1
|
Wen J, Li Z, Liu W, Yu N, Wang X. Dual-wavelength dye laser combined with betamethasone injection for treatment of keloids: protocol of a randomised controlled trial. BMJ Open 2024; 14:e084939. [PMID: 38986560 PMCID: PMC11268050 DOI: 10.1136/bmjopen-2024-084939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/27/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Keloids, benign fibroproliferative tumours characterised by excessive fibroblast proliferation and over-deposition of extracellular matrix, pose a therapeutic challenge with high recurrence rates. Betamethasone (diprospan) injection (BI) is one of the most common non-invasive therapies for keloids. Pulsed dye laser (PDL) has the function of closing microvessels, which may become one of the auxiliary treatment methods of BI and may enhance its curative effect. Some studies suggest that the combination of a dual-wavelength dye laser (DWL) and BI may offer superior efficacy. This randomised controlled trial aims to evaluate whether the combined therapy of DWL+BI outperforms BI alone in treating keloids. METHODS AND ANALYSIS This single-centre, parallel positive control, randomised trial evaluates the efficacy and safety of DWL (585 nm PDL+1064 nm neodymium-doped yttrium aluminium garnet) combined with BI for keloid treatment. Enrolling 66 adult patients, participants are randomised into DWL+BI or BI groups in a 1:1 ratio. Over 12 weeks, each group undergoes four treatment sessions, ensuring blinding for outcome assessors. Data collection occurs at multiple time points (4, 12, 24 and 52 weeks), with primary outcomes assessing the Vancouver Scar Scale (VSS) improvement rate 24 weeks after the last intervention. Secondary outcomes include VSS improvement rates, changes in keloid volume, changes in relative perfusion index measured by laser speckle contrast imaging, Patient and Observer Scar Assessment Scale results and patient satisfaction. Safety assessments include vital signs, laboratory tests, pregnancy tests and self-reports of adverse reactions. ETHICS AND DISSEMINATION The results will be presented in peer-reviewed journals and at international conferences. This study is approved by the Ethics Committee of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Register (ChiCTR2400080148).
Collapse
Affiliation(s)
- Junxian Wen
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhijin Li
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Weida Liu
- State Key Laboratory for Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nanze Yu
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Department of International Medical Service, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xiaojun Wang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| |
Collapse
|
2
|
Keloid treatments: an evidence-based systematic review of recent advances. Syst Rev 2023; 12:42. [PMID: 36918908 PMCID: PMC10012475 DOI: 10.1186/s13643-023-02192-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 02/15/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Keloids are pathologic scars that pose a significant functional and cosmetic burden. They are challenging to treat, despite the multitude of treatment modalities currently available. OBJECTIVE The aim of this study was to conduct an evidence-based review of all prospective data regarding keloid treatments published between 2010 and 2020. METHODS A systematic literature search of PubMed (National Library of Medicine), Embase (Elsevier), and Cochrane Library (Wiley) was performed in November of 2020. Search strategies with the keywords "keloid" and "treatment" were performed by a medical librarian. The search was limited to prospective studies that were peer-reviewed, reported on clinical outcomes of keloid therapies, and were published in the English language between January 1, 2010, and November 24, 2020. RESULTS A total of 3462 unique citations were identified, of which 108 studies met inclusion criteria. Current literature supports silicone gel or sheeting with corticosteroid injections as first-line therapy for keloids. Adjuvant intralesional 5-fluorouracil (5-FU), bleomycin, or verapamil can be considered, although mixed results have been reported with each. Laser therapy can be used in combination with intralesional corticosteroids or topical steroids with occlusion to improve drug penetration. Excision of keloids with immediate post-excision radiation therapy is an effective option for recalcitrant lesions. Finally, silicone sheeting and pressure therapy have evidence for reducing keloid recurrence. CONCLUSIONS This review was limited by heterogeneity of subject characteristics and study outcome measures, small sample sizes, and inconsistent study designs. Larger and more robust controlled studies are necessary to further understand the variety of existing and emerging keloid treatments, including corticosteroids, cryotherapy, intralesional injections, lasers, photodynamic therapy, excision and radiation, pressure dressings, and others.
Collapse
|
3
|
Intralesional cryotherapy versus excision with corticosteroid injections or brachytherapy for keloid treatment: Randomised controlled trials. J Plast Reconstr Aesthet Surg 2018; 71:847-856. [PMID: 29426811 DOI: 10.1016/j.bjps.2018.01.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/25/2017] [Accepted: 01/21/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Keloids are a burden for patients due to physical, aesthetic and social consequences. Treatment remains a challenge due to therapy resistance and high recurrence rates. The main goals of treatment are to improve scar appearance and symptoms and patients' quality of life (QoL). METHODS Two multicentre, randomised controlled open trials that compared 1) intralesional cryotherapy with excision and corticosteroid injections for primary keloids, and 2) intralesional cryotherapy with excision and brachytherapy for therapy resistant keloids. Primary outcome was scar appearance assessed with the Patient and Observer Scar Assessment Scale. Secondary outcomes were patient reported QoL (Skindex-29, SF-36, EQ-5D-5L), recurrence rates and scar volume reduction. For analysis, a linear mixed model was used. Power analysis indicated 33 patients in each group were needed. RESULTS The trial was prematurely terminated after inclusion of 26 patients due to unexpectedly inferior outcomes after intralesional cryotherapy. For primary keloids no convincing difference between treatments was found, but surgery improved scar appearance while cryotherapy did not. For resistant keloids, excision followed by brachytherapy improved scar appearance (POSAS) and scar symptoms (itch and pain) significantly (p < 0.001, p < 0.001 and p = 0.006 respectively) while cryotherapy did not. Neither of the treatments caused indisputable improvements in QoL. CONCLUSIONS Intralesional cryotherapy is inferior to keloid excision followed by brachytherapy for resistant keloids. In primary keloids, intralesional cryotherapy reduced keloid volume and, therefore, may be used in these patients and specific cases. Primary keloid group size was too small to draw valid conclusions, further research on the efficacy of intralesional cryotherapy for primary keloids is warranted.
Collapse
|
4
|
Park TH, Cho HJ, Lee JW, Kim CW, Chong Y, Chang CH, Park KS. Could -79 °C Spray-Type Cryotherapy Be an Effective Monotherapy for the Treatment of Keloid? Int J Mol Sci 2017; 18:ijms18122536. [PMID: 29186868 PMCID: PMC5751139 DOI: 10.3390/ijms18122536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 11/16/2022] Open
Abstract
Cryotherapy has been regarded as an effective modality for the treatment of keloids, and the spray-type device is one of the novel cryotherapeutic units. However, the biological mechanisms and therapeutic effects of this technique are incompletely studied. We evaluated the clinical efficacy of our cryotherapy protocol with molecular and pathologic evidence for the treatment of keloids. We evenly split each of ten keloid lesions into a non-treated (C-) and treated (C+) area; the C+ area was subjected to two freeze-thaw cycles of spray-type cryotherapy using -79 °C spray-type CryoPen™. This treatment was repeated after an interval of two weeks. The proliferation and migration abilities of the fibroblasts isolated from the dermis under the cryotherapy-treated or untreated keloid tissues (at least 5 mm deep) were compared and pathologic findings of the full layer were evaluated. Molecular analysis revealed that the number of dermal fibroblasts was significantly higher in C+ group as compared with C- group. The dermal fibroblasts from C+ group showed more than two-fold increase in the migration ability as compared with the fibroblasts from C- group. The expression of matrix metallopeptidase 9 was increased by more than two-fold and a significant increase in transforming growth factor beta 1 expression and Smad2/3 phosphorylation level was observed in C+ group. C+ group showed more extensive lymphoplasmacytic infiltration with thicker fibrosis and occasional "proliferating core collagen" as compared with C- group. Thus, -79 °C spray-type cryotherapy is ineffective as a monotherapy and should be used in combination with intralesional corticosteroids or botulinum toxin A for favourable outcomes in the treatment of thick keloids.
Collapse
Affiliation(s)
- Tae Hwan Park
- Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea.
| | - Hyeon-Ju Cho
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam 13488, Korea.
| | - Jang Won Lee
- Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea.
| | - Chan Woo Kim
- Department of Plastic and Reconstructive Surgery, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea.
| | - Yosep Chong
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea.
| | - Choong Hyun Chang
- Department of Plastic and Reconstructive Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Korea.
| | - Kyung-Soon Park
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam 13488, Korea.
| |
Collapse
|
5
|
Intralesional Cryotherapy versus Excision with Corticosteroids or Brachytherapy for Keloid Treatment. Plast Reconstr Surg 2015. [DOI: 10.1097/01.prs.0000472473.17120.4a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
van Leeuwen MCE, van der Wal MBA, Bulstra AEJ, Galindo-Garre F, Molier J, van Zuijlen PPM, van Leeuwen PAM, Niessen FB. Intralesional cryotherapy for treatment of keloid scars: a prospective study. Plast Reconstr Surg 2015; 135:580-589. [PMID: 25626801 DOI: 10.1097/prs.0000000000000911] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intralesional cryotherapy is a novel treatment for keloid scars in which the scar is frozen from inside. Published results are promising, but the treatment has only been tested in a Caucasian patient population. Therefore, the authors evaluated intralesional cryotherapy in a patient population including different Fitzpatrick skin types (I through VI). METHODS This prospective multicenter study with a 1-year follow-up included 27 patients with 29 keloid scars. Intralesional cryotherapy was administered with a disposable liquid nitrogen-based device called CryoShape. Scar assessment was performed using the Patient and Observer Scar Assessment Scale and four objective devices to determine scar color, scar elasticity, scar volume, and patient skin type. RESULTS Keloid scars showed an average volume decrease of 63 percent (range, 16 to 100 percent) after 12 months, compared with baseline (p < 0.01). Recurrence was seen in seven keloids (24 percent) and hypopigmentation recovered in 69 percent of all keloid scars within 12 months. Scar assessment with the Patient and Observer Scar Assessment Scale showed an overall improvement according to both doctors and patients. In addition, complaints of pain and itching were reduced. When analyzing the results per Fitzpatrick skin type, African American patients showed a higher incidence of persistent hypopigmentation (p = 0.02). CONCLUSIONS Intralesional cryotherapy for the treatment of keloid scars shows favorable results in terms of reduction of volume and complaints of pain and pruritus. However, no complete eradication was obtained in some cases and recurring scars were seen. In addition, persistent hypopigmentation proved a problem in non-Caucasian patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
Affiliation(s)
- Michiel C E van Leeuwen
- Amsterdam and Beverwijk, The Netherlands From the Departments of Plastic and Reconstructive Surgery, Biostatistics, and Surgery, and the MOVE Institute, VU University Medical Center; and the Department of Plastic and Reconstructive Surgery and the Burn Center, Red Cross Hospital
| | | | | | | | | | | | | | | |
Collapse
|
7
|
High-dose-rate brachytherapy for the treatment of recalcitrant keloids: a unique, effective treatment protocol. Plast Reconstr Surg 2014; 134:527-534. [PMID: 25158710 DOI: 10.1097/prs.0000000000000415] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Keloids cause aesthetic disfigurement and physical complaints, mainly pain and pruritus. Treatment of these scars is difficult, with high recurrence rates forming the main issue. Surgical excision with adjuvant radiotherapy is considered the most efficacious treatment. At their institution, the authors have been treating keloids with a high-dose-rate brachytherapy procedure for over 10 years, using a protocol with the lowest total radiation dosage known in the literature. METHODS This prospective study included 43 patients of all Fitzpatrick skin types, with 67 keloids in total. After extralesional excision, a radiation scheme of 2 × 6 Gy was administered in two fractions: the first within 4 hours after surgery and the second within 24 hours. Scars were measured and recurrence was judged. Scar appearance was evaluated using the Patient and Observer Scar Assessment Scale. RESULTS The recurrence rate was 3.1 percent at a mean follow-up of 33.6 months. A significant average scar surface decrease of 56.7 percent was measured (p = 0.01). Complaints of pain and pruritus decreased by 82.9 and 87.2 percent, respectively. Patients were satisfied with the treatment in 88.6 percent of the cases and with the cosmetic result in 77.1 percent. Pigmentation problems were seen in 21.4 percent of the patients, mostly in Fitzpatrick type V and VI/African American individuals. CONCLUSIONS The results of this prospective study show a good cosmetic outcome with a low recurrence rate. The unique radiation schedule proves the efficacy and safety of high-dose-rate brachytherapy and suggests the importance of immediate postoperative irradiation. In addition, only one outpatient treatment is required after surgery, enhancing patient convenience. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
|
8
|
van Leeuwen MCE, Bulstra AEJ, van Leeuwen PAM, Niessen FB. A new argon gas-based device for the treatment of keloid scars with the use of intralesional cryotherapy. J Plast Reconstr Aesthet Surg 2014; 67:1703-10. [PMID: 25257046 DOI: 10.1016/j.bjps.2014.08.046] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 08/04/2014] [Accepted: 08/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intralesional (IL) cryotherapy is a new promising technique for the treatment of keloid scars, in which the scar is frozen from inside. Multiple devices are available, mostly based on a simple liquid nitrogen Dewar system, which have a limited freezing capacity. Argon gas-based systems ensure accurate and highly controlled freezing and have shown to be effective within the field of oncologic surgery. However, this technique has never been used for the treatment of keloid scars. OBJECTIVE This prospective study evaluates an argon gas-based system for the treatment of keloids in a patient population including all Fitzpatrick skin types with a 1-year follow-up. METHODS Twenty-five patients with 30 keloid scars were included and treated with a device called Seednet (Galil Medical, Yokneam, Israel). Scar quality and possible scar recurrence were assessed before treatment and post treatment (6 and 12 months) with objective devices determining scar color, scar elasticity, scar volume, and patient's skin type. In addition, scars were evaluated using the Patient and Observer Scar Assessment Scale. RESULTS After 12 months, a significant volume reduction of 62% was obtained, p = 0.05. Moreover, complaints of pain and itching were alleviated and scar quality had improved according to the Patient and Observer Scar Assessment Scale. Scar pigmentation recovered in 62% of all keloid scars within 12 months. Five out of 30 (17%) scars recurred within 12 months, three of which had previously been treated with liquid nitrogen-based IL cryotherapy. Both recurrent and persistent hypopigmentation were mainly seen in Afro-American patients. CONCLUSIONS IL cryotherapy with the use of an argon gas-based system proves to be effective in the treatment of keloid scars, yielding volume reduction and low recurrence rates. Although hypopigmentation recovered in most cases, it is strongly related to non-Caucasian patients. Finally, additional treatment of keloid scars previously unresponsive to IL cryotherapy is predisposed to a high recurrence rate. TRIAL NUMBER NCT02063243.
Collapse
Affiliation(s)
- Michiel C E van Leeuwen
- Department of Plastic and Reconstructive Surgery, VU University Medical Center, Amsterdam, The Netherlands.
| | - Anne-Eva J Bulstra
- Department of Plastic and Reconstructive Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Frank B Niessen
- Department of Plastic and Reconstructive Surgery, VU University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
9
|
Lumenta DB, Siepmann E, Kamolz LP. Internet-based survey on current practice for evaluation, prevention, and treatment of scars, hypertrophic scars, and keloids. Wound Repair Regen 2014; 22:483-91. [DOI: 10.1111/wrr.12185] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 03/17/2014] [Indexed: 12/01/2022]
Affiliation(s)
- David B. Lumenta
- Division of Plastic, Aesthetic and Reconstructive Surgery; Department of Surgery; Medical University of Graz; Graz Austria
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Eva Siepmann
- Division of Plastic and Reconstructive Surgery; Department of Surgery; Medical University of Vienna; Vienna Austria
| | - Lars-Peter Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery; Department of Surgery; Medical University of Graz; Graz Austria
| |
Collapse
|