1. The Management of Keloids Teonia Clark

2. 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

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

4. 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

5. Chest Keloid After Burn

6. 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 and in pts w/ elevated hormone levels

7. 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.

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

9. 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.

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

11. 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.

12. 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

13. 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

14. 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.

15. 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.

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

17. 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

18. 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

19. 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.