para>Radiation therapy, 5-FU, and bleomycin are unsafe in pregnancy. Triamcinolone should be used with caution.
ISSUES FOR REFERRAL
When intralesional steroids fail, referral to dermatologist or plastic surgeon may be indicated.
ADDITIONAL THERAPIES
- Local radiotherapy may be effective after excision but carries a small risk of carcinogenesis (2)[A].
- Clinical studies are currently investigating the inhibition of the mTOR pathway as possible therapy (12).
SURGERY/OTHER PROCEDURES
- Surgery: High recurrence rate (45 " 100%) if used alone; therefore, it is used only for the debulking of large keloids or if a lesion is unresponsive to steroid injections or other therapy. Combine with preoperative steroid injection and possibly other modalities. Debulking just enough for symptomatic improvement is recommended (2)[A].
- Pulsed dye laser surgery: No definitive evidence of efficacy or advantage over other methods. Therefore, use only if other methods fail, and then use in conjunction with them. Some promise is seen in combination with triamcinolone and 5-FU (1)[A].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Monthly visits for up to 1 year for evaluation and possible steroid reinjections
PATIENT EDUCATION
- Stress the possibility of recurrence despite appropriate treatment.
- May require many months of treatment with combined modalities
- Prevention: In those with risk factors or previous keloids, caution against activities or procedures that may entail dermal disruption, and suggest early treatment of any such events.
PROGNOSIS
When treatment is successful, lesions gradually diminish over 6 to 18 months with therapy, leaving a flat, shiny scar. Although keloids can improve with treatment, cure is unlikely.
COMPLICATIONS
Skin atrophy, ulceration, depigmentation, and telangiectasias can occur as a result of local steroid injections.
REFERENCES
11 Wang XQ, Liu YK, Qing C, et al. A review of the effectiveness of antimitotic drug injections for hypertrophic scars and keloids. Ann Plast Surg. 2009;63(6):688 " 692.22 Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;125(2):557 " 568.33 Sadeghinia A, Sadeghinia S. Comparison of the efficacy of intralesional triamcinolone acetonide and 5-fluorouracil tattooing for the treatment of keloids. Dermatol Surg. 2012;38(1):104 " 109.44 Gauglitz GG, Korting HC, Pavicic T, et al. Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. Mol Med. 2011;17(1 " 2):113 " 125.55 Viera MH, Caperton CV, Berman B. Advances in the treatment of keloids. J Drugs Dermatol. 2011;10(5):468 " 480.66 Sidgwick GP, McGeorge D, Bayat A. A comprehensive evidence-based review on the role of topicals and dressings in the management of skin scarring. Arch Dermatol Res. 2015;307(6):461 " 477.77 Geria AN, Lawson CN, Halder RM. Topical retinoids for pigmented skin. J Drugs Dermatol. 2011;10(5):483 " 489.88 Bijlard E, Steltenpool S, Niessen FB. Intralesional 5-fluorouracil in keloid treatment: a systematic review. Acta Derm Venereol. 2015;95(7):778 " 782.99 Bleasdale B, Finnegan S, Murray K, et al. The use of silicone adhesives for scar reduction. Adv Wound Care (New Rochelle). 2015;4(7):422 " 430.1010 van Leeuwen MC, Bulstra AE, van Leeuwen PA, et al. 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(12):1703 " 1710.1111 Schneider M, Meites E, Daane SP. Keloids: which treatment is best for your patient? J Fam Pract. 2013;62(5):227 " 233.1212 Syed F, Sherris D, Paus R, et al. Keloid disease can be inhibited by antagonizing excessive mTOR signaling with a novel dual TORC1/2 inhibitor. Am J Pathol. 2012;181(5):1642 " 1658.
ADDITIONAL READING
- Davison SP, Dayan JH, Clemens MW, et al. Efficacy of intralesional 5-fluorouracil and triamcinolone in the treatment of keloids. Aesthet Surg J. 2009;29(1):40 " 46.
- Halim AS, Emami A, Salahshourifar I, et al. Keloid scarring: understanding the genetic basis, advances, and prospects. Arch Plast Surg. 2012;39(3):184 " 189.
SEE ALSO
Bites, Animal and Human; Burns; Leprosy; Warts
CODES
ICD10
- L91.0 Hypertrophic scar
- L73.0 Acne keloid
ICD9
701.4 Keloid scar
SNOMED
- Keloid scar (disorder)
- Acne keloid (disorder)
- Keloidal surgical scar (disorder)
CLINICAL PEARLS
- The most successful treatment of hypertrophic scar or keloid is achieved while the scar is still immature, but the overlying epithelium is intact, although this is not as yet confirmed in the literature.
- Differentiation of keloids from hypertrophic scars is vital. Keloids extend beyond the margins of the original wound and do not regress with time, but hypertrophic scars do. Treatment is similar, but keloids are much more likely to recur.
- Closing wounds with a minimum of suture tension, avoiding midsternal incisions and crossing joint lines, and injecting steroids into the incision postoperatively reduce the chance of keloids forming following unavoidable surgery.