Introduction
Keloids are benign fibrous scar growths that form because of altered wound healing. These scars are produced with overproduction of extracellular matrix and dermal fibroblasts that have a high mitotic rate. The lesions can be severely disfiguring and painful. Hypertrophic scars appear similar to keloids, but they do not extend beyond the margins of the wound. Hypertrophic scars are far less likely to recur once treated.
The precise pathogenesis of keloid formation is unknown, but certain individuals (most commonly of African descent) develop a hyperproliferation of fibroblasts in response to trauma or infection. Any skin damage (including ear piercing, lacerations, and surgery) can cause keloid formation in predisposed individuals. Recurrence after treatment is common.
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The diagnosis of keloids is based upon the clinical appearance of the lesion. The lesions may be asymptomatic but also may be pruritic, tender to palpation, or occasionally acutely painful. Most commonly, keloids occur on the ears, neck, jaw, presternal chest, shoulders, and upper back. Acne keloidalis nuchae refers to a condition resulting in inflamed pustules and papules on the posterior neck that often heal with keloid formation.
The best treatment for keloids is prevention in patients with a known predisposition. This includes preventing unnecessary trauma, such as ear piercing and elective skin surgery, whenever possible. Skin problems that damage the skin in predisposed individuals (e.g., acne, infections) should be treated as early as possible to minimize inflammation. Patients with acne keloidalis nuchae should avoid shaving in the neck region, opting instead for scissors trimming. Multiple medical treatment modalities exist (Table 25-1), and combinations of these therapies are often more effective. The earlier keloids are treated, the more likely it is that they will respond to therapy. However, recurrences are possible despite therapy.
TABLE 25-1.Treatment Options for Keloids and Hypertrophic ScarsView LargeTABLE 25-1.Treatment Options for Keloids and Hypertrophic Scars Intralesional corticosteroids Interferon alfa Excision Intralesional fluorouracil Silicone gel sheeting Intralesional verapamil Cryosurgery Laser therapy Pressure earrings Imiquimod Radiation therapy
Intralesional corticosteroids are the most commonly used therapy for keloids and hypertrophic scars. Seventy percent of patients typically respond to intralesional corticosteroid injection with flattening of keloids, although the recurrence rate may be up to 50% at 5 years. Intralesional therapy has the advantage of delivering the steroid directly into the lesion with minimal systemic effects. The skin also serves as a reservoir, allowing the steroid to act over a period of time. Corticosteroids are diluted prior to injection to minimize patient discomfort and adverse reactions. Saline or lidocaine may be used as a diluent for the corticosteroids. Corticosteroids reduce excessive scarring by reducing collagen synthesis, altering glycosaminoglycan synthesis, reducing production of inflammatory mediators, and reducing fibroblast proliferation. The most commonly used corticosteroid is triamcinolone acetonide (10 to 40 mg/mL) at 4- to 6-week intervals. To dilute a single dose of corticosteroid, it is necessary to gently shake the steroid bottle to resuspend the particles. Normal saline or 1% lidocaine without epinephrine may be used as the diluent. Do not dilute with bupivacaine and other long-acting anesthetics, because the corticosteroid will precipitate in the syringe. Immediately before injecting a lesion, gently shake or roll the syringe to ensure even suspension of the drug in the diluent.
Excision may be used if combined with preoperative, intraoperative, and/or postoperative corticosteroids. Recurrence rates from 45% to 100% have been reported in patients treated with excision alone, but that falls to <50% in patients treated with combination therapy. Care should be taken to minimize tension when closing the defect. Postoperative use of imiquimod every other day also may reduce the rate of recurrence.
Silicone gel and sheeting can be used for the management of evolving keloids and the prevention of keloids at the sites of new injuries. It may also be used for the treatment of keloid-related pain and itching. Treatment with silicone gel or sheeting appears to improve elasticity of established abnormal scars, but the evidence is from poor-quality trials. Silicone-gel sheeting and silicone gel are available both by prescription and over the counter. Therapeutic effects appear to be due to a combination of occlusion and hydration, rather than from an effect of the silicone. The sheeting is clear and sticky and should be cut to fit the size of the keloid. It is placed on top of the keloid, taped into place, and left on for 12 to 24 hours per day. The sheet is washed daily and replaced every 10 to 14 days. Effectiveness is judged after a minimum of 2 months of therapy.
Cryosurgery may be used alone or in combination with other treatment modalities. The major side effect is permanent hypopigmentation, which limits its use in darker-skinned patients. Cryosurgery affects the microvasculature and causes cell damage via intracellular crystals, leading to tissue anoxia. Generally, one, two, or three freeze-thaw cycles lasting 10 to 30 seconds each are used. Therapy is repeated once per month until a response occurs. Apply the liquid nitrogen in short application periods because of the possibility of reversible hypopigmentation. Cryotherapy can cause pain and permanent depigmentation in some patients. It combines well as a pretreatment with corticosteroid therapy.
Radiation therapy is highly successful in reducing keloid recurrence, particularly following surgical excision. However, the long-term risk of malignancy from radiation therapy does not justify its use for an essentially benign disorder. It is occasionally used for keloids that are resistant to other therapies and that are unresectable.
Topical imiquimod cream may reduce short-term recurrence postexcision. Mild irritation may be experienced with application of imiquimod, but it otherwise has few side effects. Hyperpigmentation was experienced by more than half of the patients in the study.
Pulsed dye laser treatment can be beneficial for keloids and appears to induce keloid regression through suppression of keloid fibroblast proliferation and induction of apoptosis and enzyme activity. Combination treatment with pulsed dye laser plus intralesional therapy with corticosteroids and/or fluorouracil may be superior to any of the therapies alone. Intralesional fluorouracil (5-FU), interferon alfa, doxorubicin (Adriamycin), or bleomycin may be of benefit for keloids. Some of the drugs can be used in combination with intralesional corticosteroids.
Equipment
- A Luer-Lok (twist-on) syringe (1 cc) with 27- or 30-gauge needle
- Nonsterile gloves
- Alcohol swab
- Gauze, 4 4 inches
- Protective eyewear
Indications
- Painful or unsightly keloids or hypertrophic scars
Contraindications (Relative)
- Local infection
- Severe bleeding disorders
- Extreme illness that would make wound healing difficult
- Cellulitis in the tissues to be incised
- Conditions that may interfere with wound healing (collagen vascular diseases, smoking, diabetes)
- Concurrent medications that may increase the likelihood of intraoperative bleeding (aspirin, other nonsteroidal anti-inflammatory drugs, warfarin)
- Uncooperative patient
The Procedure
Cryotherapy
Step 1
Apply liquid nitrogen for 10- to 30-second cycles up to three times. Repeat the therapy once per month until response occurs.
- PITFALL: Apply the liquid nitrogen in short application periods because of the risk of reversible hypopigmentation or permanent depigmentation in some patients.
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Triamcinolone Injection
Step 1
Consider using eutectic mixture of local anesthetics (EMLA) cream under occlusion for 1.5 hours before injection or pretreatment by applying apply liquid nitrogen for 10 to 30 seconds. Prepare the skin with alcohol. Using a 27- or 30-gauge needle with the bevel directed up toward the skin, inject enough triamcinolone to make the skin rise slightly and the keloid blanch (usually 0.1 to 0.5 mL). Inject into the keloid as the needle is withdrawn from the skin. One-mL syringes are most frequently used because the quantity of medication delivered is usually in the tenths or even hundredths of a milliliter.
- PITFALL: Be sure that the injection occurs in the bulk of the lesion and not underneath it, or lipoatrophy may occur. This is easy to recognize because the injected solution flows easily into subcutaneous fat, whereas resistance is felt when it is correctly injected into dermis.
- PEARL: Protective eyewear is strongly advised.
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Step 2
Be careful not to inject steroid into or immediately underneath the epidermis, because this increases the risk of hypopigmentation. If this occurs, usually resulting from continued pressure on the syringe plunger as the needle exits the skin, gently milk the superficially placed steroid out of the injection hole.
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Step 3
For large lesions, the needle should be withdrawn partially and redirected to cover additional areas, or the needle can be removed and reinserted in another site.
- PITFALL: Caution is needed to avoid injecting into subcutaneous tissue.
- PITFALL: Do not exceed 40 mg of the drug per visit; atrophy and hypopigmentation may occur at higher doses.
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Complications
- Systemic absorption, with potential worsening of control for diabetic patients
- Burning sensation for up to 3 to 5 minutes after injection
- Local skin atrophy
- Hypopigmentation (temporary or permanent)
- Telangiectasia formation
- Sterile abscess formation
Pediatric Considerations
Keloids are less common in children, but when they occur, the procedure is essentially the same. Consider the use of an occluded topical anesthetic to decrease the pain of injection in children.
Postprocedure Instructions
Injections can be repeated at monthly intervals. Some providers increase the concentration of triamcinolone by 10 mg/mL each visit on nonfacial lesions until the lesion softens and flattens, then decrease the strength of injections. Keloids often need multiple treatments 3 to 4 weeks apart until there is adequate flattening of the lesion. Surgical excision is recommended if there is no response after four injections.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 11900 Injection, intralesional, ≤7 lesions (report once) $86.00 0 11901 Injection, intralesional, >7 lesions (report once) $117.00 0 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
ICD-9 Code
View Large Keloid scar 701.4
Suppliers
Recommended supplies and sources may be found in Appendix I.
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