Efficacy of triple therapy in auricular keloids

Compression Therapy for Keloid Scars: A Systematic Review and Meta-analysis

Background

Keloid scars have a multitude of treatments with varying success rates. The purpose of this systematic review and meta-analysis is to study the different types of compression therapies used following surgical excision and their recurrence rates.

Methods

A literature search was conducted using the following databases: PubMed, Embase, and Cochrane Reviews. The following keywords were used in the search: "keloid" and "compression." The following inclusion criteria were used: (1) identifying lesion must be a keloid and (2) use of any type of compression therapy for keloid scar.

Results

A total of 27 articles were included in the final analysis, grouped into three treatment modalities for comparison. The three treatment modalities are (1) surgical excision and compression earring, (2) surgical excision and silicone gel sheeting, and (3) surgical excision, compression earring, and silicone gel sheeting. Based on our analysis, combination treatment with compression earring device and silicone gel sheeting had the lowest recurrence rate when compared with compression earring device or silicone gel alone, but the difference in recurrence rates between the three treatment modalities was not statistically significant.

Conclusions

There were too few studies included in each treatment modality with even fewer sample sizes, and there is a need for a greater number of studies with increased sample size to evaluate which therapy is the most efficacious in preventing keloid recurrence following surgical excision.

Keloid Intralesional Excision Reduces Recurrence: A Meta-analytic Study of the Available Literature on 608 Keloids

Background

The objective of this meta-analysis was to examine the effectiveness of keloid intralesional excision (KILE) in preventing recurrence. Treatment of keloids using surgical excision alone leads to high rates of recurrence. To date, there are no widely accepted guidelines for keloid treatment, and a multitude of adjunctive therapies are used to reduce recurrence. Despite these efforts, recurrence remains high. In this study, we conducted a meta-analysis of the existing literature on KILE to determine its role in recurrence reduction.

Methods

A literature review using PubMed, Scopus, and Web of Science databases was performed. Two authors independently evaluated studies for eligibility. Incidence of keloid recurrence was recorded, and a comprehensive meta-analysis was performed to assess the pooled keloid recurrence rate, as well as the effect of additional therapies.

Results

Twenty-two studies evaluating intralesional excision of 608 keloids were included in the study. Average time to follow-up was 19.2 months (range 6-35 months). A meta-analysis of proportions was conducted, demonstrating a pooled recurrence rate of 13% (95% confidence interval, 9%-16%). There was no evidence that using therapies in addition to KILE had a significant effect on the overall pooled recurrence rate.

Conclusions

A meta-analysis of 608 keloids shows that KILE is an effective technique in preventing keloid recurrence, with a pooled recurrence rate of 13% compared with previously reported rates of 45%-100% after complete excision. Although there are no standard guidelines for keloid treatment, our meta-analysis shows that KILE is promising in recurrence reduction.

[Principle and clinical application of keloid core excision technique]

Objective

To review the research progress of the principle and clinical application of keloid core excision technique.

Methods

The literature on keloid core excision technique at home and abroad in recent years was extensively reviewed, and the principle, development history, indications, advantages and disadvantages of this technique were summarized, and the existing controversies were analyzed.

Results

Keloid core excision is a technique to remove the inner fibrous core from the keloid and cover the defect with the keloidal flap. It reduces the wound tension, yields good aesthetic results in the treatment of ear keloids, and reduces the recurrence rate of keloids combining with adjuvant therapies.

Conclusion

The keloid core excision technique has specific advantages, yet its overall efficacy remains controversial. Further studies are imperative to explore the mechanisms regarding keloid recurrence and the vascular supply principles of the keloidal flap. It is also necessary to define appropriate surgical indications and safety protocols of this technique.

Keloid treatments: an evidence-based systematic review of recent advances

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.

Triple treatment in ear keloids: Comparison of post-excisional intralesional steroid and platelet-rich plasma treatment

PURPOSE

Ear keloids lead to psychological problems in the patient by causing complaints, such as itching and swelling. It is highly resistant to treatment, and recurrences are frequent. In the present study, the purpose was to investigate the treatment success of the intralesional steroid and PRP combination in addition to surgical excision in ear keloids. The 5-year recurrence rates and adverse effects of both treatments were also compared in this respect.

MATERIALS AND METHODS

In this study, 60 patients between the ages of 16 and 65 who were followed up between 2015 and 2020 due to ear keloids were evaluated retrospectively. Patients were divided into 3 different groups (n = 20) as (A-B-C). There were patients who had only intralesional steroid injections due to ear keloids in Group A, patients who had intraoperative/postoperative steroid injections combined with surgical excision were in Group B, and patients who had intraoperative/postoperative steroid+intraoperative Platelet-Rich Plasma (PRP) injections combined with surgical excision were in Group C.

RESULTS

It was found that the 5-year recurrence rate was the lowest in Group C (Surgical Excision+PRP + TAC). The 5-year recurrence rate of Group C was significantly lower when compared with other groups (p < 0.05). When the 5-year recurrence rate of Group A (TAC) and B (Surgical Excision+TAC) was compared, the recurrence rate of Group B was significantly lower (p < 0.05). When the adverse effects were compared, no significant differences were detected between two Groups (A-B) in terms of Skin Atrophy and Telangiectasia. Significant differences were detected between patients in Group C and other groups (p < 0.05). No significant differences were detected between Group B and C (p = 0.832).

CONCLUSION

The combination of surgical excision with Intralesional TAC and PRP treatment in patients with ear keloids should be considered as a highly successful multimodal treatment in terms of low recurrence and adverse effects.

The Efficacy of Surgical Excision Plus Adjuvant Multimodal Therapies in the Treatment of Keloids: A Systematic Review and Meta-Analysis

BACKGROUND

Research evaluating the efficacy of multimodal therapy for the treatment of keloids has reported combination regimens are most effective.

OBJECTIVE

To compare recurrence rates for keloids treated with surgery plus one adjuvant intervention (dual therapy) versus surgery plus 2 or more adjuvant interventions (triple therapy).

MATERIALS AND METHODS

Systematic literature review and meta-analysis of combination treatment for keloids.

RESULTS

After full-text review, we included 60 articles representing 5,547 keloids: 5,243 received dual therapy, 259 received triple therapy, and 45 received quadruple therapy (the latter 2 groups were combined for analysis). The difference in recurrence rates between dual (19%) and triple therapy (11.2%) was not significant (p = .343). However, the difference in recurrence rates between dual therapy using surgery and radiation (18.7%) and triple therapy using surgery, radiation, and a third intervention (7.7%) was significant (p = .002). The differences for surgery and intralesional triamcinolone (TAC) showed trends toward significance, because keloids treated with dual therapy (21.7%) had a higher recurrence rate than those treated with triple therapy comprised of surgery, TAC, and another intervention (13.7%; p = .099).

CONCLUSION

Triple therapy using surgery plus radiation and/or TAC as one of the adjuvant treatment modalities may achieve the lowest recurrence rates for keloids.

Understanding Keloid Pathobiology From a Quasi-Neoplastic Perspective: Less of a Scar and More of a Chronic Inflammatory Disease With Cancer-Like Tendencies

Keloids are considered as benign fibroproliferative skin tumors growing beyond the site of the original dermal injury. Although traditionally viewed as a form of skin scarring, keloids display many cancer-like characteristics such as progressive uncontrolled growth, lack of spontaneous regression and extremely high rates of recurrence. Phenotypically, keloids are consistent with non-malignant dermal tumors that are due to the excessive overproduction of collagen which never metastasize. Within the remit of keloid pathobiology, there is increasing evidence for the various interplay of neoplastic-promoting and suppressing factors, which may explain its aggressive clinical behavior. Amongst the most compelling parallels between keloids and cancer are their shared cellular bioenergetics, epigenetic methylation profiles and epithelial-to-mesenchymal transition amongst other disease biological (genotypic and phenotypic) behaviors. This review explores the quasi-neoplastic or cancer-like properties of keloids and highlights areas for future study.

A multimodal therapeutic approach improves the clinical outcome of auricular keloid patients

OBJECTIVE

We retrospectively studied the efficacy of personalized therapy with surgical resection plus prophylactic management of postsurgical auricular keloids by intralesional injection of betamethasone and local pressure therapy using magnets in patients with auricular keloids.

METHODS

Surgical excision was performed in all patients, and surgical techniques including fusiform excision of the keloid scar, core excision of the keloid scar followed by flap repair, and scar graft were chosen.

RESULTS

A total of 85 patients with 98 auricular keloids were eligible. Seventy-two (74%) patients had primary auricular keloids, and 13 patients had recurrent keloids after surgical excision. Keloids, were located in the helix in 28 (32.9%) cases, in the earlobe in 45 (52.9%) cases, and in the entire auricle in 12 (14.1%) cases. The size of auricular keloids ranged from 10 to 35 mm. Surgical resection was uneventful in all cases. Twenty-one (21.4%) patients received fusiform excision, 47 (47.9%) patients underwent core excision and flap repair, and 30 (30.6%) patients received skin grafts. The patients were followed up for median duration of 1 year (range: 12-24 months). The cure rate was 87.2%, and the recurrence rate was 12.8%.

CONCLUSION

A personalized surgical approach based on the characteristics of auricular keloids in each patient and a multimodal therapeutic regimen including surgical excision, glucocorticoid blockade, and intralesional injection of glucocorticoids and pressure therapy improve the cure rate and reduce the recurrence rate of auricular keloids.

Combination therapy for bulky auricular keloids: a clinical experience

Auricular keloids are common following ear piercing, infection, trauma, burns, or spontaneously, and they are highly resistant for treatment and are followed by severe cosmetic problems, especially for patients with bulky auricular keloids. The risk of recurrence and the need to return to the normal anatomy of external ear following resection is a challenge to the plastic surgeon. The authors present their experience of treating bulky auricular keloids with surgical excision, followed by immediate postoperative radiotherapy and intralesional steroid injection.

Cutaneous basal cell carcinoma arising within a keloid scar: a case report

Basal cell carcinomas (BCCs) are one of the most frequent cutaneous malignancies. The majority of BCCs are reported to occur on the auricular helix and periauricular region due to ultraviolet light exposure. Despite the frequency of BCCs, those that develop within scar tissue are rare, and the phenomenon of keloid BCCs has rarely been reported in the literature. Keloid collagen within BCCs is associated with morphoeiform characteristics, ulceration, or necrosis. Extensive keloid collagen is often seen in BCCs of the ear region, a site prone to keloid scarring. This article presents a rare case of a secondary tumor (BCC) which arose on top of a primary tumor (keloid scar) on the right auricle region in a healthy 23-year-old female after an ear piercing 2 years prior. To our knowledge, the tumor described in this case, in contrast to keloidal BCCs, has never been reported in the literature.

[What's new in instrumental dermatology?]

This "What's new in instrumental dermatology" focuses on cutaneous oncologic surgery, base on a review of the 2012-2014 literature. First, the ability of dermatologists to make a good "oncologic reading of tumors" is the key of radical surgical treatment. Advantages and disadvantages of the biopsy are discussed. Then, the second message is the management of anticoagulants, that should not be interrupted for skin surgery. Despite recommendations, this practice is not followed in 40% of cases; this point is critical because bleeding complications are minor compared to potential morbidity of thrombotic events when stopping these medications. Regarding infection, nasal carriage of Staphylococcus aureus is identified as a risk factor for wound infection. A preoperative shower with chlorhexidine and mupirocin topical decolonization of nostril reduces this risk. Surgical techniques are trying to reach minimalism, by reducing undermining and scarring. On the trunk, using deep slow resorbable sutures improve scarring. In addition using adhesive sutures (strip) reduce the wideness of scar. On the face, the lower third of the nose is the most challenging because of the free edges, which are deformable. In this location bilobed or trilobed transposition flap offer the advantage of remaining in the nasal aesthetic unit and not disturbing the free edges of the nasal orifices. Regarding scarring, early hypertrophic scar is now well defined and linked with transposition flaps of the nasal region. An early treatment with intralesional corticosteroid injection appears to be effective. Finally, the biological mechanism of the effectiveness of compression in the prevention and treatment of dystrophic scar is now clear. The mechanotransduction explain how a mechanical stress of the skin activates biological cell pathways, which regulate the quality of collagen synthesis and the arrangement of skin fibrosis.

Solitary cylindroma of tragus of the ear mimicking a keloid

Cylindromas are very rare primitive sweat gland tumours differentiating towards eccrine or apocrine line. We present a case of cylindroma of tragus of external ear in a 50-year-old female. It was diagnosed clinically as keloid. After excision, histopathological and immunohistochemistry (IHC) studies confirmed diagnosis of solitary cylindroma.