Surgical excision and postoperative radiotherapy for keloids

Treatment outcomes of surgery followed by short-course every other day radiotherapy in keloid

BACKGROUND

Postoperative radiotherapy can significantly reduce keloid recurrence. However, consensus on the optimal radiotherapy dose and treatment schedule remains elusive. This study aims to evaluate the effectiveness of surgery followed by a short-course of radiotherapy administered every other day for keloid treatment.

MATERIALS/METHODS

We conducted a retrospective analysis of 498 patients with keloids treated at our institution between January 2010 and December 2017. All patients underwent electron beam irradiation at a dose of 16 Gy, delivered in four fractions every other day, starting within 24 h post-surgery. The primary endpoint of the study was the local control rate.

RESULTS

A total of 130 (26.5%) keloids recurred after a median follow-up of 68.1months (42.6-129.9 months). The local control rates at 1 year, 3 years and 5 years for all patients were 89.5%, 82.5% and 81%, respectively. The highest recurrence rate was observed in keloids located in the chest region (50.8%), followed by the suprapubic (47.8%), head and neck (38.8%), limbs (33.3%) and ear (14%). Both multivariate and univariate analyses identified the presence of pain and or pruritus as an independently prognostic factor for keloid recurrence (p<0.0001). The local control rates at 1-year, 3-years and 5-years for patients with or without symptom of pain or pruritus were 45% vs. 98.8%, 12.5% vs. 95.9%, and 8.8% vs. 95%, respectively (HR:37.829, 95%CI: 24.385-58.686, p<0.001). In the ear keloid subgroup, the 1-year, 3-year and 5-year local control rates for patients with pruritus were significantly lower than those without pain or pruritus (60.0% vs. 97.9%, 26.7% vs. 94.7%, 26.7% vs. 94.3%, HR:30.209, 95% CI:14.793-61.69, p<0.001). The same results were found in other location(p<0.001). During treatment and follow-up, two patients experienced infections, and one patient developed a cutaneous fibroblastoma.

CONCLUSION

This study suggests that a combination of surgery followed by short-course, every-other-day radiotherapy can yield satisfactory local control rates for keloids. Pain and or pruritus symptom was an independently prognostic factors for recurrence of keloid. To further validate these results, a prospective randomized controlled trial is recommended.

Effectiveness of postoperative superficial radiotherapy following the keloid-cross-flap surgery for auricular keloid: A prospective cohort study

BACKGROUND AND PURPOSE

Retaining partial keloid skin to make cross flaps (keloid-cross-flap surgery) is a modification of the core excision. This study aimed to compare the effectiveness of superficial radiotherapy versus compression therapy after keloid-cross-flap surgery.

MATERIALS AND METHODS

In this prospective cohort study, auricular keloid patients were consecutively screened from January 2019 to December 2021. They underwent keloid-cross-flap surgery and then enter either the superficial radiotherapy or the compression treatment group. The primary outcome was the one-year keloid recurrence rate. Secondary outcomes included: non-completion rate of adjuvant treatment; Patient and Observer Scar Assessment Scale (POSAS) scores and auricular aesthetics scores, evaluated by a four-point Likert scale (1 = poor to 4 = excellent) of non-recurring patients. Propensity score matching (PSM) was used to eliminate potential confounding factors.

RESULTS

123 patients were included in the superficial radiotherapy group and 128 in the compression treatment group. Non-completion rate was significantly higher in the compression treatment group (17.97 %), while the loss rate was comparable between the two groups. Overall, 13 patients (13.54 %) relapsed in superficial radiotherapy group, while 22 patients (25.58 %) in compression group (p < 0.05). After PSM, 59 patients in each group were analyzed, and the recurrence rate was lower in the superficial radiotherapy group (13.56 %). Of relapse-free patients, no significant difference was found in PSAS scores, OSAS scores or aesthetic scores between the two groups.

CONCLUSION

Keloid-cross-flap surgery could provide favorable morphologic repair of the auricular keloid, and postoperative superficial radiotherapy shows higher compliance and lower recurrence rate comparing to compression treatment.

In the face and neck, keloid scar distribution is related to skin thickness and stiffness changes associated with movement

Keloid scars tend to occur in high-tension sites due to mechanical stimuli that are involved in their development. To date, a detailed analysis of keloid distribution focused specifically on facial and neck areas has not been reported, and limited literature exists as to the related mechanical factors. To rectify this deficiency of knowledge, we first quantified the facial and neck keloid distribution observed clinically in 113 patients. Subsequently, we performed a rigorous investigation into the mechanical factors and their associated changes at these anatomic sites in healthy volunteers without a history of pathologic scarring. The association between keloid-predilection sites and sebaceous gland-dense and acne-prone sites was also examined. To assess skin stretch, thickness and stiffness, VECTRA, ultrasound and indentometer were utilised. Baseline skin stiffness and thickness were measured, as well as the magnitude of change in these values associated with facial expression and postural changes. Within the face and neck, keloids were most common near the mandibular angle (41.3%) and lateral submental (20.0%) regions. These areas of increased keloid incidence were not associated with areas more dense in sebaceous glands, nor linked consistently with acne-susceptible regions. Binomial logistic regression revealed that changes in skin stiffness and thickness related to postural changes significantly predicted keloid distribution. Skin stiffness and thickness changes related to prolonged mechanical forces (postural changes) are most pronounced at sites of high keloid predilection. This finding further elucidates the means by which skin stretch and tension are related to keloid development. As a more detailed analysis of mechanical forces on facial and neck skin, this study evaluates the nuances of multiple skin-mechanical properties, and their changes in a three-dimensional framework. Such factors may be critical to better understanding keloid progression and development in the face and neck.

Post-Excision Soft X-Ray Radiotherapy for Keloids: Experience in a Tertiary Referral Center

INTRODUCTION

Keloid is an abnormal proliferation of scar tissue that grows beyond the original margins of the injury. Even after complete resection, recurrences are common and pose a poorly understood challenge in dermatology. There is lack of large prospective clinical trials; thus, treatment recommendations are based on retrospective analyses and small cohort studies. Superficial radiotherapy is recommended in recurrent keloids; however, the successful treatment rates vary greatly. The aim of this study was to evaluate the keloid recurrence rate after post-excision soft X-ray radiotherapy and the associated factors.

METHODS

We reviewed retrospective data of all patients, treated with adjuvant post-excision soft X-ray radiotherapy with 12 Gy in 6 sessions at the tertiary referral center, Department of Dermatology, University Hospital Zurich, Switzerland, between 2005 and 2018. We analyzed individual keloids as separate cases. Successful treatment was defined as no sign of recurrence within 2 years.

RESULTS

Of the 200 identified patients, 90 met the inclusion criteria and were included in the final analysis. In 90 patients, 104 cases of treated keloids were analyzed. Keloids were mainly located on the trunk (49%) and were mostly caused by previous surgery (52.2%). 50% of the keloids did not relapse within 2 years after therapy. A significant factor leading to recurrence was the presence of previous therapy, with prior topical therapies, such as steroid injections or 5-fluorouracil, leading to most relapses. 69.2% of keloid cases who relapsed were pretreated. Soft X-ray radiotherapy was well tolerated, with posttreatment hyperpigmentation noted in 34% of patients, particularly in patients with non-Caucasian origin (61.3%).

CONCLUSION

Treatment of refractory keloids is difficult. Post-excision radiotherapy is an established adjuvant treatment option; nevertheless, recurrence rates are high, especially in pretreated keloids. Prospective studies determining the exact dosage and fraction of post-excisional radiotherapy are needed to determine the optimal radiation parameters.

Surgery and superficial x-ray radiotherapy for keloids of the preauricular and contralateral ear lobe: Case report

The combined approach of surgical resection along with superficial x-ray radiotherapy emerges as a superior treatment option for individuals with keloids, which hold huge potential for enhancing aesthetic outcomes and preventing keloid recurrence.

Postoperative Scar Management Protocol for Asian Patients

BACKGROUND

Postoperative scar formation remains a morbidity for patients even with the advent of minimally invasive techniques. Furthermore, the significant difference between the Asian and Caucasian skin results in poorer postoperative scar outcomes in Asians, supporting the need for an evidence-based scar management protocol.

METHODS

Following a literature review of the PubMed and the Cochrane databases over the past 10 years, we constructed a novel postoperative scar management protocol for the Asian skin, utilized in a Singaporean tertiary healthcare institution.

RESULTS

We describe a timeline-based scar protocol from the point of skin closure to a minimum of 1 year of follow-up. We support the use of intraoperative botulinum toxin for selected high-risk individuals upon skin closure with a follow-up regimen in the postoperative setting. For recalcitrant keloids, we have described a multimodal therapy comprising elements of intralesional steroids, botulinum toxin, lasers, surgery, and radiotherapy.

CONCLUSIONS

A consolidated postoperative scar management protocol provides the necessary guidance for improved scar outcomes in the Asian skin. There is inherent potential in expanding the protocol to include post-traumatic and burn wounds or support other skin types including the Caucasian skin.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Ear Keloid as an Unusual Complication of Prolonged Mask Use during the COVID-19 Pandemic

The recent COVID-19 pandemic required many people to wear ear-loop face masks (ELFMs) for protracted periods, and ear injuries have been reported. Here, we report a rare case of a keloid on the right posterior ear that appeared to arise from prolonged ELFM use. A 76-year-old Japanese man presented with a 7.3 × 2.2 × 1.4-cm keloid running from the medial retroauricular sulcus to the posterior lobule. The lack of keloid history suggested the absence of genetic risk factors. The patient reported extensive mask-wearing habits that were augmented by the pandemic. The keloid developed from an ear injury. Although it healed well, it started thickening 2 months later. Because local mechanical forces (eg, pressure/friction) can promote keloid growth, the ELFM may have provoked the keloid. The patient disclosed a history of uncontrolled hypertension and diabetes mellitus, which associate with severe keloids. The whole keloid was removed via total excision, and the defect was closed primarily and subjected to 15Gy/2Fr radiotherapy. The patient was advised to use a different mask type. Twelve months later, the scar had healed without complications or recurrence and with good cosmetic outcomes. Thus, ELFMs can promote retroauricular keloid formation, possibly by imposing local pressure/friction. ELFMs may also raise local skin temperatures and humidity, thereby fostering infection, which can trigger keloids. Hypertension/diabetes may further elevate the risk of EFLM-induced keloid. Thus, an auricular keloid is an unusual complication of prolonged ELFM use. Combination therapy can have excellent outcomes. Patients with keloid risk factors should be advised to use face masks without ear loops.

Intralesional corticosteroid administration in the treatment of keloids: a survey among Dutch dermatologists and plastic surgeons

BACKGROUND

Intralesional corticosteroid administration (ICA) is a first-line therapy in keloid treatment. However, its clinical results are still highly variable and often suboptimal. Treatment results may strongly be influenced by various ways of ICA.

OBJECTIVE

To explore the prevailing practice of ICA in keloid treatment among dermatologists and plastic surgeons in the Netherlands.

METHODS

The survey was constructed based on a scoping review on ICA in keloid treatment. Members of the Dutch Society for Plastic surgery and the Dutch Society for Dermatology and Venereology were asked to participate.

RESULTS

One hundred and thirty-six responses were obtained. One hundred and thirty (95.6%) participants used triamcinolone acetonide. The majority (54.7%) did not use local anesthesia for pain reduction. Reported corticosteroid dosing that one would inject in one specific keloid differed by a factor of 40. Treatment intervals varied from 1 week to more than 8 weeks. The keloid center was most often injected (46.9%), followed by subepidermal (18.0%).

CONCLUSIONS

A wide variety in ICA for keloids is noted among dermatologists and plastic surgeons, even in a limited geographic region and when evidence points toward an optimal way of treatment. Future studies and better implementation of existing evidence may reduce variation in ICA and optimize its treatment results.

Risk factors for recurrence after keloid surgery with electron radiotherapy

The aim of this study was to investigate the effect of postoperative electron radiotherapy (RT) on local control for keloids and to identify risk factors for recurrence. The clinical data of 82 patients treated at our institution from January 2015 to October 2019 were collected. The data included the general condition of the patients, clinical characteristics of the keloids, treatment plan, local control, and treatment side effects. A total of 82 patients (129 keloids) were included. The study included 23 men (28%) and 59 females (72%). The median patient age was 32 years (range, 18-67 years). Twenty-six recurrences were observed, and the 1-, 3-, and 5-year local control rates were 93%, 81%, and 73%, respectively. Univariate analysis revealed that age (P = .03), hypertension (P = .04), scar shape (P < .001), primary site (P = .02), maximum lesion diameter (P < .001), pain and itching (P = .005), local tension (P = .005), and infection (P < .001) were risk factors for local recurrence. Multivariable analysis revealed that maximum lesion diameter (P < .001), infection (P < .001), interval between surgery and RT (P = .02), and previous treatment (P = .02) were independent risk factors. Complete excision of keloids combined with electron RT is safe and seemingly effective. For keloids with a high risk of recurrence, more aggressive treatment should be chosen, and further prospective studies are needed to explore the optimal treatment.

Microbiome dysbiosis occurred in hypertrophic scars is dominated by S. aureus colonization

Background

The mechanisms of hypertrophic scar formation and its tissue inflammation remain unknown.

Methods

We collected 33 hypertrophic scar (HS) and 36 normal skin (NS) tissues, and detected the tissue inflammation and bacteria using HE staining, Gram staining, and transmission electronic microscopy (TEM), in situ hybridization and immunohistochemistry for MCP-1, TNF-α, IL-6 and IL-8. In addition, the samples were assayed by 16S rRNA sequencing to investigate the microbiota diversity in HS, and the correlation between the microbiota and the indices of Vancouver Scar Scale(VSS)score.

Results

HE staining showed that a dramatically increased number of inflammatory cells accumulated in HS compared with NS, and an enhanced number of bacteria colonies was found in HS by Gram staining, even individual bacteria could be clearly observed by TEM. In situ hybridization demonstrated that the bacteria and inflammation cells co-localized in the HS tissues, and immunohistochemistry indicated the expression of MCP-1, TNF-α, IL-6, and IL-8 were significantly upregulated in HS than that in NS. In addition, there was a significantly different microbiota composition between HS and NS. At the phylum level, Firmicutes was significantly higher in HS than NS. At the genus level, S. aureus was the dominant species, which was significantly higher in HS than NS, and was strongly correlated with VSS indices.

Conclusion

Microbiome dysbiosis, dominated by S. aureus, occurred in HS formation, which is correlated with chronic inflammation and scar formation, targeting the microbiome dysbiosis is perhaps a supplementary way for future scar management.

The Role of Radiation Therapy in Adult and Pediatric Keloid Management: A National Survey of Radiation Oncologists

INTRODUCTION

Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians because of concern surrounding the risk of radiation-induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management.

AIM

The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers.

METHODS

An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed.

RESULTS

A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults, whereas only 54.9% supported radiation therapy for pediatric patients. Of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied 3 fraction regimens (54.4%), and delivered radiation within 24 hours postexcision (45.5%). In pediatric patients, only 42 providers reported treating at least 1 patient. The majority used electron beam radiation (76.2%), applied 3 faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%).

CONCLUSION

Although radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted because of concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.

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.

Excision and adjuvant treatment to prevent keloid recurrence. - a systematic review of prospective, clinical, controlled trials

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.

The Efficacy of Combination Therapy Involving Excision Followed by Intralesional 5-Fluorouracil and Betamethasone, and Radiotherapy in the Treatment of Keloids: A Randomized Controlled Trial

Background

Combined therapy for keloids is currently recommended. Surgery is one of the main options, but the measures to prevent recurrence after excision are still being explored.

Objective

The randomized controlled study aimed at evaluating the efficacy of excision followed by intralesional low concentrations of 5-fluorouracil (5-FU)(12.5 mg/mL) and betamethasone.

Methods

Sixty patients were randomly assigned to three groups. Patients in group A had excision followed by 5-FU and betamethasone intralesional injections, group B had 5-FU and betamethasone intralesional injections, and group C had excision followed by radiotherapy. Efficacy parameters were assessed from 8 to 12 months, including improvement on the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Scale (POSAS), as well as side effects and recurrence. Trial registration number: ChiCTR2100046025.

Results

After 4 months' treatment, the improvement of the VSS and POSAS scores in group A was not different from that in group C (P > 0.05) but was superior to that in group B (P < 0.05); the pain and pruritus of the three groups were relieved more than 50%. After 8 to 12 months' follow-up, there was no statistical difference in the incidence of side effects and recurrence among the groups (P > 0.05).

Conclusion

Excision followed by intralesional low concentrations of 5-FU (12.5mg/mL) with betamethasone is a safe and sustainable treatment for keloid, with no significant difference from excision followed by radiotherapy.

A Nomogram with the Keloid Activity Assessment Scale for Predicting the Recurrence of Chest Keloid after Surgery and Radiotherapy

BACKGROUND

Patients with chest keloids undergoing surgery and adjuvant radiotherapy still have a high recurrence rate, which is a critical problem. The level of keloid activity has not been studied, and a nomogram model for predicting keloid recurrence has not been established in previous studies.

METHODS

A total of 145 patients with chest keloids who underwent surgery and radiotherapy between January 2015 and January 2019 at Peking Union Medical College Hospital were included in our study. Demographic and clinical features and the score of KAAS were analyzed. We compared the area under the curve (AUC) and decision curve analysis (DCA) between KAAS and the Vancouver scar scale (VSS) and established a nomogram model for predicting the risk of recurrence. We used bootstrap and calibration plots to evaluate the performance of the nomogram.

RESULTS

The KAAS can predict recurrence in patients with chest keloids after surgery and radiotherapy. Areas under the curve (AUCs) of KAAS and VSS were 0.858 and 0.711, respectively (p < 0.001). Decision curve analysis (DCA) demonstrated that the KAAS was better than the VSS. Complications after treatment may be risk factors for keloid recurrence. We created a nomogram by using complications and KAAS. The AUC was 0.871 (95% CI 0.812-0.930). The ROC of the model's bootstrap was 0.865 and was well calibrated.

CONCLUSIONS

The KAAS can be used to predict the recurrence and we developed a nomogram for predicting the recurrence of chest keloids after surgery and adjuvant radiotherapy.

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 .

Current advances in the selection of adjuvant radiotherapy regimens for keloid

Keloid is a common benign skin tumor in the outpatient department, and patients are often accompanied by itching and pain. Since the pathogenesis is unknown, the effect of single method treatment is unsatisfactory, and therefore the recurrence rate is high. Therefore, comprehensive treatment is mostly used in clinical treatment. Adjuvant radiotherapy is currently one of the most effective treatments for keloid. After long-term clinical practice, brachytherapy and electron beam radiotherapy has increasingly become the gold standard of treatment, because brachytherapy provides more focused radiation treatment to focal tissue to significantly reduce recurrence rate, and better preserve normal tissue. With the development of new radiotherapy techniques, more options for the treatment of keloid. Currently, adjuvant radiotherapy has been widely recognized, but there is no consensus on the optimal protocol for adjuvant radiotherapy for keloids. This review provides a review of published treatment options and new radiotherapy techniques for adjuvant radiotherapy of keloids and gives a comprehensive evaluation for clinical treatment.

ASC-J9 Blocks Cell Proliferation and Extracellular Matrix Production of Keloid Fibroblasts through Inhibiting STAT3 Signaling

Keloids are a fibrotic skin disorder caused by abnormal wound healing and featuring the activation and expansion of fibroblasts beyond the original wound margin. Signal transducer and activator of transcription 3 (STAT3) has been found to mediate the biological functions of keloid fibroblasts (KFs). Therefore, we aimed to demonstrate whether ASC-J9, an inhibitor of STAT3 phosphorylation, can suppress the activation of KFs. Western blotting results showed that ASC-J9 inhibited the levels of COL1A1 and FN1 proteins, which were upregulated in KFs, by decreasing the expression of pSTAT3 and STAT3. RNA sequencing and in vitro studies further demonstrated that ASC-J9 treatment of KFs reduced cell division, inflammation, and ROS generation, as well as extracellular matrix (ECM) synthesis. ELISA assays verified that ASC-J9 treatment significantly mitigated IL-6 protein secretion in KFs. Transmission electron microscopy images revealed that ASC-J9 induced the formation of multilamellar bodies in KFs, which is associated with autophagy-related signaling. These results suggested that inhibiting a vicious cycle of the ROS/STAT3/IL-6 axis by ASC-J9 may represent a potential therapeutic approach to suppress cell proliferation and ECM production in KFs.

The outcome of postoperative radiation therapy following plastic surgical resection of recurrent ear keloid: a single institution experience

Background

Ear keloids are abnormal continuously growing healing process following cutaneous injury. Surgical excision is the standard treatment strategy; however, 50–80% of cases develop recurrence. Adjuvant radiotherapy (RT) is commonly offered with a marked decrease in the recurrence rate. The variation in RT protocols used in different studies leads to a bias of results analysis. The aim is to present our experience of using surgical excision with postoperative radiotherapy for recurrent ear keloids. Also, studying different variables especially dose and keloid size that affects recurrence rate. Radiotherapy complications were reported and assessed.

Patients and methods

Keloids between 2006 and 2021 were retrospectively reviewed. Fifty-five ear keloids out of 83 cases who received RT after surgical excision were included in the study. Different dose regimens including 13 Gy/1fx, 8 Gy/1fx, 10 Gy/2fx, 15 Gy/3fx, and other fractionated regimens were used. The Median follow-up period was 35 months. Recurrence-free rate (RFR), side effects, and prognostic factors were assessed.

Results

The overall 2-year RFR was 88 ± 5%. The 2-year RFR was 83 ± 8% for dose regimens with biological effective dose (BED) ≤ 40 and 92 ± 5% for regimens with BED > 40 Gy with an insignificant p value. The 2-year RFR was 74 ± 10% compared to 97 ± 3% for keloids > 2 cm and keloids ≤ 2 cm respectively (p value 0.02). The higher dose used for keloids with > 2 cm size significantly improved RFR. The orthovoltage therapy showed marginally better 2-year RFR compared to electron beam therapy; however, statistically insignificant (p value 0.09). The side effects were minimal with no reported second malignancy or serious G3-4 complications.

Conclusion

Excision followed by RT is a safe and effective treatment for recurrent ear keloids. Low and modest radiation doses are effective; however, a higher dose is recommended for keloids > 2 cm. We recommend a prospective larger-scale study to test the effect of dose and keloid size on the treatment results.

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago

BACKGROUND

In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.

METHODS

All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.

RESULTS

Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.

CONCLUSIONS

Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.

Updated Treatment for Acne: Targeted Therapy Based on Pathogenesis

Previous approaches to acne management have focused on the four main factors implicated in acne, namely, androgen-mediated sebogenesis (considered integral to acne), hyperkeratinization, colonization with Cutibacterium acnes, and inflammation related to both innate and adaptive mechanisms. Recent advances have facilitated potential novel approaches to acne management, as the pathophysiology and the immunological aspects related to acne and wound healing have evolved. Particular targets that have been shown to be closely involved in acne pathophysiology and wound healing include interleukin (IL)-1β, IL-17, IL-23, and tumor necrosis factor alpha (TNFα). Biological antibodies targeting IL-1β, IL-17, IL-23, and TNFα could provide novel approaches for treating severe acne and related disorders. Acne is primarily a disease associated with sebogenesis. Monosaturated free acids are important components. Insulin growth factor 1 (IGF-1) promotes the proliferation and differentiation of sebocytes and IL-1β. Research into the microbiome may also provide insights into potential future therapeutic options for acne. Scars, both atrophic and hypertrophic, are common sequelae to acne. Risk factors associated with the development of acne scars include genetic, systemic, local, and lifestyle factors. Pro-inflammatory cytokines have been shown to play a crucial role in the development of acne-induced hypertrophic scars. Treatment for extensive inflammatory keloid scarring is limited. Surgery and postoperative radiotherapy are two possible options. Transforming growth factor-β (TGFβ), IL-6, matrix metalloproteinase (MMP), IGF-1, and B cells are found in keloid or hypertrophic scar tissues. Biological antibodies targeting these cytokines may be a potential strategy for the prevention and treatment of this type of scar in the future. Future treatment for acne should embrace approaches that target the main etiological factors of acne. In particular, specific emphasis on aggressive treatment in the acute inflammatory phase to reduce the likelihood of scarring and other clinical sequelae, such as pigmentary changes would be highly desirable. Treatment for established acne-induced sequelae should also be considered.

Outcomes of Surgical Excision and High-Dose-Rate Brachytherapy for Earlobe Keloids

BACKGROUND

Radiotherapy as an adjuvant therapy to surgical resection has shown variable rates of recurrence treating earlobe keloids. The purpose of this study was to describe our experience with surgical excision followed by high-dose-rate brachytherapy and present our outcomes after 24 months of follow-up.

METHODS

Retrospective chart of 14 patients with 14 earlobe keloids treated with surgical excision followed by high-dose-rate brachytherapy, between January 2015 and May 2016 were enrolled. Database included demographics, Fitzpatrick skin type, laterality, lesion size, and follow-up visits information. Outcomes were assessed in terms of keloid recurrence rates, complications, and patient subjective aesthetical result satisfaction after 24 months of follow-up.

RESULTS

All procedures were completed without complications. Three patients experienced keloid recurrence after 6 (14.28%) and 12 months (7.14%). Three patients experienced mild signs of self-limited post-radiation dermatitis. Self-assessment of aesthetical result was considered "very good" in 71.43% of patients.

CONCLUSION

Surgical excision followed by high-dose-rate brachytherapy is secure and effective to treat earlobe keloids, and can be considered a first line combined treatment. Larger clinical trials comparing different irradiation protocols are still needed.

Combination Therapy Composed of Surgery, Postoperative Radiotherapy, and Wound Self-management for Umbilical Keloids

A universally accepted therapeutic strategy for umbilical keloids has not been determined. Our team has had considerable success with combination therapy composed of surgical excision followed by postoperative radiotherapy and steroid plaster/injection.

The Latest Strategy for Keloid and Hypertrophic Scar Prevention and Treatment: The Nippon Medical School (NMS) Protocol

In 2006, we established a scar/keloid-specialized unit in the Department of Plastic, Reconstructive, and Aesthetic Surgery at Nippon Medical School (NMS) in Tokyo, Japan. In the ensuing 15 years, we treated approximately 2,000 new scar/keloid patients annually. This extensive experience has greatly improved the efficacy of the treatments we offer. Therefore, we discuss here the latest NMS protocol for preventing and treating keloids and hypertrophic scars. While this protocol was optimized for Japanese patients, our experience with a growing body of non-Japanese patients suggests that it is also effective in other ethnicities. The extensive evidence-based experience underlying the NMS protocol suggests that it may be suitable as the foundation of a standard international prevention/treatment algorithm for pathological scars.

The Effects of Timing of Postoperative Radiotherapy on Hypertrophic Scar in a Rabbit Model

Background

Hypertrophic scar is associated with excessive proliferation of fibroblasts, the accumulation of collagen fibers, and angiogenesis associated with chronic inflammation. Scar resection, combined with radiotherapy, is widely used in clinical practice, but timing remains controversial. This study aimed to investigate the association between the timing of postoperative radiotherapy and the effects on hypertrophic scar in a rabbit model.

Material/Methods

Forty New Zealand white rabbits, 8–12 months old, weighing 1.8–2.3 kg were used in the model of hypertrophic scar and underwent surgical resection with or without postoperative radiotherapy. The study groups included: Group 1, the non-resection group; Group 2, the resection and non-radiotherapy group; Group 3, the immediate postoperative radiotherapy group; Group 4, the 12-hour postoperative radiotherapy group; Group 5, the 24-hour postoperative radiotherapy group; Group 6, the 48-hour postoperative radiotherapy group; Group 7, the 72-hour postoperative radiotherapy group; and Group 8, the 120-hour postoperative radiotherapy group. The rabbit ear skin was observed after treatment, and the hypertrophic scar index (HI), fibroblast numerical area density (NA), and collagen fiber area density (AA) were determined.

Results

The HI, NA, and AA were significantly lower after 48 hours of postoperative radiotherapy (P<0.05), with the effects occurring mainly within 24 hours. There was no difference in HI, NA, and AA between the radiotherapy and non-radiotherapy groups within 24 hours after surgery.

Conclusions

In a rabbit model of hypertrophic scar, surgical resection combined with radiotherapy resulted in an optimal effect within 24 hours after surgery.

Brachytherapy in Belgium in 2018. A national survey of the brachytherapy study group of the Belgian SocieTy for Radiotherapy and Oncology (BeSTRO)

PURPOSE

To explore the current practices patterns and evaluate the actual brachytherapy (BT) resources in Belgium.

MATERIAL AND METHODS

In 2019, the Brachytherapy Study Group proposed to conduct a survey on behalf of the Belgian SocieTy of Radiation Oncology (BeSTRO) in order to identify current BT practice patterns. An electronic questionnaire was sent to all primary radiotherapy centers in Belgium. This questionnaire was based on the questionnaire that was used by the Italian Association of Radiation Oncology (AIRO) in 2016, asking for: (a) General information on the Radiation Oncology Centre; (b) BT equipment and human resources; (c) BT procedures; (d) BT assessment (number of patients treated annually, treated sites, and different modalities of treatments).

RESULTS

All 24 radiation oncology centers (100% response rate) answered the questionnaire and gave also information on the performance of brachytherapy in their (eventual) satellite centers. Eighteen (18) BT afterloader units were installed and operational in 2018. Thirteen centers mentioned a prostate seed implant program, one center a prostate and eye plaque program and one center only an eye plaque program. Less than 50% of centers have the infrastructure to offer the full-range of BT in their own department. In 2018, 1486 patients received a BT-treatment, 28% of them were treated by prostate seed implant, 8% were treated by eye-(seed) BT and 64% by high dose rate (HDR)/pulsed dose rate (PDR) BT. Forty-five percent of HDR/PDR patients were treated by vaginal dome BT, 22% by intra-uterine BT, 11% by skin BT, 10% by breast BT (almost exclusively in one centre), 8% for benign pathology (keloid) and the remaining 4% were treated for prostate (as a boost or as salvage in one centre), anal, penile, lung or oesophageal cancer.

CONCLUSIONS

Belgian radiotherapy departments often perform BT only in a (highly) selected group of pathologies, resulting in a limited number of patients treated by this technique despite the sufficient availability of BT equipment. Modern indications are often not covered, hence patients do not have regular access to recognized treatment options, possibly leading to inferior oncological outcome. BeSTRO will use the results of this survey to stimulate improvements in training, awareness, education, implementation, collaboration and cooperation in the field of brachytherapy.