Intralesional excision as a surgical strategy to manage keloid scars: what's the evidence?

The clinical efficacy of single-hole punch excision combined with intralesional steroid injection for nodular keloid treatment: a self-controlled trial

There are many methods to treat keloid, including various excision operations, laser, injection and radiotherapy. However, few studies have explored the effectiveness of single-hole punch excision in keloid treatment. This study aimed to investigate the efficacy and safety of lateral punch excision combined with intralesional steroid injection for keloid treatment through self-control trial. In this self-controlled trial, 50 patients meet the diagnosis of nodular keloid, and try to choose left-right symmetrical control, one skin lesion in the control group (50 skin lesionsin total) and the other in the observation group (50 skin lesions in total).The keloids in the treatment group were initially treated with punch excision combined with intralesional steroid injection, followed by injection treatment alone. Keloids in the control group received intralesional steroid injection alone. The Vancouver Scar Scale (VSS) of the keloid before and after the punch excision was evaluated; the keloid scores at different time points and the number of injection treatments required in both groups were compared, and adverse reactions were observed. The effective rate of the observation group was 86.0%, which was significantly higher than that of the control group (66.0%), and the recurrence rate of 22% was lower than that of the control group (χ2 = 4.141,63417), all of which were statistically significant (all P < 0.05). At the end of treatment, the VSS and total injection times in the observation group were significantly lower than those in the control group (t = 5.900,3.361), with statistical significance (P < 0.01). The combination of single-hole punch excision and intralesional steroid injection is an effective method to treat multiple nodular keloids, shortening the treatment course of tralesional steroid injection without obvious adverse reactions.

Selective therapy (cryo or scalpel) combined with multimodal therapy for treating keloids

Background

Keloids are less responsive to any single treatment modality; hence, there is a need for combination therapy that can yield satisfactory outcomes.

Objective

The present study assessed efficacy and safety of combination therapy-surgical excision or cryotherapy and intralesional corticosteroids along with 5-fluorouracil [IL (S + 5-FU)] injection, followed by silicone gel sheet (SGS) under compression therapy in the treatment of keloids.

Materials and Methods

This was a retrospective, observational study comprising 21 clinically diagnosed keloid patients. All patients were treated with the stated combination therapy. Data about demographic, lesions, procedural characteristics, and treatment outcomes were reported.

Results

Of 21, 11 (52.4%) patients were treated with liquid nitrogen (LN2) cryotherapy, and 10 (47.6%) patients were treated with surgical excision. Mean age was 30.8 ± 7.6 (range: 14-44) years with slight male (52.4%) predominance. A mean surface area of keloid lesion was 96.8 ± 170.5 cm3. The most frequently involved site was auricle (8 [38.1%] patients). Patients received the following types of treatments: intralesional LN2 cryotherapy (6 [28.6%]), intralesional excisional surgery (6 [28.6%]), surface LN2 cryotherapy (5 [23.8%]), and extralesional excisional surgery (4 [19.0%]). Complications of recurrence (2 [9.5%]), secondary infections (2 [9.5%]), persistent postinflammatory hypopigmentation (1 [4.8%]), and atrophic scarring with postinflammatory hyperpigmentation (1 [4.8%]) were reported. After a study period of 2.5 years, 100% cure rate was achieved.

Conclusion

Combination therapy of surgical excision or cryotherapy and IL (S + 5-FU), followed by SGS under compression, was safe and effective in treating keloids.

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

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

Surgical Core Excision With Tongue Flap Closure in Combination With Electron Beam Radiotherapy in the Treatment of Ear Keloids

BACKGROUND

Ear keloids are disfiguring disorders resistant to various treatments.

OBJECTIVE

The authors aimed to assess the efficacy of surgical treatment of ear keloids in a Chinese population using a tongue flap with electron beam radiotherapy.

METHODS

The authors conducted a retrospective analysis of 41 patients treated at the Affiliated Hospital of Nantong University between January 2018 and May 2021. Core excision with a tongue flap was performed, followed by 3 days of electron beam radiotherapy and 3 to 6 months of pressure clip application. The Vancouver Scar Scale (VSS) and the Visual Analog Scale (VAS) were used to assess the results.

RESULTS

The mean age of the patients was 28.10 years (9-61 years). Postoperative follow-up ranged from 5 to 32 months (mean:12.07). The patients underwent 3 days of postoperative radiotherapy followed by pressure clips for 2 to 6 months. Thirty-seven patients had no recurrence, whereas 4 had a mild recurrence (<3 mm in height) with redness and itchiness. The VSS and VASscores significantly decreased. (p < .05).

CONCLUSION

Excision with a tongue flap and radiotherapy can be used as the primary treatment for ear keloids considering the good outcome and long-term management.

Management of Spontaneous and Pruritic Keloids: A Case Report

Spontaneous chest wall keloid scars can occur without any history of trauma and are rare. Some keloids present with intense pruritus or paresthesia, prompting patients to seek treatment. Currently, many treatment options are available in medicine. However, for this case report a less invasive treatment modality is evaluated. This clinical case report will present Kenalog-40 injections as a treatment option to treat a spontaneous keloid scar. Observation of this treatment option has illustrated a reduction in size and improvement in pruritus, paraesthesia and discoloration.

Concomitant therapy of surgical shave excision and intralesional injections for ear keloids: Early results from a retrospective cohort study

Introduction

Keloids are hypertrophic scars that commonly arise in the ear region. The authors’ objectives were to (1) evaluate effectiveness of surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections; and (2) evaluate safety and patient satisfaction.

Methods and Materials

This study was a retrospective chart review of patients who received treatment of extralesional surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections to treat ear keloids at a single outpatient dermatology clinic. A prospective patient questionnaire was administered to the same patient population to collect recurrence and patient satisfaction.

Results

A total of 45 patients were included, consisting of 84.4% females (n = 38) and 15.6% males (n = 7) with a mean age of 25.5 years. Through retrospective chart review, early recurrence was seen in 6.7% of patients (n = 3), and via the prospective patient questionnaire, 11.1% of patients noted early keloid recurrence (n = 5). Of the patients who expressed their level of satisfaction in-clinic, 96.0% (n = 24) reported being satisfied or very satisfied and 4.0% (n = 1) were dissatisfied. Satisfaction was also assessed through the prospective patient questionnaire; of those who consented to the questionnaire, 100.0% (n = 24) were satisfied or very satisfied. Only 20.0% (n = 9) of all patients reported experiencing side effects, consisting of pruritus (11.1%; n = 5), tenderness (4.4%; n = 2), pain (2.2%; n = 1), and mild atrophy (2.2%; n = 1).

Conclusion

Extralesional surgical shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections may represent a promising treatment option for ear keloids.

Evidence Level: 3 retrospective cohort study.

Lay Summary

Keloids are a type of raised scar, which can be painful and itchy for patients. Keloids can occur on various part of the body, including on the ear. They are challenging to treat and tend to come back. There are many treatment options, however, there is not one universal best treatment for keloids on the ear. We hoped to discover if shave excision followed by intralesional triamcinolone acetonide and onabotulinumtoxinA injections is effective at treating keloids on the ear. In order to answer this we completed a chart review of clinic patients, who have already completed the following combination treatment for keloids on the ear. The keloids were treated first by physically removing the bulk of the keloid with a scalpel, which is called shave excision. After the removal, triamcinolone acetonide and onabotulinumtoxinA were injected directly into the keloid. The rate of patient satisfaction and the rate of the keloid returning were collected during in-clinic visits and an optional post-clinic patient questionnaire. The treatment effectiveness and side effects experienced were reported during in-clinic visits. This indicated that with the low rate of side effects, high patient satisfaction, and low rate of keloid return, this treatment combination should be considered as an option for keloids on the ear. However, since this review was completed at one clinic with a small population of patients, it is not fully known if this treatment combination will work for all patients.

Monoclonal Antibodies Addressed to Factors of Signalization in Keloid Scars: Opportunities and Areas of Action

The advance of technology has made possible the use of new techniques within medicine for the treatment of diseases; monoclonal antibodies are a clear example of this. Keloid scars are one of the most difficult pathologies to treat due to the high percentage of recidivism, formed by the growth of a scar with benign fibrous tissue in genetically predisposed individuals, resulting from a process of inflammation and abnormal scarring. Monoclonal antibodies, being a line of treatment that has increased over the years, can show a new frontier in the treatment of them by focusing on the signaling that causes it. We review the literature on the signaling mechanisms of keloid scars and the possible monoclonal approach.

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

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

Dynamics of the Activity of MAP-Kinase Cascades in the Healing Process of Postoperative Musculocutaneous Wounds

Background. Management of the reparative process is an urgent task of modern medicine. In our opinion, the development of pathogenetically grounded approaches to optimizing the repair process for managing the interrelations of stromal cells is promising. One of the promising areas in this regard is the impact on the MAPK-cascades.Aim: to study the expression of MAP-kinase mechanisms in the regulation of repair by the example of a musculocutaneous wound.Methods. A linear muscular skin wound was modeled using Wistar rats weighing 220–250 g at the age of 9 months (n = 24). Immunofluorescence staining was performed to detect the activity of p38, JNK, and ERK MAPK cascades from 1 to 30 days.Results. It was established that specific staining in the area of connective tissue formation during staining with p38 MAPK and its phosphorylated form was first observed on the 3rd day, and its maximum severity occurred at the same time. On the 7th and 14th day, small zones in the area of scar formation were minimally stained. The phosphorylated part of the JNK-cascade in the zone of traumatic injury was detected starting from the 1st day after the injury. Bright color persisted on the 3rd day. On the 7th day, the color was minimal, and by the 14th day a second wave of expression was observed. ERK-staining was observed from the 1st to the 14th day with a peak activity on the 3rd day.Conclusion. Thus, we revealed the simultaneous involvement of p38, JNK-, and ERK-cascades in the regulation of the reparative process in the conditions of a musculoskeletal wound. At the same time, it is noteworthy that the peak activity of all cascades coincides and falls on the 3rd day.