Keloids are skin lesions of abnormal and excessive scar proliferation that have no agreed upon gold standard of therapy. Extensive research in this area has shown that both intralesional triamcinolone and verapamil are effective in their treatment.

Network Meta-Analysis of Different Clinical Commonly Used Drugs for the Treatment of Hypertrophic Scar and Keloid

Background: There is no uniform treatment for pathological scars, including keloids and hypertrophic scars, in clinic currently. Previously, multiple randomized controlled trials have examined the clinical efficacy of different treatments. Nonetheless, the results are inconsistent, and many treatments have not been directly compared. This makes it difficult to conclude which approach is more favorable, in terms of efficacy and safety, for the treatment of pathological scarring. This study aimed at evaluating the efficacy of different injection and topical treatment strategies for hypertrophic scar and keloid.

Methods: Relevant literature from PubMed, Medline, Embase, Scopus, the Cochrane Central Register of Controlled Trials (CCRCT), and WHO International Clinical Trials Registry Platform (WHO-ICTRP) were searched, from database inception through November 2020. Randomized clinical trials evaluating different treatment strategies of pathological scars, including triamcinolone acetonide (TAC), verapamil (VER), 5-fluorouracil (5-FU), botulinum toxin A (BTA), bleomycin (BLM), and silicone gels were included in the study.

Results: The network meta-analysis included a total of 2,009 patients from 29 studies. A network meta-analysis of injection and topical treatment strategies showed that the efficacy of TAC combined with BTA was best in the treatment of pathological scars. Combination therapies of TAC with 5-FU and TAC with BTA significantly improved the clinical efficiency. However, there was no statistically significant difference between other treatment strategies. The order of efficacy predicted by the surface under the cumulative ranking (SUCRA) curve was as follows: TAC+BTA (82.2%) > TAC+5-FU (69.8%) > BTA (67.3%) > 5-FU+silicone (59.4%) > TAC+silicone (58.3%) > 5-FU (49.8%) > BLM (42.0%) > TAC (26.7%) > VER (26.2%) > silicone (18.3%). There was no publication bias revealed based on the funnel diagram.

Conclusion: This study recommends intralesional injection of TAC-BTA and TAC-5-FU combined therapies. But for patients who cannot tolerate the side effects, the use of silicone gels in combination with TAC is recommended. However, these conclusions need to be further confirmed by more randomized controlled trials.

Surgical approach in the management of ear keloids: our experience with 30 patients

BACKGROUND

Ear keloids are benign, fibrous proliferations due to excessive collagen synthesis and deposition. It is a popular practice to pierce earlobes for decorative earrings and adornment; this might trigger the keloid process. Although there are varied treatment modalities, it is unsatisfactory and has always been a challenge. The aim is to evaluate the efficacy of surgical treatment with intralesional therapy in auricular keloids.

METHODS

We included 30 patients with 45 keloids over the ear. Patients were evaluated (including detailed history, complete physical and local examination), and photographs and written informed consent were taken. They were treated with: excision and closure, intralesional and/or surface cryotherapy, ablative laser, intralesional steroids, and 5-fluorouracil. Excision and closure, and intralesional cryotherapy were done under local anesthesia. Closure was done after intramarginal excision with or without raising auto flaps, followed by intraoperative intralesional steroids to margins. Recurrence was assessed at 3 weeks, 3 months, 6 months, and 1 year.

RESULTS

The age group of patients ranged from 14 to 57 years. A total of 32 out of 45 (71.1%) keloids were excised and were combined with intraoperative and postoperative intralesional steroid injection, with sessions depending on the patient's response. Eight (17.7%) and five (11.1%) keloids were treated using intralesional cryotherapy and only intralesional steroids, respectively. A total of 16.6% of patients had recurrence with one patient having recurrence of bilateral earlobes keloid.

CONCLUSION

Keloidectomy with intraoperative and postoperative intralesional steroid injections has been very effective in the treatment of ear keloids. Different treatment modalities act synergistically, but excision surgery gives good results as it aims at maintaining ear architecture.

Comparative efficacy and safety of verapamil and triamcinolone in keloid and hypertrophic scar treatment: a meta-analysis

Keloids and hypertrophic scars are harmful to physical and psychological health. The study aims to compare the efficacy and safety of verapamil and triamcinolone in the treatment of keloids and hypertrophic scars. Relevant publications were searched from PubMed, Embase, Cochrane library, CNKI, Weipu, and Wanfang databases. Results were expressed as weighted mean differences (WMDs) or the relative ratios (RRs) with 95% confidence interval (CI). Pooled estimates were calculated using random-effects or fixed-effects models according to the heterogeneity among studies. The pooled results indicated that the triamcinolone treatment showed significantly better effectiveness in height (at 12, 15, 18, 21, and 24 weeks), pliability (at 3, 6, 9, 21, and 24 weeks) and vascularity (at 3, 6, 9, and 12 week) than that of verapamil (P < .05). Moreover, the side effects such as skin atrophy (RR = 0.13, 95% CI: 0.04 to 0.42, P = .001), telangiectasia (RR = 0.08, 95% CI: 0.02 to 0.28, P < .001), and hyperpigmentation (RR = 0.12, 95% CI: 0.03 to 0.44, P = .001) of verapamil were significantly less than those in triamcinolone. This meta-analysis showed that triamcinolone had a better therapeutic efficacy than verapamil, while verapamil was more safety.

Comparing the Efficacy and Safety of Intralesional Verapamil With Intralesional Triamcinolone Acetonide in Treatment of Hypertrophic Scars and Keloids: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Clinical treatment of hypertrophic scars (HSs) and keloids is often unsatisfactory. Intralesional injections of triamcinolone acetonide (TAC) and verapamil are widely used to treat HSs and keloids, but their efficacy and safety are controversial.

OBJECTIVES

The aim of this study was to conduct a meta-analysis of the effectiveness and safety of verapamil and TAC in the treatment of HSs and keloids.

METHODS

Embase, Google Scholar, and PubMed were searched for randomized controlled trials (RCTs) from inception to February 2020. RCTs that evaluated treatment effects with the Vancouver Scar Scale or reported adverse effects were included. The continuous data and the dichotomous variables were analyzed as mean difference (MD) and relative risk (RR), respectively.

RESULTS

Seven RCTs (461 patients) were included. Compared with verapamil, TAC rapidly changed the ∆height (MD = 0.07; P < 0.05) and ∆pliability (MD = 0.23; P < 0.05) after the first session, but subsequent treatments resulted in no significant differences in the ∆height, ∆pigmentation, ∆vascularity, and ∆pliability. Although total adverse effects (RR = 0.42; P = 0.1) were not significantly different, in the subgroup analysis the incidence of telangiectasia (RR = 0.04; P < 0.05) and skin atrophy (RR = 0.10; P < 0.05), but not pain (RR = 1.27; P = 0.77), was significantly lower with verapamil than with TAC.

CONCLUSIONS

Verapamil may be an effective substitute for TAC. Although total adverse effects did not change, the incidence of telangiectasia and skin atrophy was lower with verapamil than with TAC.

LEVEL OF EVIDENCE: 4

The Efficacy of Drug Injection in the Treatment of Pathological Scar: A Network Meta-analysis

BACKGROUND

Pathological scars mainly include hyperplastic scars and keloids, and there is no uniform treatment standard for the treatment of pathological scar in clinic now. Drug injection in the treatment of pathological scar is widely used because of its advantages of less trauma and simple operation. Therefore, we used a network meta-analysis to compare the curative effect of four kinds of drugs which are commonly used in the treatment of pathological scar such as botulinum toxin type A, corticosteroids (including diprospan and triamcinolone acetonide (TAC)), verapamil and 5-fluorouracil (5-FU), systematically. It is hoped that our study will provide evidence for the choice of drugs in the treatment of pathological scar by injection.

METHODS

Relevant articles from Wanfang, VIP, CNKI, PubMed, Cochrane Library and Embase databases were extracted by us. They were included into a network meta-analysis to compare the four kinds of drugs which are commonly used in the treatment of pathological scar.

RESULTS

The network meta-analysis included a total of 1513 patients from 23 studies. Through meta-analysis, we found that the efficacy of botulinum toxin type A combined with corticosteroid drugs was best in the treatment of pathological scar by injection. There was no significant difference between botulinum toxin type A, corticosteroids combined with 5 Fu, verapamil and 5-FU. The efficacy of corticosteroids combined with 5-FU was better than that of corticosteroids alone and verapamil alone, but there was no significant difference between them and 5-FU. Further, the order of efficacy predicted by the SUCRA curve was as follows: botulinum toxin type A combined with corticosteroids > corticosteroids combined with 5-FU > botulinum toxin type A > corticosteroids > 5-FU > verapamil. Moreover, no publication bias was found in the funnel diagram.

CONCLUSION

In the injection treatment of pathological scar, we recommend the combined injection of two drugs, especially botulinum toxin type A combined with corticosteroids. The effective treatment of botulinum toxin type A combined with corticosteroids in the treatment of pathological scar is as follows: Patients were treated once monthly with intralesional injection of TAC (0.1 ml/cm³) mixed with botulinum toxin type A (2.5 IU/cm³) for a total of 3 treatments. However, there are still limitations in this network meta-analysis, and its conclusion still needs to be further confirmed by more randomized controlled trials.

LEVEL OF EVIDENCE III

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 .

Management of keloid scars: noninvasive and invasive treatments

Scars vary from mature linear scars to abnormal excessive scars such as hypertrophic scars and keloid scars. Keloid scars are fibro-proliferative disease entities that reflect an abnormal process of wound healing. They can cause pain, itching, stiffness, and psychological distress, all of which can affect quality of life. Various treatment options have been advocated as ways to prevent and treat keloid scars. These include noninvasive treatments such as use of silicone gel sheeting and compression therapy, and invasive treatments such as intralesional corticosteroid injections, surgery, and radiotherapy. Novel treatments include chemotherapy, immunotherapy, and anti-inflammatory therapies. Unfortunately, keloids continue to pose a significant challenge due to the lack of efficacious treatments. Therefore, clinicians should be familiar with various therapeutic options and apply the most suitable treatment plan for patients. In this review, we introduce the current therapeutic options for the management of keloid scars.

The safety and efficacy of intralesional triamcinolone acetonide for keloids and hypertrophic scars: A systematic review and meta-analysis

BACKGROUND

Triamcinolone acetonide (TAC) is widely used for hypertrophic scars and keloids; however, TAC has variable efficacy and safety in different individuals.

PURPOSE

To evaluate the efficacy and safety of intralesional TAC for treatment of hypertrophic scars and keloids.

DATA SOURCES

Searches of PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov prior to 25 March 2020.

STUDY SELECTION

Randomized controlled trials in English that compared TAC with a placebo or other medications that are commonly used for intralesional injection in hypertrophic scars and keloids.

DATA EXTRACTION

Primary outcomes were reduction in scar height, vascularity, pliability, pigmentation, total scores on the Vancouver Scar Scale (VSS) or patient and observer scar assessment scale (POSAS), telangiectasia, and skin atrophy. Secondary outcomes included overall scar improvement.

DATA SYNTHESIS

Fifteen trials met the inclusion criteria. In the short term, TAC was associated with a significant improvement in vascularity (MD: -0.22, 95% CI: -0.42 to -0.02) and pliability (MD: -0.25, 95% CI: -0.44 to -0.06) compared to verapamil. In the medium term, compared to TAC, 5-FU showed a significant improvement in scar height (SMD: 0.95, 95% CI: 0.15-1.75), while TAC led to a significant improvement in vascularity compared to 5-FU (MD: -0.45, 95% CI: -0.76 to -0.14). Compared to TAC, TAC+5-FU showed a significant improvement in pliability (SMD: 0.98, 95% CI: 0.17-1.78) and pigmentation (MD: 0.45, 95% CI: 0.12-0.78). Botulinum toxin type A resulted in significantly better pliability (SMD: 1.99, 95% CI: 0.98-3.00) compared to TAC. In the long term, compared to TAC, 5-FU led to a significant improvement in scar height (MD: 0.55, 95% CI: 0.17-0.93), but significantly less vascularity (MD: -0.35, 95% CI: -0.65 to -0.05). Compared to TAC, TAC+5-FU produced a significant improvement in scar height (MD: 1.50, 95% CI: 1.12-1.88), pliability (MD: 0.45, 95% CI: 0.10-0.80), and pigmentation (MD: 0.55, 95% CI: 0.24-0.86).

CONCLUSION

TAC may be beneficial for the short-term treatment of hypertrophic scars and keloids; however, 5-FU, 5-FU+TAC, and verapamil may produce superior results for medium- and long-term treatments. TAC injections at concentrations of 20 mg/ml or 40 mg/ml are more likely to result in skin atrophy compared to 5-FU or verapamil, and are more likely to cause telangiectasia than 5-FU, 5-FU+TAC, or bleomycin.

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.

Efficacy and safety of verapamil vs triamcinolone acetonide for keloids and hypertrophic scars: A systematic review and meta-analysis

The treatment of keloids and hypertrophic scars remains a challenge. Although triamcinolone acetonide (TAC) is one of the most common and effective treatments for keloids and hypertrophic scars, TAC is not effective in some patients, and some may even experience adverse outcomes. Verapamil might be considered a safe alternative to TAC. The aim of this study was to compare the efficacy and safety of verapamil and TAC for the treatment of keloids and hypertrophic scars. Three databases (Medline, EMBASE, and CENTRAL database) were electronically searched from 1997 to December 2019. Article selection was limited to randomized controlled trials (RCTs) and controlled clinical trials (CCTs). Two authors independently assessed the selection of studies, risk of bias, and extracted the data. Mean differences (MDs) were computed for continuous variables, risk ratios (RRs) were computed for dichotomous variables, and 95% confidence intervals (CIs) were calculated for both assessments. Five RCTs were included, comprising a total of 215 patients (273 scars). Vancouver Scar Scale (VSS) parameters (such as height, vascularity, pliability, and pigmentation) were reported as the outcome measures and provided detailed values in four studies. No significant differences were observed between verapamil and TAC in the reduction of height (MD 0.57, 95% CI -0.94 to 2.08, P = .46), vascularity (MD 0.30, 95% CI -0.42 to 1.02, P = .41), pliability (MD 0.67, 95% CI -1.12 to 2.47, P = .46), and degree of pigmentation (MD 0.14, 95% CI -0.41 to 0.69, P = .61). Adverse outcomes were reported in four studies. The results showed that the incidence of telangiectasia and skin atrophy that used verapamil was significantly lower than that for TAC. Concerning the treatment of keloids and hypertrophic scars, even though verapamil was safer than TAC, TAC worked faster than verapamil. Furthermore, we did not find any clear evidence that verapamil was more or less effective than TAC. Considering the high degree of safety of verapamil, we suggest that verapamil might be used as an alternative treatment when TAC results in adverse outcomes.