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Evidence-Based Therapies for Treating Keloid Scarring

Skin Conditions, General | December 16, 2014 | Author: The Super Pharmacist

skin, general

Evidence-Based Therapies for Treating Keloid Scarring

Keloid scarring is a condition that can be very challenging to treat successfully because the mechanisms that cause it are not yet fully understood by the medical community. As a result, there are several evidence-based options available to the patient. The best therapeutic option will depend on a number of different factors, including the underlying conditions that may have contributed to the keloid developing; the size and location of the keloid; whether the patient has a history of recurrent keloids; and the physician’s recommendations and capabilities. A recent comprehensive review indicated that a combination of different therapies may be the best approach for treating the condition.[1] This has been supported by a number of other studies that have examined combinations of the following therapies. In general, these studies have found that combining two or more therapies consistently provides better clinical outcomes than using standalone treatments.

Topical and airtight dressings for treating keloid scarring

Various bandages and occlusive (airtight) dressings have been applied with success to keloid scarring as both preventative and palliative therapies.[2] These treatments are preferred by some physicians because they have minimal side effects, although their prescription is dependent on whether they are practical for the patient’s condition. The primary dressings used in treating keloid scarring include silicone gel and compression earrings. Silicone is applied either in sheets impregnated with gel, or else a topical application of the gel that is secured with an occlusive bandage.[3] Compression earrings are applied after keloids have been removed from the earlobes and are worn 24 hours a day until the patient’s physician advises otherwise.[4] Both methods have good rates of success as well as prevention of recurrent scars.

Intralesional injections for treating keloid scarring

Intralesional injections for treating keloid scarringOne of the primary treatments for treating keloid is the administration of Intralesional steroid injections, in which triamcinolone is directly delivered percutaneously to the skin lesions.

Typically, injections are administered every two to six weeks until improvement is seen. This method is designed to directly treat scarring while minimising any systemic side effects of the medication.

Reviews generally support intralesional injections efficacy in treating the majority of keloid scars.[5], [6]. 

Side effects of this method include widened blood vessels near the skin (called telangiectasias) and subcutaneous atrophy, or depressions in the skin at the site of the treatment, although both can heal on their own.[7] Alternatives to intralesional steroid injections are currently under investigation. One recent study investigating the effects of interferon injections found promising results when compared to outcomes using steroids.[8] Another study examined bleomycin injections and found that they may be more successful than steroid injections.[9] These budding areas of research are in their infancy and results should be treated cautiously at this stage.

Laser therapy for treating keloid scarring

Laser therapy has been used to treat hypertrophic scars since the late 1990s with very good results, but there is less evidence supporting their application in treating keloid scars.[17] There are a number of different laser therapies available, including pulsed dye lasers (PDL), intense pulsed light (IPL) and carbon dioxide fractional lasers. There is not yet a broad consensus in the research literature supporting one type over another for treating keloids, although recent research suggests that PDL is the most promising avenue.

Combining intralesional injections with IPL therapy has been shown to provide better clinical outcomes than intralesional injections only.[18]

Surgical removal for treating keloid scarring

Surgically removing keloid scars is one of the oldest techniques for treating the condition. 

Surgical removal for treating keloid scarringThough while it is generally successful initially, surgery often results in a very high rate of recurrence; in some cases the recurrent scar is bigger than the first one.[10] Recurrence is preventable, however. Combining surgical removal with additional therapy such as intralesional injections, topical dressings and radiotherapy has been shown to significantly reduce the rate of recurrence following surgery.[11]

Radiation therapy for treating keloid scarring

Radiation therapy is typically prescribed as an adjunct treatment of keloid scars to surgery.[12] While some concerns about the safety of radiation therapy persist, a retrospective study found that there was little causal relationship between carcinoma and postoperative radiation therapy used for keloid scarring.[13] Several studies have determined that radiation therapy combined with surgery is a highly effective treatment that prevents recurrence.[14]

Cryotherapy for treating keloid scarring

Cryotherapy typically involves the application of liquid nitrogen at low temperatures to treat keloid scarring, and has been applied as a stand-alone or adjunct treatment. Several studies have reported that success rates of cryotherapy are mixed, and this may be due to the timing of the application as well as other factors.[15],[16] Cryotherapy has been shown to be effective as an adjunct treatment for intralesional steroid injections. One potential side effect is hypopigmetation, or the loss of skin colour due to melanin depletion.

Prevention of keloid scarring

As with many other conditions, preventative care is one of the most successful ways to treat keloid scarring. Preventative care is applied most successfully when the patient is made aware of their risk factors for developing a condition. There are a number of risk factors for keloid scarring.

Family History. The first and most important is having a family history of keloids; heredity plays a major factor in the probability of developing chronic conditions.

Blood Type. There is also evidence that having blood type A increases a person’s risk factor level for developing keloid scarring, although the underlying reasons are not entirely understood.

Age. Younger persons are more prone to keloids, particularly those between the ages of 10 and 30. This may be due to changing molecular structures as we age, and it is associated with the risk of keloids related to body piercings between these ages.

Skin Pigment. There is some evidence that having darker skin pigments can increase the likelihood of developing keloids, but there has not yet been a comprehensive clinical trial investigating this phenomenon, so it is difficult to say with certainty that it is in fact the case.

Pregnancy. Finally, being pregnant can cause an increased risk of developing keloids, presumably because of elevated levels of oestrogen during pregnancy.[19]

Persons who have elevated risk factors for keloids can take preventative steps such as avoiding body piercings, cosmetic surgery and tattoos. Additionally, combining preventative treatments such as intralesional steroids or radiation therapy following medically necessary surgeries will minimize the risk of developing keloids as a result.

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References

1. Al-Attar, Ali, et al. "Keloid pathogenesis and treatment." Plastic and reconstructive surgery 117.1 (2006): 286-300.

2. Berman, B., and F. Flores. "The treatment of hypertrophic scars and keloids."European Journal of Dermatology 8.8 (1999): 591-6.

3. Fulton, James E. "Silicone gel sheeting for the prevention and management of evolving hypertrophic and keloid scars." Dermatologic surgery 21.11 (1995): 947-951.

4. Lawrence, W. Thomas. "Treatment of earlobe keloids with surgery plus adjuvant intralesional verapamil and pressure earrings." Annals of plastic surgery 37.2 (1996): 167-169.

5. Connell, P. G., and C. C. Harland. "Treatment of keloid scars with pulsed dye laser and Intralesional steroid."  Journal of Cosmetic and Laser Therapy 2.3 (2000): 147-150.

6. Gold, Michael H., et al. "Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting." Dermatologic surgery 27.7 (2001): 641-644.

7. Jacobs, M. B. "Local subcutaneous atrophy after corticosteroid injection."Postgraduate medicine 80.4 (1986): 159-160.

8. Lee, June Hyunkyung, Seong Eon Kim, and Ai‐Young Lee. "Effects of interferon‐α2b on keloid treatment with triamcinolone acetonide intralesional injection." International journal of dermatology 47.2 (2008): 183-186.

9. Naeini, Farahnaz Fatemi, Jamshid Najafian, and Koorosh Ahmadpour. "Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars." Dermatologic surgery 32.8 (2006): 1023-1030.

10. Rockwell, W. Bradford, I. Kelman Cohen, and H. Paul Ehrlich. "Keloids and hypertrophic scars: a comprehensive review." Plastic and reconstructive surgery 84.5 (1989): 827-837.

11. Berman, Brian, and Harlan C. Bieley. "Adjunct therapies to surgical management of keloids." Dermatologic surgery 22.2 (1996): 126-130.

12. Ragoowansi, Raj, et al. "Treatment of keloids by surgical excision and immediate postoperative single-fraction radiotherapy." Plastic and reconstructive surgery 111.6 (2003): 1853-1859.

13. Norris, James EC. "Superficial x-ray therapy in keloid management: A retrospective study of 24 cases and literature review." Plastic and reconstructive surgery 95.6 (1995): 1051-1055.

14. Klumpar, David I., John C. Murray, and Mitchell Anscher. "Keloids treated with excision followed by radiation therapy." Journal of the American Academy of Dermatology 31.2 (1994): 225-231.

15. Zouboulis, Christos C., et al. "Outcomes of cryosurgery in keloids and hypertrophic scars: a prospective consecutive trial of case series." Archives of dermatology 129.9 (1993): 1146-1151.

16. Rusciani, Luigi, Giuseppe Rossi, and Riccardo Bono. "Use of cryotherapy in the treatment of keloids." The Journal of dermatologic surgery and oncology19.6 (1993): 529-534.

17. Bouzari, Navid, Stephen C. Davis, and Keyvan Nouri. "Laser treatment of keloids and hypertrophic scars." International journal of dermatology 46.1 (2007): 80-88.

18. Meymandi, Simin Shamsi, Azadeh Rezazadeh, and Ali Ekhlasi. "Studying Intense Pulsed Light Method Along With Corticosteroid Injection in Treating Keloid Scars." Iranian Red Crescent medical journal 16.2 (2014).

19. Kim, Hyung-Do, et al. "Recurrent Auricular Keloids during Pregnancy." Archives of plastic surgery 40.1 (2013): 70-72.

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