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Huang Y, Ren S, Yang Q. Efficacy and Safety of Excision Combination Therapies for Earlobe Keloids: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2024:10.1007/s00266-024-04092-0. [PMID: 38789810 DOI: 10.1007/s00266-024-04092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/15/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Different combinations of excision and adjuvant therapies have been applied to improve outcomes for earlobe keloids, though evidence in this field is still lacking. OBJECTIVES This study sought to systematically investigate efficacy and safety of these treatments. METHODS We conducted a systematic search on PubMed, Embase, Web of Science, and Cochrane Library to find all relevant studies. Meta-analysis of recurrence rates (RRs) and adverse event rates with 95% confidence intervals, and individual participants data (IPD) were calculated for each intervention when possible. Otherwise, narrative syntheses were performed. RESULTS A total of 85 articles, covering 23 treatments for earlobe keloids, were included, indicating a preference for multiple combination therapy. The estimated RRs for 6 interventions (i.e., excision monotherapy, combinations of excision with imiquimod, pressure therapy, radiotherapy, steroids, and steroids with pressure therapy) appeared to be comparable. Electron radiotherapy was found to have potential advantages over X-ray treatment, contributing to the observed heterogeneity. Further meta-analysis using IPD revealed that both combination therapies of excision plus steroid therapy (p=0.003) and excision plus radiotherapy (p=0.003) yielded better recurrence-free survival compared to excision alone. The median recurrence-free interval for combination therapy was 10 months. Adverse event rates were similar among different intervention groups. CONCLUSIONS This study suggests that combining excision with radiotherapy or perioperative steroid therapy has the potential to improve prognosis of earlobe keloids without increasing the risk of adverse events. Overall evaluation of patients' conditions and further studies with sufficient follow-up are warranted for clinical practice. 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 .
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Affiliation(s)
- Ying Huang
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Badachu Road 33, Beijing, People's Republic of China
| | - Shuofang Ren
- Department of Cardiac Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qinghua Yang
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Badachu Road 33, Beijing, People's Republic of China.
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Zhang Y, Wu M, Liu D, Panayi AC, Xu X, Luo L, Feng J, Ou Y, Lin T, Cui Y. Recurrence and Complications of Peri-operative Steroid Injection of Keloids: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2024:10.1007/s00266-024-03935-0. [PMID: 38561576 DOI: 10.1007/s00266-024-03935-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/05/2024] [Indexed: 04/04/2024]
Abstract
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 ."
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Affiliation(s)
- Yihan Zhang
- Shantou University Medical College, Shantou, 515041, China
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Mengfan Wu
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Dandan Liu
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Adriana C Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Xiangwen Xu
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Lin Luo
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Jun Feng
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Yanting Ou
- Shantou University Medical College, Shantou, 515041, China
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Tingyin Lin
- Shantou University Medical College, Shantou, 515041, China
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China
| | - Yongyan Cui
- Department of Plastic and Reconstructive Surgery, Peking University Shenzhen Hospital, 1120 Lianghua Road, Shenzhen, 518036, Guangdong, People's Republic of China.
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Thariat J, Little MP, Zablotska LB, Samson P, O’Banion MK, Leuraud K, Bergom C, Girault G, Azimzadeh O, Bouffler S, Hamada N. Radiotherapy for non-cancer diseases: benefits and long-term risks. Int J Radiat Biol 2024; 100:505-526. [PMID: 38180039 PMCID: PMC11039429 DOI: 10.1080/09553002.2023.2295966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE The discovery of X-rays was followed by a variety of attempts to treat infectious diseases and various other non-cancer diseases with ionizing radiation, in addition to cancer. There has been a recent resurgence of interest in the use of such radiotherapy for non-cancer diseases. Non-cancer diseases for which use of radiotherapy has currently been proposed include refractory ventricular tachycardia, neurodegenerative diseases (e.g. Alzheimer's disease and dementia), and Coronavirus Disease 2019 (COVID-19) pneumonia, all with ongoing clinical studies that deliver radiation doses of 0.5-25 Gy in a single fraction or in multiple daily fractions. In addition to such non-cancer effects, historical indications predominantly used in some countries (e.g. Germany) include osteoarthritis and degenerative diseases of the bones and joints. This narrative review gives an overview of the biological rationale and ongoing preclinical and clinical studies for radiotherapy proposed for various non-cancer diseases, discusses the plausibility of the proposed biological rationale, and considers the long-term radiation risks of cancer and non-cancer diseases. CONCLUSIONS A growing body of evidence has suggested that radiation represents a double-edged sword, not only for cancer, but also for non-cancer diseases. At present, clinical evidence has shown some beneficial effects of radiotherapy for ventricular tachycardia, but there is little or no such evidence of radiotherapy for other newly proposed non-cancer diseases (e.g. Alzheimer's disease, COVID-19 pneumonia). Patients with ventricular tachycardia and COVID-19 pneumonia have thus far been treated with radiotherapy when they are an urgent life threat with no efficient alternative treatment, but some survivors may encounter a paradoxical situation where patients were rescued by radiotherapy but then get harmed by radiotherapy. Further studies are needed to justify the clinical use of radiotherapy for non-cancer diseases, and optimize dose to diseased tissue while minimizing dose to healthy tissue.
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Affiliation(s)
- Juliette Thariat
- Department of Radiation Oncology, Comprehensive Cancer Centre François Baclesse, Caen, France
- Laboratoire de Physique Corpusculaire IN2P3, ENSICAEN/CNRS UMR 6534, Normandie Université, Caen, France
| | - Mark P. Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, Maryland, USA
| | - Lydia B. Zablotska
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Pamela Samson
- Department of Radiation Oncology, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - M. Kerry O’Banion
- Department of Neuroscience, Del Monte Institute for Neuroscience, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Klervi Leuraud
- Research Department on Biological and Health Effects of Ionizing Radiation (SESANE), Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Carmen Bergom
- Department of Radiation Oncology, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri, USA
- Cardio-Oncology Center of Excellence, Washington University, St. Louis, Missouri, USA
| | - Gilles Girault
- Comprehensive Cancer Centre François Baclesse, Medical Library, Caen, France
| | - Omid Azimzadeh
- Federal Office for Radiation Protection (BfS), Section Radiation Biology, Neuherberg, Germany
| | - Simon Bouffler
- Radiation Protection Sciences Division, UK Health Security Agency (UKHSA), Chilton, Didcot, UK
| | - Nobuyuki Hamada
- Biology and Environmental Chemistry Division, Sustainable System Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), Abiko, Chiba, Japan
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Katano A, Minamitani M, Yamashita H. Risk factors for local recurrence of keloids and hypertrophic scars after postoperative electron beam radiotherapy. J Cancer Res Ther 2024; 20:163-166. [PMID: 38554315 DOI: 10.4103/jcrt.jcrt_1861_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/10/2022] [Indexed: 04/01/2024]
Abstract
OBJECTIVE Keloids and hypertrophic scars are benign fibroproliferative lesions that occur as a result of skin injury. Postoperative radiation therapy is used to reduce the recurrence rate because of the high recurrence rate with surgical treatment alone. This study aimed to identify the risk factors for recurrence after postoperative electron beam radiotherapy. MATERIALS AND METHODS Patients with keloid or hypertrophic scars with at least one lesion and who underwent postoperative electron beam radiotherapy at our institution from June 2013 to March 2022 were included in the study, while patients with a follow-up period of fewer than three months were excluded. RESULTS A retrospective analysis was performed on 94 lesions in 81 patients. Exactly two years after the treatment, the actuarial local control rate was 86.4%. The chest wall, shoulder, and suprapubic area were identified as high-risk recurrence sites. Compared to other body sites, these sites had significantly lower local control rates (two-year local control rates: 75.5% vs. 95.2%, P = 0.005). After multivariate analysis, treatment site (P = 0.014), male gender (P = 0.019), and younger age (P = 0.029) were revealed to be statistically significant risk factors for local recurrence. Risk factors for keloid recurrence after postoperative electron beam radiotherapy were therefore identified. CONCLUSION This result could be used for follow-up and as a determinant for the optimal dose/fractionation of postoperative radiotherapy.
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Affiliation(s)
- Atsuto Katano
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Masanari Minamitani
- Department of Comprehensive Radiation Oncology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Bhattacharya N, Bhattacharya K, Chandran T. Treatment of Keloids with Surgery and Immediate Postoperative Radiotherapy: Knowledge Gained Over 17 Years. Indian J Plast Surg 2023. [DOI: 10.1055/s-0043-1761599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Abstract
Background The treatment of keloidal scars with radiotherapy has been practiced for more than a century. Radiotherapy post-surgery has been deemed necessary and effective in preventing recurrence but still, no clear guidelines exist as to the best modality of radiotherapy, the ideal dose, and the time it should be given for keloidal scars. The purpose of this study is to confirm the effectiveness of this treatment and address these issues.
Methods Since 2004, 120 patients presenting with keloidal scars were seen by the author. Out of them, 50 were managed with surgery followed by HDR brachytherapy/electron beam radiotherapy delivering 2000 rads to the scar within 24 hours of surgery. Patients were followed up for at least 18 months to assess the scar status and the recurrence of keloids. Recurrence was defined as the appearance of a nodule or an obvious return of the keloid within 1 year of treatment.
Results Three patients developed a nodule in the scar, which was deemed a recurrence, making an incidence of 6%. There was no major problem after immediate postoperative radiotherapy. Five patients had delayed healing at 2 weeks and a hypertrophic scar was noted in five patients at 4 weeks that settled with conservative measures.
Conclusion Treating the vexing problem of keloids with surgery and immediate postoperative radiotherapy is safe and effective. We recommend that this be adopted as the standard treatment in keloid management.
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Affiliation(s)
- Neela Bhattacharya
- Department of Plastic Surgery, Anandaloke Multispeciality Hospital, Siliguri, West Bengal, India
| | - Kaushik Bhattacharya
- Department of General Surgery, CAPF Composite Hospital, Siliguri, West Bengal, India
| | - T.C. Chandran
- Institute For Research and Rehabilitation of Hand and Department of Plastic Surgery, Govt. Stanley Medical College, Chennai, Tamil Nadu, India
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Bjerremand JR, Haerskjold A, Karmisholt KE. Excision and adjuvant treatment to prevent keloid recurrence. - a systematic review of prospective, clinical, controlled trials. J Plast Surg Hand Surg 2023; 57:38-45. [PMID: 35848929 DOI: 10.1080/2000656x.2022.2097251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Keloids are defined as the formation of collagen-rich scar tissue extending beyond the original lesion. Not all keloids respond to conventional treatment with intralesional triamcinolone injections. Recurrence of keloids after primary excision is reported in almost 100% of cases and should therefore always be followed by adjuvant treatment. Currently, consensus on preferred adjuvant treatment in relation to keloid excision is lacking. This study seeks to systematically review evidence on the efficacy of adjuvant treatments in relation to keloid excision. A systematic literature review was conducted on PubMed. Titles, abstracts, and articles were screened and sorted according to defined inclusion- and exclusion criteria. Each study was evaluated according to the Oxford Centre for Evidence-Based Medicine, OCEBM, Levels of Evidence by two independent authors. Seven studies were eligible. Adjuvant treatment methods included intralesional triamcinolone injection, radiotherapy, silicone gel, pressure therapy, verapamil hydrochloride and 5-fluorouracil. While all the included studies reported promising results, two studies showed that minimizing dosages when treating with radiotherapy or triamcinolone should be considered to avoid adverse events. However, a high risk of bias was found in all the included studies.
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Affiliation(s)
- Julie R Bjerremand
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ann Haerskjold
- Department of Dermatology, Venerology and Wound Healing, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Katrine E Karmisholt
- Department of Dermatology, Venerology and Wound Healing, Bispebjerg University Hospital, Copenhagen, Denmark
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desJardins-Park HE, Gurtner GC, Wan DC, Longaker MT. From Chronic Wounds to Scarring: The Growing Health Care Burden of Under- and Over-Healing Wounds. Adv Wound Care (New Rochelle) 2022; 11:496-510. [PMID: 34521257 PMCID: PMC9634983 DOI: 10.1089/wound.2021.0039] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 09/03/2021] [Indexed: 12/26/2022] Open
Abstract
Significance: Wound healing is the largest medical market without an existing small molecule/drug treatment. Both "under-healing" (chronic wounds) and "over-healing" (scarring) cause a substantial biomedical burden and lifelong consequences for patients. These problems cost tens of billions of dollars per year in the United States alone, a number expected to grow as the population ages and the prevalence of common comorbidities (e.g., diabetes) rises. However, no therapies currently exist to produce the "ideal" healing outcome: efficient wound repair through regeneration of normal tissue. Recent Advances: Ongoing research continues to illuminate possible therapeutic avenues for wound healing. By identifying underlying mechanisms of wound repair-for instance, tissue mechanics' role in fibrosis or cell populations that modulate wound healing and scarring-novel molecular targets may be defined. This Advances in Wound Care Forum issue includes reviews of scientific literature and original research from the Hagey Laboratory for Pediatric Regenerative Medicine at Stanford and its alumni, including developing approaches for encouraging wound healing, minimizing fibrosis, and coaxing regeneration. Critical Issues: Wound healing problems reflect an enormous and rapidly expanding clinical burden. The issues of both under- and over-healing wound outcomes will continue to expand as their underlying causes (e.g., diabetes) grow. Targeted treatments are needed to enable wound repair with functional tissue restoration and decreased scarring. Future Directions: Basic scientists will continue to refine understanding of factors driving undesirable wound outcomes. These discoveries are beginning to be translated and, in the coming years, will hopefully form the foundation for antiscarring drugs and other wound therapeutics.
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Affiliation(s)
- Heather E. desJardins-Park
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford, California, USA
- Institute for Stem Cell Biology and Regenerative Medicine; Stanford University School of Medicine, Stanford, California, USA
| | - Geoffrey C. Gurtner
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford, California, USA
| | - Derrick C. Wan
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford, California, USA
| | - Michael T. Longaker
- Hagey Laboratory for Pediatric Regenerative Medicine, Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford, California, USA
- Institute for Stem Cell Biology and Regenerative Medicine; Stanford University School of Medicine, Stanford, California, USA
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Yuan B, Miao L, Mei D, Li L, Hu Z. A Signature of Genes Featuring FGF11 Revealed Aberrant Fibroblast Activation and Immune Infiltration Properties in Keloid Tissue. Emerg Med Int 2022; 2022:4452687. [PMID: 35982730 PMCID: PMC9381289 DOI: 10.1155/2022/4452687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 06/24/2022] [Indexed: 11/23/2022] Open
Abstract
Keloid is a fibroproliferative disorder in the skin, which manifested with extensive deposition of collagen and extracellular matrix. Its etiology remains a mystery and its recurrence rate remains high despite combinative treatment regimens. Current hypotheses of its pathogenesis centered on the role of inflammatory processes as well as immune infiltration in the microenvironment. However, there are a lot of discrepancies when it comes to the verification of certain well-recognized pathways involved in the dysfunctional fibroblast. Further exploration and characterization are required to reveal the driving force and even leading genes responsible for keloid formation. In this study, we provided supportive evidence of the immunologic nature of keloids distinct from normal fibroblasts and physiological scars by incorporating multiple available expressional profiles in the Gene Expression Omnibus (GEO). Through differential analyses and functional analyses, we identified a set of genes that successfully captures the dissimilarities between keloid lesions and nonlesions. They were differentially regulated in keloid samples and had opposite behavior in exposure to hydrocortisone. A key signature of six genes featuring FGF11 not only was highly correlated with significantly dysregulated fibroblast activation but also reflected various levels of immune cell infiltration. FGF11, in particular, revealed the heterogenous immunologic nature of keloid lesions. This study further supported that aberrant fibroblast was one of the main contributing factors and shed some light on investigating immune properties in future studies.
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Affiliation(s)
- Bo Yuan
- Dermatology Department, The Affiliated Hospital of Medical School, Ningbo University, No.247 Renmin Road, Jiangbei District, Ningbo 315020, China
| | - Linlin Miao
- Surgery Department, School of Medicine, Ningbo University, No.818, Fenghua Road, Jiangbei District, Ningbo 315211, China
| | - Disen Mei
- Basic Medicine Experiment Center, School of Medicine, Ningbo University, No.818, Fenghua Road, Jiangbei District, Ningbo 315211, China
| | - Lingzhi Li
- Dermatology Department, The Affiliated Hospital of Medical School, Ningbo University, No.247 Renmin Road, Jiangbei District, Ningbo 315020, China
| | - Zhu Hu
- Plastic and Reconstructive Surgery Department, The Affiliated Hospital of Medical School, Ningbo University, No.247 Renmin Road, Jiangbei District, Ningbo 315020, China
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Chan LJ, Greenberg HL. Establishment of an efficacious treatment period for prophylaxis of auricular keloid recurrence postexcision using topical imiquimod 5%: A demonstrative case series. JAAD Case Rep 2022; 26:41-44. [PMID: 35865725 PMCID: PMC9294493 DOI: 10.1016/j.jdcr.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lina J Chan
- Kirk Kerkorian School of Medicine at UNLV, Las Vegas, Nevada
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Intralesional Keloid Excision Followed by Single Fraction Electron Beam Radiotherapy and Postoperative Local Steroids: a Non-randomized Open Study on Recurrence Rate. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03511-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Margiotta E, Ramras S, Shteynberg A. Recurrence of Primary and Secondary Keloids in a Select African American and Afro-Caribbean Population. Ann Plast Surg 2022; 88:S194-S196. [PMID: 35513318 DOI: 10.1097/sap.0000000000003173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Keloid formation occurs with increased incidence in African Americans and Afro-Caribbeans when compared with other ethnic populations. Although surgical management and nonsurgical management of keloids are mainstays of treatment, there are significant variations within studies comparing the efficacy of intraoperative steroid injection, postoperative radiotherapy, or a combination of both modalities. The purpose of our study is to evaluate the efficacy of different treatment modalities used for treatment of keloids and to determine their recurrence in a select Afro-Caribbean population. METHODS A retrospective review of the plastic surgery case list from January 2015 to October 2019 was conducted, with identification of 46 Afro-Caribbean and African American patients with 56 keloids. Each patient was contacted to determine whether they had experienced recurrence of their keloid(s). Eighteen patients were lost to follow-up, resulting in 28 patients with 35 keloids included in our study. The treatment protocol involved surgical excision for all keloids, with selective additional triamcinolone 40 mg/mL injection intraoperatively, immediate postoperative radiotherapy, or intraoperative triamcinolone injection with postoperative radiotherapy. Recurrence rates between the different treatment groups were calculated, and statistical analyses were performed using IBM SPSS Statistics, with a value of P < 0.05 deeming statistical significance. RESULTS Our study demonstrates that postoperative recurrence rates of primary and secondary keloids were 43% and 58%, respectively. Results of recurrence rate varied by specific treatment modality; keloid excision yielded a rate of only 54%, keloid excision with postoperative radiation yielded a rate of 83%, keloid excision with intraoperative triamcinolone injection yielded a rate of 33%, and keloid excision with a combination of intraoperative triamcinolone injection and postoperative radiation yielded a rate of 33%. CONCLUSION Patients of Afro-Caribbean and African American ethnicity are more heavily affected by the formation of keloids compared with other population groups. Results of varying modalities for keloid management demonstrate that patients who received a combination of excision with intraoperative triamcinolone injection, with or without postoperative radiation, had the lowest recurrence rates compared with other treatment protocols including excision alone and excision with postoperative radiation only.
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Affiliation(s)
- Elysa Margiotta
- From the General Surgery, Maimonides Medical Center, Brooklyn NY
| | - Sean Ramras
- General Surgery, Waterbury Hospital, Waterbury CT
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Optimizing surgical outcome of auricular keloid with a novel multimodal approach. Sci Rep 2022; 12:3533. [PMID: 35241718 PMCID: PMC8894473 DOI: 10.1038/s41598-022-07255-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/04/2022] [Indexed: 11/12/2022] Open
Abstract
Various treatments are available for auricular keloids, but none has an absolute advantage. A practical and safe therapy to optimize the surgical outcome for auricular keloids is needed. We adopted a multimodal treatment of surgical enucleation, core fillet flap reconstruction, intraoperative corticosteroid injection, and immediate postoperative radiotherapy. There were no routine intralesional corticosteroid injections during follow-up. Keloid recurrences, complications, and risk factors for recurrences were analyzed. The outcome was compared with other published literatures. 45 auricular keloids were included in this study. 85.7% were female with an average age of 27.1 ± 7.5 years, and averaged size was 1.8 × 1.2 ± 0.9 × 0.6 cm. 71.1% were located at ear helix with 28.9% at the ear lobe. Nine keloids were classified as Chang-Park classification type I, 30 for type II, two for type III, and four for IV. The average radiation dosage was 1578.6 cGy. The recurrence rate was 6.7% at an average 24.1-month follow-up. There were no complications of surgery, radiotherapy, and intralesional corticosteroid injection. Our recurrence rate was lower than those in mono-adjuvant therapies of intraoperative corticosteroid injection or radiotherapy. This one-session multimodal approach optimizes treating auricular keloids with a low recurrence rate and minimal post-radiation and long-term corticosteroid injection-related complications.
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Pires JA, Bragato EF, Momolli M, Guerra MB, Neves LM, de Oliveira Bruscagnin MA, Ratto Tempestini Horliana AC, Porta Santos Fernandes K, Kalil Bussadori S, Agnelli Mesquita Ferrari R. Effect of the combination of photobiomodulation therapy and the intralesional administration of corticoid in the preoperative and postoperative periods of keloid surgery: A randomized, controlled, double-blind trial protocol study. PLoS One 2022; 17:e0263453. [PMID: 35167583 PMCID: PMC8846523 DOI: 10.1371/journal.pone.0263453] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 01/20/2022] [Indexed: 11/18/2022] Open
Abstract
Keloid scars are characterized by the excessive proliferation of fibroblasts and an imbalance between the production and degradation of collagen, leading to its buildup in the dermis. There is no “gold standard” treatment for this condition, and the recurrence is frequent after surgical procedures removal. In vitro studies have demonstrated that photobiomodulation (PBM) using the blue wavelength reduces the proliferation speed and the number of fibroblasts as well as the expression of TGF-β. There are no protocols studied and established for the treatment of keloids with blue LED. Therefore, the purpose of this study is to determine the effects of the combination of PBM with blue light and the intralesional administration of the corticoid triamcinolone hexacetonide on the quality of the remaining scar by Vancouver Scar Scale in the postoperative period of keloid surgery. A randomized, controlled, double-blind, clinical trial will be conducted involving two groups: 1) Sham (n = 29): intralesional administration of corticoid (IAC) and sham PBM in the preoperative and postoperative periods of keloid removal surgery; and 2) active PBM combined with IAC (n = 29) in the preoperative and postoperative periods of keloid removal surgery. Transcutaneous PBM will be performed on the keloid region in the preoperative period and on the remaining scar in the postoperative period using blue LED (470 nm, 400 mW, 4J per point on 10 linear points). The patients will answer two questionnaires: one for the assessment of quality of life (Qualifibro-UNIFESP) and one for the assessment of satisfaction with the scar (PSAQ). The team of five plastic surgeons will answer the Vancouver Scar Scale (VSS). All questionnaires will be administered one, three, six, and twelve months postoperatively. The keloids will be molded in silicone prior to the onset of treatment and prior to excision to assess pre-treatment and post-treatment size. The same will be performed for the remaining scar at one, three, six, and twelve months postoperatively. The removed keloid will be submitted to histopathological analysis for the determination of the quantity of fibroblasts, the organization and distribution of collagen (picrosirius staining), and the genic expression of TGF-β (qPCR). All data will be submitted to statistical analysis.
Trial registration: This study is registered in ClinicalTrials.gov (ID: NCT04824612).
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Affiliation(s)
- Jefferson André Pires
- Department of Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- Department of Plastic Surgery, Mandaqui Hospital Complex, São Paulo, São Paulo, Brazil
| | - Erick Frank Bragato
- Department of Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Marcos Momolli
- Department of Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Marina Bertoni Guerra
- Department of Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Leonel Manea Neves
- Department of Plastic Surgery, Mandaqui Hospital Complex, São Paulo, São Paulo, Brazil
| | | | | | | | - Sandra Kalil Bussadori
- Department of Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
| | - Raquel Agnelli Mesquita Ferrari
- Department of Biophotonics Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- Department of Rehabilitation Science Applied to Health Sciences, Universidade Nove de Julho (UNINOVE), São Paulo, São Paulo, Brazil
- * E-mail:
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Dong W, Qiu B, Fan F. Adjuvant Radiotherapy for Keloids. Aesthetic Plast Surg 2022; 46:489-499. [PMID: 34415398 DOI: 10.1007/s00266-021-02442-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/20/2021] [Indexed: 11/24/2022]
Abstract
Radiotherapy is one of the therapeutic methods for keloids, and the irradiation technique has innovated from superficial X-ray to brachytherapy after decades of clinical practice. At present, the application of adjuvant radiotherapy has been widely accepted by clinicians, while the consensus of optimal adjuvant radiotherapy strategies for keloids has not been reached. Factors such as radiation timing, dose, fractions, and lesion locations may be associated with the clinical outcomes of patients with keloids after radiotherapy while a comprehensive review is lacking. Herein, this review summarized the published literature of adjuvant radiotherapy for keloids involving mechanism, timing, dose, fractions, and complications, etc., which may facilitate clinical decision making.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 .
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Affiliation(s)
- Wenfang Dong
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Badachu Road, Shijingshan District, Beijing, 100144, China
| | - Bin Qiu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, 100191, China
| | - Fei Fan
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Badachu Road, Shijingshan District, Beijing, 100144, China.
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Efficacy of Surgical Excision and Brachytherapy in the Treatment of Keloids: A Retrospective Cohort Study. Adv Skin Wound Care 2021; 33:1-6. [PMID: 33065689 DOI: 10.1097/01.asw.0000717228.02752.4e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate the efficacy of a protocol combining surgical excision and high-dose-rate brachytherapy for treatment of keloids. METHODS The authors performed a unicentric retrospective cohort study between 2013 and 2018. The minimum follow-up was 12 months. All patients treated for keloids at the authors' institution were included. Extralesional excision was performed with placement of a brachytherapy sheath under the skin. The total dose of irradiation was 18 Gy. The postoperative results were evaluated for aesthetic and functional outcomes with a validated scale, as well as the presence or absence of recurrence. RESULTS Fifteen patients were lost to follow-up. Thirty-eight patients with 67 keloids were included. The control rate was 94%. The aesthetic and functional outcomes were considered good in 62% of cases. The main limitation of the study was the small patient population. CONCLUSIONS Extralesional excision combined with postoperative high-dose-rate brachytherapy seems to be one of the most effective invasive protocols to treat and prevent keloids.
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The Effectiveness of Immediate Triamcinolone Acetonide Injection after Auricular Keloid Surgery: A Prospective Randomized Controlled Trial. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3729. [PMID: 34367855 PMCID: PMC8337065 DOI: 10.1097/gox.0000000000003729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/08/2021] [Indexed: 11/26/2022]
Abstract
The earlobe and helix are common sites for keloids following ear piercing. First-line therapy involves intra-keloidal excision followed by triamcinolone acetonide (TA) injection. Yet, the optimal timing for TA injection after keloid excision remains debated. The objective of this study was to compare outcomes between immediate and delayed TA injection after auricular keloid excision. Methods This was a prospective, controlled trial with patients randomized into immediate or delayed groups. The Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) were used to evaluate scar quality. The number of recurrent keloid cases was recorded, defined as a VSS height of 3, POSAS thickness greater than 5, or an increase in VSS height or POSAS thickness after keloid excision. Overall complications were recorded. A P value less than 0.05 was considered statistically significant. Results The immediate group contained 18 patients, and the delayed group had 16 patients. The mean age of patients was 25.52 years, and the mean maximum keloid diameter was 14.49 mm (7-32.5 mm). The immediate group reported a statistically significant lower recurrence rate than did the delayed group at 5 months (P = 0.042). No significant differences were noted between VSS and POSAS scores at 3 months, and no complications were recorded during the study. Conclusions Immediate TA injection is an acceptable option for auricular keloid treatment. Here, it was associated with a lower recurrence rate than with delayed injection and resulted in no complications. The immediate and delayed groups had similar outcomes for VSS and POSAS.
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Management of keloid scars: noninvasive and invasive treatments. Arch Plast Surg 2021; 48:149-157. [PMID: 33765731 PMCID: PMC8007468 DOI: 10.5999/aps.2020.01914] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/11/2021] [Indexed: 12/11/2022] Open
Abstract
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.
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A retrospective study of hypofractionated radiotherapy for keloids in 100 cases. Sci Rep 2021; 11:3598. [PMID: 33574426 PMCID: PMC7878871 DOI: 10.1038/s41598-021-83255-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/01/2021] [Indexed: 11/08/2022] Open
Abstract
At present, the consensus on the best treatment for keloids is the combination of clinical and surgical therapies, if necessary, associated with adjuvant radiotherapy like brachytherapy. Whereas, the uniform scheme of radiotherapy in keloids is unclear. Here, we conducting a retrospective analysis to assess the efficacy and safety of a specific treatment regimen (20 Gy in 5 fractions) in keloid patients. We retrospectively analysed the medical records of keloid patients receiving auxiliary postoperative radiotherapy (PORT) treatment from 2009 to 2019. The patients were treated with the hypofractionation method of 20 Gy in 5 fractions. We compared the local control rate and complications, using the chi-square test and logistic regression analyses. After screening, we identified 100 keloid patients in this study, with a median follow-up of 59 months. In this study, the overall local control rate of keloid lesions was 84.8%. After multivariate analyses (primary keloid or not, family history, interval from surgery to irradiation and site), our research showed that primary keloid, site and interval from surgery to irradiation were significantly related to recurrence. Acute radiation injury and late radiation injury accounted for 3% (erythema) and 1% (skin sclerosis) of the total cases, respectively. Our results indicate that a postoperative hypofractionation with radiation dose of 20 Gy in 5 fractions may be effective, easy to accept and safe for keloid patients.
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Aljodah MA, Alfeehan M, Al-Zajrawee M. Outcome of recurrent auricular keloid treatment with a combination of surgical excision and perioperative corticosteroid injection. J Cutan Aesthet Surg 2021; 14:392-396. [PMID: 35283593 PMCID: PMC8906279 DOI: 10.4103/jcas.jcas_186_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Auricular keloids that occur after ear piercing or other traumas can challenge surgeons as recurrence is frequent; there has been no consensus about the best management protocol. Surgical excision combined with perioperative corticosteroid injections is frequently used as first-line therapy, but recurrent auricular keloids are usually shifted to a combination of radiotherapy and surgical excision. Objectives: The objective is to evaluate the rate of recurrence when recurrent auricular keloids are treated with surgical excision with perioperative corticosteroid injections. Materials and Methods: Between February 2017 and January 2020, 41 patients (52 auricles) with recurrent auricular keloids were treated by extralesional keloid excision combined with five corticosteroid steroid injections (two preoperative, one intraoperative, and two postoperative doses). Recurrence was recorded if the surgical scar showed hypertrophy or started to rise above the level of the margins. Results: The mean postoperative follow-up was 13.04 months (ranging from 6 to 24 months). Recurrence was recorded in five auricles (9.6%) during the follow-up period. Conclusion: Perioperative corticosteroid injections combined with surgical excision of auricular keloids are still a valid option in recurrent cases, and it is a useful choice when radiotherapy facilities are limited.
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Hadedeya D, Shalaby M, Akkera M, Lee G, Harris K, Kholmatov R, Anwar M, Murad F, Alawaad S, Kandil E. Prophylactic external beam radiation therapy for keloid prevention in thyroid surgery patients. Gland Surg 2021; 10:65-72. [PMID: 33633963 PMCID: PMC7882325 DOI: 10.21037/gs-20-511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/18/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Poor cosmesis, secondary to keloid or hypertrophic scar, following thyroid surgery may cause considerable patient distress and be a significant challenge to treat. In this case series we examined the efficacy of prophylactic external beam radiation therapy (EBRT) for prevention of keloid formation in keloid-prone patients undergoing thyroid surgery. While much has been published about documenting the efficacy in reducing keloid formation following keloid excision, very little literature exists documenting prophylactic use related to surgeries with the goal of prevent de novo keloid formation. METHODS We retrospectively evaluated a series of ten patients, who underwent a prophylactic EBRT for keloid prevention after thyroid surgery between January 2013 and February 2019. Patient demographics, primary diagnosis, surgical procedure, EBRT dosage, and post-operative visit records were reviewed. RESULTS All ten patients who received EBRT for keloid prophylaxis following a thyroid surgery were female. Half of the patients were African Americans, 40% Caucasians, and 10% Hispanic. The mean age was 46.40±15.63 years with BMI of 31.5±5.5 kg/m2. Radiation was initiated within 6 hours of the surgery with an average radiation dose per session of 5.7±1.7 Gy. The total average EBRT dose delivered was 17.4±4.2 Gy. Mean follow-up period was 13 months post-thyroidectomy, with the longest follow-up at 23 months. One patient, who underwent a lateral neck dissection in addition to thyroid surgery, developed hypertrophic scar in less than 10% of her incision length. Nine other patients (90%) showed no post-surgical keloid nor hypertrophic scar formation and patients were satisfied with postsurgical cosmesis. CONCLUSIONS We examined the efficacy of prophylactic EBRT in keloid-prone patients undergoing thyroid surgery. Prophylactic EBRT following thyroid surgery is effective in achieving a satisfactory cosmetic outcome in patients at high risk for keloid formation.
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Affiliation(s)
- Deena Hadedeya
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mahmoud Shalaby
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mounika Akkera
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Grace Lee
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Kendra Harris
- Department of Radiation Oncology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Roostam Kholmatov
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Muhammad Anwar
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Fadi Murad
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Saad Alawaad
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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Gold MH, Nestor MS, Berman B, Goldberg D. Assessing keloid recurrence following surgical excision and radiation. BURNS & TRAUMA 2020; 8:tkaa031. [PMID: 33225004 PMCID: PMC7666880 DOI: 10.1093/burnst/tkaa031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/02/2020] [Accepted: 06/28/2020] [Indexed: 01/01/2023]
Abstract
Keloids are a fibroproliferative disorder that can result from a cutaneous injury to the reticular dermis. Recurrence rates as high as 100% have been reported following surgical excision alone. Consequently, a variety of post-surgical techniques have been employed to prevent keloid recurrence, including the use of radiation. Although numerous studies have shown post-excisional X-rays, electron beam, lasers and brachytherapy can reduce the rate of keloid recurrence, numerous inconsistencies, including a wide range of definitions for keloid recurrence, make it difficult to compare study outcomes. The review aims to examine the various means for defining keloid recurrence in clinical trials involving the use of radiation therapy. Searches of the Cochrane Library and PubMed were performed to identify the available information for post-surgical keloid recurrence following radiation therapy. Each identified study was reviewed for patient follow-up and criteria used to define keloid recurrence. The search results included clinical studies with external beam radiation, brachytherapy and superficial radiation therapy. Many studies did not include a definition of keloid recurrence, or defined recurrence only as the return of scar tissue. Other studies defined keloid recurrence based on patient self-assessment questionnaires, symptoms and scar elevation and changes in Kyoto Scar Scale, Japan Scar Workshop Scale and Vancouver Scar Scale scores. The results of this review indicate keloidectomy followed by radiation therapy provide satisfactory recurrence rates; however, clinical studies evaluating these treatments do not describe treatment outcomes or use different definitions of keloid recurrence. Consequently, recurrence rates vary widely, making comparisons across studies difficult. Keloid recurrence should be clearly defined using both objective and subjective measures.
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Affiliation(s)
- Michael H Gold
- Gold Skin Care Center, 2000 Richard Jones Road, Suite 220, Nashville, TN 37215
| | - Mark S Nestor
- Center for Clinical and Cosmetic Research, 2925 NE 199th St, Suite 205, Aventura, FL 33180
| | - Brian Berman
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - David Goldberg
- Skin Laser & Surgery Specialists of NY/NJ, 110 E. 55th Street, 13th floor, New York, NY 10022
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Treatment of keloids with a single dose of low-energy superficial X-ray radiation to prevent recurrence after surgical excision: An in vitro and in vivo study. J Am Acad Dermatol 2020; 83:1304-1314. [PMID: 32540415 DOI: 10.1016/j.jaad.2020.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although keloids have been empirically treated with steroids and radiation, evidence-based radiation parameters for keloid therapy are lacking. OBJECTIVE To determine evidence-based radiation parameters for blocking keloid fibroblast proliferation in vitro and apply them to patients. METHODS The effects of various radiation parameters and steroids on cell proliferation, cell death, and collagen production in keloid explants and fibroblasts were evaluated with standard assays. Effective radiation parameters were then tested on patients. RESULTS No differences were observed between the effects of 50 and 320 kV radiation or between single and fractionated radiation doses on keloid fibroblasts. A 3 Gy, 50 kV dose inhibited keloid fibroblast proliferation in culture, whereas 9 Gy completely blocked their outgrowth from explants by inducing multiple cell death pathways and reducing collagen levels. Thirteen of 14 keloids treated with a single 8 Gy, 50 kV dose of radiation did not recur, although 4 patients with 6 keloids were lost to follow-up. LIMITATIONS Seventy-five percent of patients received steroids for pruritus, whereas approximately 25% of patients were lost to follow-up. CONCLUSIONS A single 8 Gy dose of superficial 50 kV radiation delivered an average of 34 days after keloid excision maybe sufficient to minimize recurrence, including in individuals resistant to steroids. Higher radiation energies, doses, or fractions may be unnecessary for keloid therapy.
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Maemoto H, Iraha S, Arashiro K, Ishigami K, Ganaha F, Murayama S. Risk factors of recurrence after postoperative electron beam radiation therapy for keloid: Comparison of long-term local control rate. Rep Pract Oncol Radiother 2020; 25:606-611. [PMID: 32523428 DOI: 10.1016/j.rpor.2020.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/25/2020] [Accepted: 05/06/2020] [Indexed: 11/17/2022] Open
Abstract
Aim To investigate the new risk factors for keloid recurrence after postoperative electron beam radiotherapy (RT) and evaluate the effectiveness of tranilast in combination with electron beam RT by comparing the local control rate. Background Identifying patients at high risk of recurrence after postoperative RT for keloids remains a challenge. Besides, no study examined the effectiveness of tranilast in combination with RT after surgery for the prevention of keloids recurrence. Materials and Methods This study included 75 lesions in 59 consecutive patients who had undergone postoperative RT at our institute. The follow-up period and prescription of tranilast were examined beside several potential risk factors, such as multiple lesions, size, and shape. Results The median follow-up was 72 months (range, 6-147 months). Twenty-one lesions in 17 patients recurred in a median of 12 months after treatment (range, 1-60 months). Local control rates of all 75 lesions were estimated as 93%, 78%, 70%, and 68% at 1, 2, 5, and 10 years. Multiple lesions constituted a significant risk of recurrence (P = 0.03). A larger long axis was significantly related to the recurrence (P < 0.01). Irregular shape was associated with a significantly worse local control rate (P = 0.02). There was no significant difference in the local control rate between patients receiving tranilast and those who did not (P = 0.52). Conclusions Multiple lesions and irregular shape were risk factors of keloid recurrence after postoperative electron beam RT. The effectiveness of tranilast was not demonstrated in the study.
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Affiliation(s)
- Hitoshi Maemoto
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa, Japan
| | - Shiro Iraha
- Department of Radiology, Okinawa Prefectural Nanbu Medical Center & Children's Medical Center, Okinawa, Japan
| | | | - Kousei Ishigami
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa, Japan
| | - Fumikiyo Ganaha
- Department of Radiology, Okinawa Prefectural Nanbu Medical Center & Children's Medical Center, Okinawa, Japan
| | - Sadayuki Murayama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa, Japan
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Choi YJ, Lee YH, Lee HJ, Lee GY, Kim WS. Auricular keloid management in Asian skin: Clinical outcome of intralesional excision and postoperative triamcinolone acetonide intralesional injection. J Cosmet Dermatol 2020; 19:3041-3047. [PMID: 32301234 DOI: 10.1111/jocd.13383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 03/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Various options such as surgical excision, steroid injection, cryotherapy, pressure dressing, and radiation therapy are available for the treatment of auricular keloids. In particular, auricular keloid therapy using surgical excision is important because recurrence rates are low compared with keloids occurring in other parts of the body. AIMS We aimed to evaluate the clinical outcomes of intralesional excision followed by postoperative triamcinolone acetonide intralesional injection (TA ILI) as auricular keloid treatments. METHODS We conducted a surgery records and chart review of patients who underwent auricular keloid treatment with intralesional excision and TA ILI. Reduction in height and volume was assessed by two blinded dermatologists. We also analyzed the recurrence rate over a 2-year period and evaluated patient satisfaction using an 11-point questionnaire (0-10). RESULTS Eighteen Korean patients (2 males and 16 females) with a mean age of 26.5 years and a total of 20 lesions were evaluated. Lesion types by descending frequency were lobular (n = 10, 50%), anterior/posterior button (n = 3, 15%), wrap-around (n = 3, 15%), dumbbell (n = 2, 10%), and sessile (n = 2, 10%). The total recurrence rate was 5% (1/20) within the 24-month follow-up period. Significant reduction (> 50%) in height and volume was achieved in 95% of patients. No serious or persistent adverse events were reported during the follow-up period. CONCLUSION We confirmed that TA ILI after intralesional excision can be effective for auricular keloid management. A low recurrence rate similar to that of postoperative radiation therapy was obtained with an effective surgical procedure and minimal postoperative treatment.
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Affiliation(s)
- Young-Jun Choi
- Department of Dermatology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Ho Lee
- Department of Dermatology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heun Joo Lee
- Department of Dermatology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ga-Young Lee
- Department of Dermatology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won-Serk Kim
- Department of Dermatology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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desJardins-Park HE, Mascharak S, Chinta MS, Wan DC, Longaker MT. The Spectrum of Scarring in Craniofacial Wound Repair. Front Physiol 2019; 10:322. [PMID: 30984020 PMCID: PMC6450464 DOI: 10.3389/fphys.2019.00322] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 03/11/2019] [Indexed: 12/11/2022] Open
Abstract
Fibrosis is intimately linked to wound healing and is one of the largest causes of wound-related morbidity. While scar formation is the normal and inevitable outcome of adult mammalian cutaneous wound healing, scarring varies widely between different anatomical sites. The spectrum of craniofacial wound healing spans a particularly diverse range of outcomes. While most craniofacial wounds heal by scarring, which can be functionally and aesthetically devastating, healing of the oral mucosa represents a rare example of nearly scarless postnatal healing in humans. In this review, we describe the typical wound healing process in both skin and the oral cavity. We present clinical correlates and current therapies and discuss the current state of research into mechanisms of scarless healing, toward the ultimate goal of achieving scarless adult skin healing.
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Affiliation(s)
- Heather E. desJardins-Park
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Shamik Mascharak
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Malini S. Chinta
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Derrick C. Wan
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Michael T. Longaker
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, United States
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Yeo DC, Wiraja C, Miao Q, Ning X, Pu K, Xu C. Anti-Scarring Drug Screening with Near-Infrared Molecular Probes Targeting Fibroblast Activation Protein-α. ACS APPLIED BIO MATERIALS 2018; 1:2054-2061. [DOI: 10.1021/acsabm.8b00528] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- David C. Yeo
- School of Chemical and Biomedical Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459, Singapore
| | - Christian Wiraja
- School of Chemical and Biomedical Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459, Singapore
| | - Qingqing Miao
- School of Chemical and Biomedical Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459, Singapore
| | - Xiaoyu Ning
- School of Chemical and Biomedical Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459, Singapore
- NTU Institute for Health Technologies, Interdisciplinary Graduate School, Nanyang Technological University, 50 Nanyang Drive, Singapore 637553, Singapore
| | - Kanyi Pu
- School of Chemical and Biomedical Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459, Singapore
| | - Chenjie Xu
- School of Chemical and Biomedical Engineering, Nanyang Technological University, 62 Nanyang Drive, Singapore 637459, Singapore
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The Effects of Postoperative Intralesional Corticosteroids in the Prevention of Recurrent Earlobe Keloids: A Multispecialty Retrospective Review. Dermatol Surg 2018; 44:865-869. [DOI: 10.1097/dss.0000000000001474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Khalid FA, Farooq UK, Saleem M, Rabbani J, Amin M, Khan KU, Mehrose Y, Tarar MN. The efficacy of excision followed by intralesional 5-fluorouracil and triamcinolone acetonide versus excision followed by radiotherapy in the treatment of ear keloids: A randomized control trial. Burns 2018. [PMID: 29534885 DOI: 10.1016/j.burns.2018.02.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The ear is the common site for keloid formation especially in women after ear piercing. Surgery is the main stay of treatment in these lesions but there are large numbers of treatment failures in surgery alone. OBJECTIVE The objective of this study was to compare the efficacy of post-excision intralesional 5-fluorouracil/triamcinolone acetonide (5-FU/TAC) and post-excision radiotherapy in the treatment of ear keloids. STUDY DESIGN A randomized controlled trial. SETTING The study was conducted from May 2014 to January 2015 at Jinnah Burn and Reconstructive Surgery Centre, Allama Iqbal Medical College, Lahore. SUBJECT & METHODOLOGY After approval from the hospital ethical committee, 60 patients presented in the outpatient department fulfilling the inclusion criteria were selected and randomly assigned in two groups with the help of the random number table. Patients in group A had excision followed by intralesional 5-FU/TAC injections while patients of group B had excision followed by radiotherapy. Patients were assessed at 6 months after completion of treatment for efficacy (no recurrence within 6 months of treatment). RESULTS In our study total of 60 patients completed the study, with 30 patients in each group. 7 patients (23.34%) in Group-A and 9 patients (30%) in Group-B were males while 23 patients (76.67%) in Group-A and 21 patients (70%) in Group-B were females i.e. male to female ratio is 1:2.75. Mean age was 31.8+6.48years. The comparison of frequency of efficacy in both groups showed that 73.33% (n=22) in Group-A and 43.33% (n=13) in Group-B had efficacy, p value was calculated as 0.01, showing a significant statistical difference. CONCLUSION Excision and intralesional 5-FU/TAC is an effective treatment for keloids on the ears.
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Affiliation(s)
- Farrukh Aslam Khalid
- Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, Lahore, Pakistan; Children Reconstructive Surgery and Research Centre, Shalamar Hospital/Shalamar Medical College, Lahore, Pakistan.
| | - Usman Khalid Farooq
- Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, Lahore, Pakistan
| | - Muhammad Saleem
- Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, Lahore, Pakistan
| | - Jibran Rabbani
- Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, Lahore, Pakistan; Children Reconstructive Surgery and Research Centre, Shalamar Hospital/Shalamar Medical College, Lahore, Pakistan
| | - Muhammad Amin
- Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, Lahore, Pakistan
| | - Kamal Uddin Khan
- Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, Lahore, Pakistan
| | - Younas Mehrose
- Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, Lahore, Pakistan
| | - Moazzam N Tarar
- Jinnah Burn and Reconstructive Surgery Center, Allama Iqbal Medical College, Lahore, Pakistan
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Greywal T, Krakowski AC. Pediatric dermatology procedures and pearls: Multimodal revision of earlobe keloids. Pediatr Dermatol 2018; 35:268-270. [PMID: 29266377 DOI: 10.1111/pde.13374] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Keloid scars are benign proliferations of fibrous tissue and collagen that usually occur in response to cutaneous injury. Many treatment modalities have been described in the literature, with variable rates of recurrence and no clear consensus. Keloids remain a therapeutic challenge to patients and physicians alike. Herein we describe a novel technique for treating recurrent earlobe keloids in an outpatient setting with multimodal therapy including shave removal followed immediately by ablative fractional laser resurfacing (AFR) and laser-assisted delivery (LAD) of corticosteroids.
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Affiliation(s)
- Tanya Greywal
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital and University of California at San Diego, San Diego, CA, USA
| | - Andrew C Krakowski
- Division of Pediatric and Adolescent Dermatology, Rady Children's Hospital and University of California at San Diego, San Diego, CA, USA.,DermOne, West Conshohocken, PA, USA
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Marshall CD, Hu MS, Leavitt T, Barnes LA, Lorenz HP, Longaker MT. Cutaneous Scarring: Basic Science, Current Treatments, and Future Directions. Adv Wound Care (New Rochelle) 2018; 7:29-45. [PMID: 29392092 DOI: 10.1089/wound.2016.0696] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 07/01/2016] [Indexed: 12/12/2022] Open
Abstract
Significance: Scarring of the skin from burns, surgery, and injury constitutes a major burden on the healthcare system. Patients affected by major scars, particularly children, suffer from long-term functional and psychological problems. Recent Advances: Scarring in humans is the end result of the wound healing process, which has evolved to rapidly repair injuries. Wound healing and scar formation are well described on the cellular and molecular levels, but truly effective molecular or cell-based antiscarring treatments still do not exist. Recent discoveries have clarified the role of skin stem cells and fibroblasts in the regeneration of injuries and formation of scar. Critical Issues: It will be important to show that new advances in the stem cell and fibroblast biology of scarring can be translated into therapies that prevent and reduce scarring in humans without major side effects. Future Directions: Novel therapies involving the use of purified human cells as well as agents that target specific cells and modulate the immune response to injury are currently undergoing testing. In the basic science realm, researchers continue to refine our understanding of the role that particular cell types play in the development of scar.
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Affiliation(s)
- Clement D. Marshall
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael S. Hu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Tripp Leavitt
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Leandra A. Barnes
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - H. Peter Lorenz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael T. Longaker
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Ramirez-Fort MK, Meier B, Feily A, Cooper SL, Lange CS. Adjuvant irradiation to prevent keloidal fibroproliferative growth should be standard of care. Br J Dermatol 2017; 177:e327-e328. [PMID: 28730611 DOI: 10.1111/bjd.15667] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M K Ramirez-Fort
- Radiation Oncology, Medical University of South Carolina, Charleston, SC, U.S.A.,Urology, Weill Cornell Medicine, New York, NY, U.S.A.,Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, NY, U.S.A
| | - B Meier
- Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - A Feily
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - S L Cooper
- Radiation Oncology, Medical University of South Carolina, Charleston, SC, U.S.A
| | - C S Lange
- Radiation Oncology, State University of New York Downstate Medical Center, Brooklyn, NY, U.S.A
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Michael AI, Ademola SA, Olawoye OA, Iyun AO, Adebayo W, Oluwatosin OM. Pediatric keloids: A 6-year retrospective review. Pediatr Dermatol 2017; 34:673-676. [PMID: 29023993 DOI: 10.1111/pde.13302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND/OBJECTIVES Keloids are reportedly rare at the extremes of life. We sought to describe the epidemiology of pediatric keloids seen at the plastic surgery outpatient department of the University College Hospital, Ibadan. METHODS We retrospectively reviewed all children younger than 19 years who presented with nonburn keloids between 2008 and 2014. Data were obtained on age; duration, size, and location of the keloid; family history; mode of treatment; and outcome. Outcome variables were recurrence and wound complications. Data were analyzed using the Pearson chi-square test for discreet variables and the independent-sample t test for continuous variables. P < .05 was taken as statistically significant. RESULTS Within the review period, 304 patients presented with keloids, of whom 40 (13.1%) were younger than 19 years. There was a female preponderance (n = 23, 57.5%). The mean age at onset of the keloid was 9.3 years (range 3 months-18 years). Thirty (75%) patients had keloids in the head and neck region. Keloids were sporadic in 31 (77.5%) patients. Nineteen (47.5%) patients had multimodal treatment for keloid. The recurrence rate was 20%. Recurrence was significantly associated with the size of the lesion (P = .003). CONCLUSION Keloids during childhood are not rare. More attention should be paid to the management of keloids in this age group.
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Affiliation(s)
- Afieharo I Michael
- Department of Plastic, Reconstructive and Esthetic Surgery, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Samuel A Ademola
- Department of Plastic, Reconstructive and Esthetic Surgery, University College Hospital, Ibadan, Oyo State, Nigeria.,Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Olayinka A Olawoye
- Department of Plastic, Reconstructive and Esthetic Surgery, University College Hospital, Ibadan, Oyo State, Nigeria.,Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Ayodele O Iyun
- Department of Plastic, Reconstructive and Esthetic Surgery, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Wasiu Adebayo
- Department of Plastic, Reconstructive and Esthetic Surgery, University College Hospital, Ibadan, Oyo State, Nigeria
| | - Odunayo M Oluwatosin
- Department of Plastic, Reconstructive and Esthetic Surgery, University College Hospital, Ibadan, Oyo State, Nigeria.,Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
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Treatment of Keloids With Excision and Adjuvant Radiation: A Single Center Experience and Review of the Literature. Ann Plast Surg 2017; 78:157-161. [PMID: 27775986 DOI: 10.1097/sap.0000000000000903] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management of keloids has remained a conundrum, because an optimum treatment regimen has yet to be elucidated. Currently, treatment varies widely between more conservative measures, such as steroid injections, topical medications, and silicone sheeting, to more aggressive options, such as surgery and postoperative radiation. The latter combination has been touted to have superior results, with the lowest rates of pathologic scar recurrence. METHODS We performed a retrospective review to critically evaluate the effectiveness of surgical excision and radiation treatment in patients with keloids. Surgical resection of surgeon-selected keloids, combined with state-of-the-art postoperative cutaneous radiation therapy, was used at a major tertiary referral center. For patients with poor follow-up, phone calls were made to determine recurrence. In addition, we present a review of the current literature to provide a comprehensive synopsis of current keloid treatment. RESULTS A total of 69 patients' records were reviewed. There were a total of 84 keloids upon pathology review. The overall recurrence rate for all keloids was 27%, and in those followed greater than 1 year, recurrence for keloids was 74%. About half the patients with more than 1 year of follow-up experienced recurrence more than 1 year after treatment. CONCLUSIONS At this time, the evidence supporting surgery and radiation for the treatment of keloids remains equivocal, and randomized controlled studies are needed to determine the efficacy of this treatment protocol. Most importantly, our data reinforce the need for long-term follow-up in this patient population.
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Abstract
BACKGROUND Keloid and hypertrophic scars represent an aberrant response to the wound healing process. These scars are characterized by dysregulated growth with excessive collagen formation, and can be cosmetically and functionally disruptive to patients. OBJECTIVE Objectives are to describe the pathophysiology of keloid and hypertrophic scar, and to compare differences with the normal wound healing process. The classification of keloids and hypertrophic scars are then discussed. Finally, various treatment options including prevention, conventional therapies, surgical therapies, and adjuvant therapies are described in detail. MATERIALS AND METHODS Literature review was performed identifying relevant publications pertaining to the pathophysiology, classification, and treatment of keloid and hypertrophic scars. RESULTS Though the pathophysiology of keloid and hypertrophic scars is not completely known, various cytokines have been implicated, including interleukin (IL)-6, IL-8, and IL-10, as well as various growth factors including transforming growth factor-beta and platelet-derived growth factor. Numerous treatments have been studied for keloid and hypertrophic scars,which include conventional therapies such as occlusive dressings, compression therapy, and steroids; surgical therapies such as excision and cryosurgery; and adjuvant and emerging therapies including radiation therapy, interferon, 5-fluorouracil, imiquimod, tacrolimus, sirolimus, bleomycin, doxorubicin, transforming growth factor-beta, epidermal growth factor, verapamil, retinoic acid, tamoxifen, botulinum toxin A, onion extract, silicone-based camouflage, hydrogel scaffold, and skin tension offloading device. CONCLUSION Keloid and hypertrophic scars remain a challenging condition, with potential cosmetic and functional consequences to patients. Several therapies exist which function through different mechanisms. Better understanding into the pathogenesis will allow for development of newer and more targeted therapies in the future.
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Carvajal CC, Ibarra CM, Arbulo DL, Russo MN, Solé CP. Postoperative radiotherapy in the management of keloids. Ecancermedicalscience 2016; 10:690. [PMID: 27994646 PMCID: PMC5130331 DOI: 10.3332/ecancer.2016.690] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Indexed: 11/29/2022] Open
Abstract
Background The high recurrence rate following keloid resection has generated interest in adjuvant treatments for this disease. Objective This study assesses keloid recurrence when treated with surgery and adjuvant radiotherapy. Methods Retrospective analysis of resected keloids in patients referred to a Chilean radiation oncology centre between 2006 and 2013. Local recurrence was defined as new tissue growth on the surgical scar margin. Results Around103 keloids were analysed in 63 patients treated with 15 Gy in three fraction radiotherapy which was initiated on the same day as the surgery (75% of cases). The median keloid diameter was 6 cm; the most common site was thoracic (22%); the most common cause was prior surgery (35%); 37% caused symptoms, and several (47%) had received prior treatment with corticosteroids (32%), or surgery (30%). The median follow-up was three years, and 94% of recurrences occurred during the first year following treatment. Uni and multivariate analyses showed that an absence of symptoms was a protective factor for recurrence (OR: 0.24), while the time interval from onset to treatment with surgery plus radiotherapy >4.2 years was a risk factor (OR: 2.23). The first year recurrence rate was 32% and stabilised at 32% by the second year with no recurrences after 15 months. Conclusions The combination of surgery and radiotherapy proved to be a good therapeutic alternative in the management of keloids. Our results are similar to those described in the literature for a dose of 15 Gy. Given these results, our centre will implement a new dose escalation protocol to improve future outcomes.
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Affiliation(s)
| | - Carla M Ibarra
- Servicio de Cirugía General, Hospital Militar, Santiago, Chile
| | | | - Moisés N Russo
- Servicio de Radioterapia, Clínica IRAM, Santiago 7630595, Chile
| | - Claudio P Solé
- Service de Radiothérapie, Institut Gustave Roussy, París 94805, France
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Brachytherapy of the Skin: Cancers and Other Diseases. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Shin JY, Kim JS. Could 5-Fluorouracil or Triamcinolone Be an Effective Treatment Option for Keloid After Surgical Excision? A Meta-Analysis. J Oral Maxillofac Surg 2015; 74:1055-60. [PMID: 26529198 DOI: 10.1016/j.joms.2015.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/03/2015] [Accepted: 10/05/2015] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Jin Yong Shin
- Professor, Department of Plastic and Reconstructive Surgery, College of Medicine, Chonbuk National University, Jeonju, Korea
| | - Jong Seung Kim
- Professor, Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Chonbuk National University, Jeonju, Korea.
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Surgical Excision with Adjuvant Irradiation for Treatment of Keloid Scars: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e440. [PMID: 26301129 PMCID: PMC4527614 DOI: 10.1097/gox.0000000000000357] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/20/2015] [Indexed: 11/26/2022]
Abstract
Background: Excision followed by adjuvant irradiation is considered safe and most efficacious for treatment of keloid scars. Recently, different authors published successful treatment protocols and recommended the following: (1) the use of high-dose-rate brachytherapy instead of low-dose-rate brachytherapy or external radiation; (2) a short-time interval between operation and irradiation; (3) single fraction instead of multifraction irradiation; and (4) a minimum of 12- to 24-month follow-up post treatment. Methods: This study evaluates the above recommendations with a systematic review of the English-language literature, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Both PubMed and EMBASE were searched. Studies were graded according to the American Society of Plastic Surgeons Rating Levels of Evidence. Results: Thirty-three studies were selected. Six studies were graded as level of evidence type II studies and 27 as type III. High-dose-rate brachytherapy showed lower recurrence rates compared with low-dose-rate brachytherapy and external radiation. A short-time (<7 hours) interval between scar excision and irradiation results in a lower recurrence rate compared with long-time intervals (>24 hours). Single-fraction irradiation showed promising results in terms of recurrence rate and patient convenience. Finally, scar recurrences were seen between 2 and 36 months, with a mean of 15 months. Conclusions: Based on this systematic review of the literature, the evidence confirms the recommendations stated by authors in the recent years. However, due to the lack of high-quality randomized studies, the quality of this evidence is limited. More randomized studies will generate stronger recommendations.
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Determination of the optimal frequency of injection of triamcinolone: monitoring change in volume of keloid lesions following injection of 40 mg of triamcinolone. EUROPEAN JOURNAL OF PLASTIC SURGERY 2015. [DOI: 10.1007/s00238-015-1139-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Taheri A, Moradi Tuchayi S, Alinia H, Orscheln CS, Mansoori P, Feldman SR. Topical clobetasol in conjunction with topical tretinoin is effective in preventing scar formation after superficial partial-thickness burn ulcers of the skin: A retrospective study. J DERMATOL TREAT 2014; 26:361-4. [PMID: 25424054 DOI: 10.3109/09546634.2014.991677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Deep erythema and inflammation after re-epithelialization of superficial wounds is a sign of scar formation. Corticosteroids may prevent scarring by suppression of inflammation and fibroblast activity. Tretinoin may increase the efficacy of corticosteroids in this setting. OBJECTIVE To evaluate the efficacy of corticosteroids plus tretinoin for prevention of scars after superficial wounds. METHODS In a retrospective study of patients with superficial partial thickness thermal skin burn, we compared the patients who received clobetasol plus tretinoin after re-epithelialization with patients who did not receive any medication. Clobetasol propionate 0.05% ointment was used twice daily with overnight occlusive dressing in conjunction with twice weekly topical tretinoin 0.05% cream. RESULTS Among 43 patients who had light pink or no erythema after re-epithelialization and consequently did not receive clobetasol + tretinoin, no scar was developed. Among patients who had deep erythema after re-epithelialization, rate of scar formation was significantly higher in 14 patients who did not receive clobetasol + tretinoin than in 21 patients who received clobetasol + tretinoin (64% and 19%, respectively; p = 0.01). CONCLUSION Clobetasol + tretinoin can significantly decrease the incidence of scar formation in patients with inflammation after re-epithelialization of superficial wounds.
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Affiliation(s)
- Arash Taheri
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine , Winston-Salem, NC , USA
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Ji J, Tian Y, Zhu YQ, Zhang LY, Ji SJ, Huan J, Zhou XZ, Cao JP. Ionizing irradiation inhibits keloid fibroblast cell proliferation and induces premature cellular senescence. J Dermatol 2014; 42:56-63. [PMID: 25425417 DOI: 10.1111/1346-8138.12702] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 10/06/2014] [Indexed: 11/27/2022]
Abstract
Keloids are one of the common refractory conditions in dermatology and aesthetic plastic surgery. The most effective treatment is superficial radiotherapy followed by surgical removal. The rate of recurrence is strongly associated with the total dose of ionizing irradiation, and the underlying mechanism remains unclear. In this study, we used primary keloid fibroblasts (KFb) isolated from patient samples to investigate the effects of X-ray radiation on cell proliferation, cell toxicity and cell cycle, as detected by CCK-8 assay kit and flow cytometer. In addition, we examined senescence-associated β-galactosidase activity and the associated gene expression using real-time polymerase chain reaction and western blot in KFb exposed to X-ray radiation. X-ray radiation inhibited cell proliferation and induced cell senescence in KFb in a dose-dependent manner. Inhibition of cell proliferation and induction of cellular senescence were mediated by interruption of the cell cycle with an extended G0/G1 phase. Furthermore, the expressions of senescence-associated genes p21, p16 and p27 were upregulated both at mRNA and protein levels in KFb exposed to X-ray radiation. Taken together, our data indicate that X-ray radiation may prevent the recurrence of keloids by controlling fibroblast proliferation, arresting the cell cycle and inducing premature cellular senescence.
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Affiliation(s)
- Jiang Ji
- Department of Dermatology, The Second Affiliated Hospital of Soochow University, Suzhou, China
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Abstract
This article presents an overview of the literature regarding treatments for keloid disease, hypertrophic scars, and striae distensae in dark pigmented skin. Striae, keloid, and hypertrophic scarring present a challenging problem for both the clinician and patient. No single therapy is advocated for hypertrophic scars, keloid scars, or striae distensae. New therapies have shown promise in the treatment of hypertrophic and keloid scars, and in patients with dark pigmented skin. This article provides guidance on the assessment and determination of patients' suitability for certain treatment options, as well as advice on the follow-up of patients affected with problematic scarring and striae.
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Affiliation(s)
- Sara Ud-Din
- Plastic and Reconstructive Surgery Research, Manchester Institute of Biotechnology, University of Manchester, 131 Princess Street, Manchester M1 7DN, UK; Plastic and Reconstructive Surgery Research, Faculty of Medical and Human Sciences, Institute of Inflammation and Repair, University Hospital of South Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Ardeshir Bayat
- Plastic and Reconstructive Surgery Research, Manchester Institute of Biotechnology, University of Manchester, 131 Princess Street, Manchester M1 7DN, UK; Plastic and Reconstructive Surgery Research, Faculty of Medical and Human Sciences, Institute of Inflammation and Repair, University Hospital of South Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
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Abstract
Most surgical patients end up with a scar and most of these would want at least some improvement in the appearance of the scar. Using sound techniques for wound closure surgeons can, to a certain extent, prevent suboptimal scars. This article reviews the principles of prevention and treatment of suboptimal scars. Surgical techniques of scar revision, i.e., Z plasty, W plasty, and geometrical broken line closure are described. Post-operative care and other adjuvant therapies of scars are described. A short description of dermabrasion and lasers for management of scars is given. It is hoped that this review helps the surgeon to formulate a comprehensive plan for management of scars of these patients.
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Affiliation(s)
- Mohit Sharma
- Department of Plastic Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Abhijeet Wakure
- Department of Plastic Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Ud-Din S, Bayat A. Strategic management of keloid disease in ethnic skin: a structured approach supported by the emerging literature. Br J Dermatol 2014; 169 Suppl 3:71-81. [PMID: 24098903 DOI: 10.1111/bjd.12588] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2013] [Indexed: 12/11/2022]
Abstract
Keloid disease (KD) is a common, benign, dermal fibroproliferative growth of unknown aetiology. Lesions tend to grow over time; they often recur following therapy and do not regress spontaneously. KD causes considerable discomfort due to pain, pruritus and inflammation, and a significant psychosocial impact with reduced quality of life. It is unique to humans and occurrence is higher in individuals with dark, pigmented, ethnic skin. There is a strong familial heritability, with a high ethnic predisposition in individuals of African, Asian and Hispanic descent. High recurrence rates and unknown resolution rates present a major problem for both the patient and clinician. Many treatment modalities exist; however, there is no single advocated therapy. Therefore, the aim of this review was to explore the most current literature regarding the range of treatment options for KD and to offer a structured approach in the management of KD, based on evidence and experience, to aid clinicians in their current practice. A focused history involving careful evaluation of the patient's symptoms, signs, quality of life and psychosocial well-being should direct targeted therapy, complemented with regular follow-up and re-evaluation. Many treatment modalities, such as intralesional steroid injection, silicone gel application, cryotherapy, lasers, 5-fluorouracil and, relatively recently, photodynamic therapy, are currently being used in clinical practice for the management of KD. Combination therapies have also been shown to be beneficial. However, there is a lack of robust, randomized, level-one, evidence-controlled trials evaluating these treatment options. Management of KD in ethnic pigmented skin remains a clinical challenge. Thus, a strategic approach with structured assessment, targeted therapy and focus on prevention of recurrence is highly recommended. Quality evidence is essential in order to tailor treatment effectively for the ethnic patient presenting with KD.
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Affiliation(s)
- S Ud-Din
- Plastic and Reconstructive Surgery Research, Bayat Research Group, Manchester Institute of Biotechnology, University of Manchester, 131 Princess Street, Manchester, M1 7DN, U.K; University Hospital of South Manchester NHS Foundation Trust, Institute of Inflammation and Repair, Dermatology Group, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, M23 9LT, U.K
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Monstrey S, Middelkoop E, Vranckx JJ, Bassetto F, Ziegler UE, Meaume S, Téot L. Updated scar management practical guidelines: non-invasive and invasive measures. J Plast Reconstr Aesthet Surg 2014; 67:1017-25. [PMID: 24888226 DOI: 10.1016/j.bjps.2014.04.011] [Citation(s) in RCA: 199] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 02/27/2014] [Accepted: 04/16/2014] [Indexed: 12/12/2022]
Abstract
Hypertrophic scars and keloids can be aesthetically displeasing and lead to severe psychosocial impairment. Many invasive and non-invasive options are available for the plastic (and any other) surgeon both to prevent and to treat abnormal scar formation. Recently, an updated set of practical evidence-based guidelines for the management of hypertrophic scars and keloids was developed by an international group of 24 experts from a wide range of specialities. An initial set of strategies to minimize the risk of scar formation is applicable to all types of scars and is indicated before, during and immediately after surgery. In addition to optimal surgical management, this includes measures to reduce skin tension, and to provide taping, hydration and ultraviolet (UV) protection of the early scar tissue. Silicone sheeting or gel is universally considered as the first-line prophylactic and treatment option for hypertrophic scars and keloids. The efficacy and safety of this gold-standard, non-invasive therapy has been demonstrated in many clinical studies. Other (more specialized) scar treatment options are available for high-risk patients and/or scars. Pressure garments may be indicated for more widespread scarring, especially after burns. At a later stage, more invasive or surgical procedures may be necessary for the correction of permanent unaesthetic scars and can be combined with adjuvant measures to achieve optimal outcomes. The choice of scar management measures for a particular patient should be based on the newly updated evidence-based recommendations taking individual patient and wound characteristics into consideration.
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Affiliation(s)
- Stan Monstrey
- Plastic and Reconstructive Surgery Department, Burn Centre, Ghent University Hospital, Ghent, Belgium.
| | - Esther Middelkoop
- Association of Dutch Burn Centres, Beverwijk and Department of Plastic Reconstructive and Hand Surgery, Research Institute MOVE, VU University Medical Centre, Amsterdam, The Netherlands
| | - Jan Jeroen Vranckx
- Department of Plastic and Reconstructive Surgery, KUL Leuven University Hospitals, Leuven, Belgium
| | - Franco Bassetto
- Plastic Surgery Institute, University of Padova, Padua, Italy
| | | | - Sylvie Meaume
- Geriatric Department, Rothschild Hospital, University of Paris 6, Paris, France
| | - Luc Téot
- Wound Healing Unit and Burns Surgery, Montpellier University Hospital, Montpellier, France
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The facial keloid: a comparison of treatment outcome between intralesional steroid injection and excision combined with radiotherapy. EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-014-0957-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Taheri A, Mansoori P, Al-Dabagh A, Feldman SR. Are corticosteroids effective for prevention of scar formation after second-degree skin burn? J DERMATOL TREAT 2013; 25:360-2. [DOI: 10.3109/09546634.2013.806768] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Arash Taheri
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine,
Winston-Salem, NC, USA
| | - Parisa Mansoori
- Department of Pathology, Wake Forest School of Medicine,
Winston-Salem, NC, USA
| | - Amir Al-Dabagh
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine,
Winston-Salem, NC, USA
| | - Steven R. Feldman
- Department of Dermatology, Center for Dermatology Research, Wake Forest School of Medicine,
Winston-Salem, NC, USA
- Department of Pathology, Wake Forest School of Medicine,
Winston-Salem, NC, USA
- Department of Public Health Sciences, Wake Forest School of Medicine,
Winston-Salem, NC, USA
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Fredman R, Tenenhaus M. Cushing's syndrome after intralesional triamcinolone acetonide: A systematic review of the literature and multinational survey. Burns 2013; 39:549-57. [DOI: 10.1016/j.burns.2012.09.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 08/14/2012] [Accepted: 09/22/2012] [Indexed: 01/04/2023]
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Are auricular keloids and persistent hypertrophic scars resectable? The role of intrascar excision. Ann Plast Surg 2013; 69:637-42. [PMID: 23154335 DOI: 10.1097/sap.0b013e318274d876] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Intrascar excision with debulking procedure is a good choice for scar revision in unique 3-dimensional facial aesthetic units, especially in the auricular area. It can remove or reduce scars in a shorter course without distortion of the surrounding anatomic structures and visible operative scars. This retrospective study was done to present intrascar excision procedures in persistent auricular hypertrophic scars or keloids. METHODS Between 1997 and 2010, 18 ears in 13 patient cases with persistent hypertrophic scars and/or keloids in their external ear due to burns or trauma were collected for evaluation. There were 10 males and 3 females. The age distributions ranged from 5 to 49 years with an average of 20.1 years. All received intrascar excision with debulking procedure for their ear deformity. One case combined with YV-plasty procedure to obtain better aesthetic result. The follow-up period ranged from 0.3 to 14 years with an average of 3.6 years. RESULTS There was no recurrence in a series of average 3.6 years follow-up. Of the 13 patients, 11 (84.6%) objectively presented good and satisfactory surgical outcomes and the other 2 patients were acceptable. CONCLUSIONS The intrascar excision in auricular persistent scars or keloids has the following advantages: it (1) achieves primary closure, (2) does not distort the anatomic landmarks, (3) does not sacrifice the important structures, (4) has a debulking effect, (5) can be done anytime, even if scars are not mature, (6) has good cosmetic results, (7) may combine with Z- or VY-plasty for functional improvement, and (8) has minimal complications.
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