Role of liquid nitrogen alone compared with combination of liquid nitrogen and intralesional triamcinolone acetonide in treatment of small keloids

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.

Combination cryotherapy and intralesional corticosteroid versus steroid monotherapy in the treatment of keloids

BACKGROUND

Keloids are common and have significant negative effects on quality of life. There is a need for more effective treatment approaches for keloids.

AIMS

We investigated treatment outcomes of intralesional triamcinolone acetonide (IL TAC) compared with combination IL TAC and cryotherapy, including changes in pruritus, pain, and keloid size.

PATIENTS/METHODS

We performed a prospective study of patients referred to one provider who treated patients with combination therapy and compared them to a historic control cohort treated with IL TAC alone. All patients were seen at Thomas Jefferson University between 2019 and 2021. Patient demographics, location of keloids, and inciting events were recorded. Pruritus and pain scores were self-reported by patients using a 10-point Likert scale administered as standard of care. Changes in keloid size were denoted as "No change," "up to 50% decrease," "more than 50% decrease," and "completely flattened."

RESULTS

While both treatments produced a significant reduction in mean pruritus and pain scores, there was no difference between the two treatment groups (p = 0.3933 and p = 0.2123, respectively). A greater percentage of keloids in the combination therapy group had a post-treatment size difference greater than 50% compared with those in the IL TAC only treatment group (p = 0.0021). In the subgroup of pubic keloids, all lesions treated with combination IL TAC and cryotherapy responded remarkably well to treatment.

CONCLUSIONS

While both IL TAC and IL TAC with cryotherapy were effective at reducing pruritus and pain, combination therapy was more effective in reducing keloid size, specifically for pubic keloids.

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.

Cryotherapy: A Successful Monotherapy for Earlobe Keloids

A keloid represents an excessive overgrowth of skin beyond the boundaries of an injury. Earlobe keloids usually follow ear piercing and can become large, sometimes producing remarkable disfigurement. Surgical excision, pressure dressing, intralesional corticosteroid injection, cryosurgery, radiation, and lasers have all been used to treat earlobe keloids. However, none has produced uniformly satisfactory results. Combinations of more than one modality have also been employed to yield successful outcomes. We describe cryotherapy as a single modality to treat seven-year-old, multiple earlobe keloids. Three cryotherapy sessions with two freezing-thawing cycles of 30-40 seconds' freezing time and two minutes' thawing time, undertaken one month apart, resulted in complete flatness of the keloids and no recurrence after 5 years. We also evaluate keloid-related and operational factors that determine the success of cryotherapy as a monotherapy for earlobe keloids.

Keloids and Hypertrophic Scars: A Spectrum of Clinical Challenges

Since their earliest description, keloids and hypertrophic scars have beleaguered patients and clinicians alike. These scars can be aesthetically disfiguring, functionally debilitating, emotionally distressing, and psychologically damaging, culminating in a significant burden for patients. Our current understanding of keloid pathophysiology has grown and continues to advance while molecular biology, genetics, and technology provide ever-deepening insight into the nature of wound healing and the pathologic perturbations thereof. Greater understanding will lead to the development and application of refined therapeutic modalities. This article provides an overview of our current understanding of keloids, highlighting clinical characteristics and diagnostic criteria while providing a comprehensive summary of the many therapeutic modalities available. The proposed mechanism, application, adverse events, and reported efficacy of each modality is evaluated, and current recommendations are summarized.

Could 5-Fluorouracil or Triamcinolone Be an Effective Treatment Option for Keloid After Surgical Excision? A Meta-Analysis

PURPOSE

There is no universally accepted treatment regimen to decrease the recurrence rate of keloid formation after its removal, although many treatment options have been suggested. The purpose of this study was to investigate treatment options to prevent keloid recurrence after surgical excision.

MATERIALS AND METHODS

A systematic literature review and meta-analysis was performed using the Medline, Embase, and Cochrane databases. Predictor variables were 5-fluorouracil (5-FU) or triamcinolone adjuvant therapy, and the outcome variable was keloid recurrence rate. The Newcastle-Ottawa scale was used to assess the quality of the studies and the Cochrane risk-of-bias tool was used. Publication bias was evaluated using a funnel plot.

RESULTS

There were 1,224 publications identified; after screening, 5 were selected for review (1 retrospective cohort, 3 prospective cohorts, and 1 randomized controlled trial). The mean level of keloid recurrence was statistically lower in patients who received 5-FU compared with those who did not (control group; risk ratio, 0.18; 95% confidence interval [CI], 0.04 to 0.75). Triamcinolone was ineffective in lowering the keloid recurrence (risk difference, 0.06; 95% CI, -0.16 to 0.28).

CONCLUSION

5-FU can be considered an effective treatment to decrease keloid recurrence after surgical excision, although further research, including a randomized controlled trial, is required.

Emerging Therapies for Scar Prevention

Significance: There are ∼12 million traumatic lacerations treated in the United States emergency rooms each year, 250 million surgical incisions created worldwide every year, and 11 million burns severe enough to warrant medical treatment worldwide. In the United States, over $20 billion dollars per year are spent on the treatment and management of scars. Recent Advances: Investigations into the management of scar therapies over the last decade have advanced our understanding related to the care of cutaneous scars. Scar treatment methods are presented including topical, intralesional, and mechanical therapies in addition to cryotherapy, radiotherapy, and laser therapy. Critical Issues: Current treatment options for scars have significant limitations. This review presents the current and emerging therapies available for scar management and the scientific evidence for scar management is discussed. Future Directions: Based upon our new understanding of scar formation, innovative scar therapies are being developed. Additional research on the basic science of scar formation will lead to additional advances and novel therapies for the treatment of cutaneous scars.

Construction of corneal epithelium with human amniotic epithelial cells and repair of limbal deficiency in rabbit models

This study aims to evaluate the effect of a human amniotic epithelial cell (HAEC)-rabbit corneal stroma tissue-engineered cornea on ocular reconstruction in three different animal models. HAECs were isolated from human placenta, seeded onto rabbit corneal stroma. HAECs-rabbit corneal stroma tissue engineering cornea transplantation was examined in three distinct rabbit models: transplantation of cornea constructed (1) with lamellar corneal HAECs and rabbit corneal stroma, (2) with central corneal HAECs and rabbit corneal stroma, or (3) with full-thickness corneal HAECs and rabbit corneal stroma. In the tissue engineering corneal transplantation groups in all three models, the mean number of days to corneal epithelial healing was significantly shorter than that in the control group and the mean number of days to corneal neovascularization was significantly greater than in the control group. In addition, in the tissue engineering corneal transplantation groups in the central lamellar cornea model and the full-thickness corneal transplantation model neovascularization, corneal turbidity, and epithelial fluorescence were significantly less than in the control groups. HAECs can be induced to differentiate into corneal epithelial cells, which may be suitable for the reconstruction of the corneal epithelium in cases of limbal stem cell deficiency.

Update on scar management: guidelines for treating Asian patients

BACKGROUND

Following injury, Asian skin has a tendency towards hyper-pigmentation and scar formation, and therefore the prevention of scarring is particularly important in Asian patients. Since publication of an International Clinical Recommendation on Scar Management in 2002, there have been numerous publications in the field of scar management. Advances in understanding scar formation have also led to the introduction of new treatments as well as a better understanding of established therapeutic options.

METHODS

A literature search for abstracts, clinical trials and meta-analyses evaluating scar prevention and treatment was performed using PubMed and the Cochrane Database of Systematic Reviews. Based on this data a panel of experts formulated treatment recommendations for Asian patients.

RESULTS

Following surgery, scar prevention should be initiated in all Asian patients due to the high risk of poor scars. There is strong evidence for the efficacy of silicone based products, and due to their ease of use, they can be considered first-line therapy. Silicone gel (versus silicone gel sheets) products have demonstrated efficacy. For patients who fail to respond to first-line therapy, intralesional steroid injections, radiation therapy, and intralesional 5-flourouracil injections have achieved widespread acceptance. Laser treatments have been increasingly used, although the evidence remains largely anecdotal without a clear consensus on optimal wavelength, or amount of energy. Surgical approaches have increased in sophistication with recognition of the impact that tension has on scar formation.

CONCLUSION

Updated scar management recommendations will benefit practitioners making decisions regarding optimal, evidence-based treatment strategies for their patients.

Cryotherapy in treatment of keloids: evaluation of factors affecting treatment outcome

BACKGROUND

Keloids are cosmetically disfiguring benign fibrous outgrowths, which present as a major therapeutic dilemma due to their frequent recurrence. Despite a wide therapeutic armamentarium available for these scars, none has been found to be completely effective and satisfactory. Cryosurgery has offered some promise in the treatment of keloids.We conducted this study to evaluate the effect of cryotherapy in treatment of keloids and to relate the treatment outcome with the clinico-etiological factors.

MATERIALS AND METHODS

A hospital-based interventional study was conducted in 30 patients of keloids. Patients received two freeze thaw cycles of 15 seconds each at four weekly intervals for six sessions or flattening greater than 75%; whichever occurred earlier. Patients were assessed after three treatment sessions and at treatment completion regarding thickness and firmness of lesions. Patient satisfaction scale was used to evaluate the treatment outcome at completion of six treatment sessions. Paired Students t-test and Analysis of variance (ANOVA) were used for statistical analysis.

RESULTS

Average flattening noted after 3 and 6 sessions of cryotherapy was 30.76% and 58.13%, respectively. The duration of lesions and thickness of keloids correlated significantly with the result of treatment. The site and aetiology did not influence the outcome of cryosurgical treatment.

CONCLUSION

Cryotherapy seems to be an effective treatment modality for keloids of recent onset, particularly smaller lesions. Duration and thickness of the keloids were found to be the most important factors in determining treatment outcome with cryotherapy in our study. Larger studies are, however, required to confirm the efficacy of this treatment modality and to validate our findings of the factors affecting treatment outcome.