Management of Keloids Draws on Clinical Wisdom

Selected by Pietro Cazzola

KeloidsWoodinville, WASH. – Make decisions about whether to surgically or medically manage keloids according to features of the lesion and patient-related factors, especially likely treatment compliance, Dr. Hilary E. Baldwin advised.

“Step one when we are dealing with our patients with keloids is trying to decide what the patients actually hope for,” Dr. Baldwin said at the annual Coastal Dermatology Symposium. That might be eradication of the keloid; palliation of symptoms such as itching or pain; flattening, lightening, or softening of the keloid; ability to wear clip-on earrings; or restoration of mobility.
“Most patients, in my opinion, are actually not surgical candidates, and most need to be convinced to pursue other options,” said Dr. Baldwin of the dermatology department at the State University of New York, Brooklyn.

Surgical management
Size and shape should factor into decisions about surgical removal of keloids, said Dr. Baldwin. Larger keloids are not much more difficult to remove than smaller ones, and pedunculated keloids are generally the most amenable to surgery, she noted.
Keloid age also comes into play, as the older, mature, brown lesions are less likely to recur after surgery than the younger, pink, symptomatic ones. Location affects outcome as well, Dr. Baldwin said. Keloids on the jaw, the deltoid, mid-back, mid-chest, and upper back are most likely to recur if treated surgically, and those in low-tension areas are less likely to do so.
Surgery also may be considered for keloids that are truly unresponsive to intralesional corticosteroids, but those are uncommon as previous lack of response is usually because of an inadequate dose, Dr. Baldwin explained.
“Most important is patient commitment. They often believe that cutting is a quick fix and they are not going to have to do anything afterward, and they are poor flight risks because of that,” she said. Statistics suggest that the nearly 100% of keloids recur with surgery alone, but the value falls to 50% with adjunctive corticosteroids, and 20% with adjunctive radiation therapy, she added.

Adjunctive therapies
When adjunctive corticosteroids are used after surgery, the steroid is injected into the base and walls of the excision site, according to Dr. Baldwin; her preference is to use 40 mg/cc triamcinolone, with injections given for at least 6 months.
“Radiation therapy ... works really well postop; in fact, it’s our best adjunctive therapy, if you’re not afraid of it and the patient’s not afraid of it,” she said. At her institution, this therapy is completed within a week after surgery, “so even if patients are a flight risk, they always return for that first visit, and then they are done with at least one adjunctive therapy.”
The main barrier to use has been a fear of secondary malignancy. But reports of cancer after radiation therapy are rare and questionably associated with the treatment, Dr. Baldwin said.
Pressure dressings also are effective, and these are most practical in the form of compression earrings worn after excision of earlobe keloids, usually for at least 6 months. The earrings also come in a form called “sleepers” that may be more acceptable to patients.
Interferon injections also can help prevent recurrence. “I treat the very first day ... into the wall and into the base, just as I would with steroids, and then repeat 1 week later,” Dr. Baldwin explained. “So if you use this and radiation therapy, 1 week later, you have finished two adjunctive therapies.”
Especially challenging are keloids nearly obliterating normal tissue, such as extensive earlobe keloids. “I call them last-chance keloids,” Dr. Baldwin commented. “If I don’t do a good job and don’t have good adjunctive therapy, it’s going to regrow and that’s the last time I am going to be able to cut. The earlobe will be eaten away with keloid, and we are never going to be able to give [the patient] an earlobe on which to hang an earring.”
After excision of last-chance keloids, “I recommend that you do everything ... Use everything that is available to you,” Dr. Baldwin advised. In addition to excision, that includes “intralesional steroids, intralesional interferon, radiation therapy, and earrings. Why pick one? Use them all if appropriate, and you are much less likely to have a recurrence,” she said.

Medical management
Medical therapy is indicated for large, sessile keloids and for those located in areas where surgery could lead to complications, according to Dr. Baldwin.
In these cases, intralesional corticosteroids are the mainstay, and her preference is to use a high dose of triamcinolone. “I only use 40 [mg/cc]—that’s it. I never use anything less,” she said. “I don’t care where the keloid is: A keloid on the face is the same as a keloid on the back. Most of the failures that I see are due to inadequate concentration. It’s almost always on the face where people are a little bit shy about using the extraordinarily high doses,” she added.
Dr. Baldwin dismissed the dogma of not exceeding 40 mg per month, given that this translates to a dose of just 50 mg of prednisone. “I will sometimes use 80 [mg] in one sitting. I don’t really have that kind of a restriction because it doesn’t make a ton of sense,” she said.
For pre-injection anesthesia, Dr. Baldwin recommended applying topical anesthetic followed by a lidocaine ring block. When treating hard keloids, to prevent backwash of the corticosteroid along the needle track, she said she preapplies Krazy Glue and, immediately after removing the needle, applies a strip of precut tape.
Patients should be advised of the possible complications of hypopigmentation, telangiectasia, and atrophy. “You also have to warn your patients about what I call the Play-Doh effect,” whereby the keloid spreads as it softens, Dr. Baldwin said. “So the footprint is ultimately much bigger than it was originally, although it’s now flatter.”
Intralesional injection of 5-fluorouracil can be used alone or with admixed steroids. However, Dr. Baldwin said that in her hands, the combination has been disappointing, perhaps because the triamcinolone is diluted in the process. “So I’ve reconsidered recently the possibility of doing the steroids the way I like it and following [with 5-fluoruracil] in addition to it, rather than diluting my triamcinolone,” she said.
The newest nonsurgical therapy is intralesional cryotherapy, whereby the keloid is frozen from the inside out with a probe attached to a cryotherapy device, so it eventually undergoes necrosis while the skin is preserved. The reduction in volume achieved has ranged from 51% to 93% across studies, with minimal to no hypopigmentation.
“The probe itself unfortunately costs $450 and is not reusable, which is a problem. At the present time this is not covered by insurance,” said Dr. Baldwin, who disclosed no relevant conflicts of interest. “But for keloids that really can’t be treated any other way, it has been quite helpful.”

The meeting was presented by the Caribbean Dermatology Symposium.

S London