The Management of Keloids Teonia Clark

What is a keloid A keloid is a growth of extra scar tissue where the skin has healed after an injury Extends beyond original bounds Raised and firm Rarely occur distal to wrist or knee Has a preference to the ear, sternum, deltoid and mandible

What causes keloids? Trauma Scarring after surgery Burns Inflammation Foreign- body reactions Endocrine dysfunction

Chest Keloid After Open Heart Surgery Radiation is not the treatment of choice for chest because of the chance of malignancies. Thyroid and breast cancer have been reported to develop after radiation for keloids. Tx devices are not stable on the chest

Chest Keloid After Burn

Who gets keloids? Anyone can get them but people of darker skin are more prone. African Americans, Hispanics, and Asians are more likely to keloid than Caucasians More common in ppl under 30. Risk peaking between 10-20 and in pts w/ elevated hormone levels

X-ray Ultrasound CT MRI- T1 MRI- T2 PET Scrintigraphy Imaging X-ray Ultrasound CT MRI- T1 MRI- T2 PET Scrintigraphy Scintigraphy is a technique that uses a scintillation counter to obtain an image.

What types of treatment are available? Radiation Steroid Injection Surgery cryosurgery 5-fu interferon pressure devices

Keloid Case #1 22 Yr old male presents with keloid of the left buttock and an umbilical hypertrophy Hx of Lipoma Patient was treated with several attempts of surgical removal Hypertrophied umbilical scar is the result of the umbilical cord being cut after childbirth and not being treated.

Radiation Treatment After Radiation Before Radiation The size of the keloid was about 40x22x10 c on the left buttock

Keloid Case #2 34-year old female presents with recurrent keloid behind her left ear. Patient was treated in 5 fx’s to a total of 1500 cGy, 300 cGy/day with 6MeV and 1cm bolus. A 6x6 cone was used. She has a hx of endometrial cancer and a family hx of ovarian cancer from her mother. The pt was positioned on her right side w/ a wedge behind her back for support and strapped to the PSA (for fear of heights). Her ear was taped and the bolus was placed on top.

Superficial Brachytherapy After Keloidectomy 21 patients studied from 4/08-4/09 36 histologically confirmed keloids were treated with HDR-SB All pt’s had a keliodectomy All patients of Asian ethnicity (18-69) Median age 41 16 female and 5 male

The keloids were located on the anterior chest wall, scapular, lower jaw, suprapubic area and other areas Ir-192 was used 20 Gy in 4 fx/day was used for the suprapubic, lower jaw, scapular and chest wall 15 Gy in 3 fx/day was used for all other lesions Only 2 pt had recurrance Of these 2 pt’s 1 had dysraphia No other patients had reactions other than erythema

Managing Keloids and Hypertrophic Scars Keloids can be developed either by family heredity or high risk trauma (i.e. surgery, ear piercing, burns). They can be prevented if anticipated with the use of injection, silicone or taping Once they are established they are difficult to and have a high recurrence rate.

Mangement cont… Before a procedure ask the patient if they have had problems with scarring in the past. Have an informed consent discussing the risk and potential to scar or keloid. Use pressure earrings for pierced ears Top choices for tx are: Presssure tx Steroid inj Silicone sheeting Cryotherapy is useful for small lesion like acne but leave darker skin hypopigmentated. Surgery causes more scar tissue and needs to be followed by one of the above treatments. Radiation was used with a 56% response rate.

Chest Keloid After Acne Scar Cryotherapy would probably be good on this because the scars are small and the skin is not dark

Summary Keloids are either hereditary or obtained through trauma. Keloids can be managed but once established they are more difficult to treat. Radiation is used but not as the first treatment choice Pressure tx, Steroid inj and silicone tx are preferred

All of the following are the treatment of choice for keloids except: Excision alone Excision with adjuvant therapy (e.g. radiation) Pressure treatment Intralesional injection of steroids Topical Cream

All of the following statements about keloids are true except? Keloids do not regress spontaneously Keloids extend beyond the boundaries of the original wound Keloids or hypertrophic scars are best managed by excision and careful reapproximation of the wound Keloid tissue contains an abnormally large amount of collagen.