Management of Keloids and Hypertrophic ScarsSee intralesional corticosteroids keloid handout on keloidswritten by the authors of this article. Keloids and hypertrophic scars represent an exuberant healing response that poses a challenge for physicians. Patients at high risk of keloids are usually younger than 30 years and have darker skin. Sternal skin, shoulders and upper arms, earlobes, and cheeks are most susceptible to developing keloids and hypertrophic scars. High-risk trauma includes burns, ear intralesional corticosteroids keloid, and any factor that prolongs wound healing.
Management of Keloids and Hypertrophic Scars - American Family Physician
See related handout on keloids , written by the authors of this article. Keloids and hypertrophic scars represent an exuberant healing response that poses a challenge for physicians. Patients at high risk of keloids are usually younger than 30 years and have darker skin. Sternal skin, shoulders and upper arms, earlobes, and cheeks are most susceptible to developing keloids and hypertrophic scars. High-risk trauma includes burns, ear piercing, and any factor that prolongs wound healing.
Keloid formation often can be prevented if anticipated with immediate silicone elastomer sheeting, taping to reduce skin tension, or corticosteroid injections. Once established, however, keloids are difficult to treat, with a high recurrence rate regardless of therapy. Evidence supports silicone sheeting, pressure dressings, and corticosteroid injections as first-line treatments. Cryotherapy may be useful, but should be reserved for smaller lesions.
Surgical removal of keloids poses a high recurrence risk unless combined with one or several of these standard therapies. Alternative postsurgical options for refractory scars include pulsed dye laser, radiation, and possibly imiquimod cream. Intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections appear to be beneficial for treatment of established keloids.
Despite the popularity of over-the-counter herb-based creams, the evidence for their use is mixed, and there is little evidence that vitamin E is helpful. Keloids are elevated fibrous scars that extend beyond the borders of the original wound, do not regress, and usually recur after excision.
Cryotherapy is useful for smaller lesions e. Intralesional corticosteroid injections for prevention and treatment of keloids and hypertrophic scars are a practical first-line approach for the family physician.
Silicone elastomer sheeting is a noninvasive, but time-intensive, first-line option for prevention and treatment of keloids and hypertrophic scars. Pressure dressings or garments are effective for prevention of hypertrophic scars, especially in burns.
When first-line treatments for keloids and hypertrophic scars fail, combination therapy surgery, silicone sheeting, and corticosteroid injections is an effective second-line option. Limited clinical trials have failed to demonstrate lasting improvement of established keloids and hypertrophic scars with onion extract topical gel e.
For information about the SORT evidence rating system, go to https: Commonly occur on the sternal skin, shoulders and upper arms, earlobes, and cheeks.
Investigation of recurrence rates among earlobe keloids utilizing various postoperative therapeutic modalities. Eur J Plast Surg. The primary risk factor for keloids is darkly pigmented skin, which carries a to fold increased risk, perhaps because of melanocyte-stimulating hormone anomalies. Keloids are more common in persons younger than 30 years, with risk peaking between 10 to 20 years of age, and in patients with elevated hormone levels e.
Certain types of trauma and delayed healing longer than three weeks heighten keloid incidence even more, with burns carrying the highest risk. Acne keloids are particularly common. Keloids are more than just cosmetically unacceptable; many are also pruritic and painful.
They often result in severe emotional distress. Mild trauma, often from shaving, can result in formation of a keloid, such as this one along the hairline. Before any surgical procedure, patients should be asked if they have had previous problems with scarring.
Discuss the potential for keloids as part of informed consent, and discourage ear piercing and other elective procedures in persons with dark skin. If ears are pierced despite this advice, pressure earrings are commercially available for reducing keloid risk. If surgery cannot be avoided in a high-risk patient, immediate silicone elastomer sheeting or corticosteroid injections should be instituted.
Anything that expedites wound healing and diminishes skin tension e. One small study showed that hypertrophic scars occurred in five out of 24 repairs with Dermabond versus three out of 28 repairs with traditional suture. Keloid and hypertrophic scar therapy is challenging and controversial Table 2. The large number of treatment options is a reflection of the poor quality of research on this topic, with no single proven best treatment or combination of treatments.
First-line options include silicone sheeting, pressure treatment, and corticosteroid injections, but all of these require exemplary adherence and follow-up. Cryotherapy is useful, but only for smaller lesions, such as those resulting from acne. Cryotherapy may cause hypopigmentation in patients with dark skin. Surgical removal of keloids, although temporarily gratifying, is almost invariably followed 50 to percent by even more aggressive regrowth of scar tissue.
A variety of other choices are emerging, but are less well studied. Review of multiple case studies 8. Postsurgical intralesional corticosteroid injection triamcinolone acetonide [Kenalog] 10 to 40 mg per mL at six-week intervals.
Review of multiple case studies 9. Postsurgical fluorouracil, triamcinolone acetonide, and pulsed dye laser best outcomes. Intralesional corticosteroid injection triamcinolone acetonide 10 to 40 mg per mL at six-week intervals.
Specialist referral needed; expensive; variable results depending on trial controversial. Case studies 15 , Review of multiple case studies 7. Postsurgical interferon alfa-2b 1. Review of multiple case studies 9 , Prospective case study Information from references 1 , 7 through 9 , and 12 through Corticosteroid injections for prevention and treatment of keloids and hypertrophic scars are perhaps the first-line option for family physicians.
Corticosteroids suppress inflammation and mitosis while increasing vasoconstriction in the scar. Triamcinolone acetonide suspension Kenalog 10 to 40 mg per mL depending on the site is injected intralesionally, which, although painful, will eventually flatten 50 to percent of keloids, with a 9 to 50 percent recurrence rate.
Corticosteroid injections are more effective if combined with surgery; the sooner instituted, the greater the likelihood of success.
Common adverse effects include atrophy, telangiectasias, and hypopigmentation. Silicone elastomer sheeting is a noninvasive and extensively studied approach to the prevention and treatment of keloids and hypertrophic scars.
Silicone sheets are thought to work by increasing the temperature, hydration, and perhaps the oxygen tension of the occluded scar, causing it to soften and flatten. More than 60 products have been marketed, including silicone sheets, strips, gels, sprays, and foams.
Most are available over the counter, but can be expensive. To be effective, sheets must be worn over the scar for 12 to 24 hours per day for two to three months. The sheets can be reused until they start to disintegrate. Although most studies suggest silicone sheeting results in fewer scars in persons at risk, a recent Cochrane review concluded that most research in this area was of poor quality and highly susceptible to bias. However, pressure dressings 24 to 30 mm Hg must be worn for six to 12 months, which is difficult and uncomfortable for most patients.
If neither silicone nor corticosteroids are effective over 12 months, second-line surgical treatment followed by corticosteroids and possibly silicone sheeting should be considered. The use of corticosteroid injections following keloid surgery reduces the recurrence rate to lless than 50 percent. Immediate wound edge corticosteroid injection after the excision is followed by weekly injections for two to five weeks and monthly injections for three to six months.
The cream is applied on alternate nights for eight weeks after surgery. Although the trials have been small, the postsurgical recurrence rate averaged only 28 percent over a six- to nine-month follow-up period, with best results 2. Treatment of keloids with short-pulsed, nm pulsed dye laser has shown limited promise, with a 57 to 83 percent improvement rate.
Laser-treated portions of keloidal median sternotomy scars showed significant improvement in erythema, pruritus, and scar height compared with untreated portions of the same scars, and these improvements persisted for at least six months. The effectiveness of this therapy remains controversial, however, with other studies showing insignificant reduction in scar thickness. Other therapies with limited studies include intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections.
Although all of these have results comparable or sometimes superior to corticosteroid injection and silicone sheeting, the optimal keloid therapy remains undefined. Combinations of therapies have proved superior to individual approaches. Intralesional fluorouracil 50 mg per mL, two to three times per week appears to shrink keloids safely while avoiding the tissue atrophy and telangiectasia that may occur with repeated corticosteroid injections.
Combining corticosteroids and fluorouracil diminished the adverse effects of corticosteroids. Rare skin complications of fluorouracil may include hyperpigmentation and wound ulceration. No systemic adverse effects e. Bleomycin is another useful chemotherapeutic agent; a standard approach is bleomycin tattooing 0.
Intralesional interferon alfa-2b 1. A liposome-encapsulated interferon alfa-2b cream is also being investigated for scar reduction. Radiation, alone or more commonly after keloid excision, is a much more controversial option. It may pose a risk of local growth inhibition in children and possibly subsequent cancer. Commondosesrangebetween1,to 2, rads over five to six sessions following surgery.
Many patients use topical vitamin E alpha-tocopherol hoping its antioxidant properties will prevent scars. However, there is little evidence that it is helpful, and some patients develop a contact dermatitis that may delay healing. Another over-the-counter option is onion extract topical gels e. Although one trial compared this product favorably with corticosteroids, another showed that it was ineffective in improving scar height and itching.
Moist exposed burn ointment contains multiple herbs with betasitosterol, which provides hydration and possible benefits to wound healing. Already a member or subscriber?
Reprints are not available from the authors. Treatment of keloids and hypertrophic scars. Arch Facial Plast Surg.