Nico Mousdicas MD, Indianapolis, IN, USA
on Apr 25, 2006
Would consider doing trial therapy on one lesion, by injecting
Interferon intralesionally and perilesionally , shave use Aldara
to open wound and once healed apply tailor made Compression
garment to assess results and proceed from there. Good case
which warrants imperical therapy
Shahbaz Janjua MD, Consultant Dermatologist, Ayza Skin
and Research Centre, Lalamusa, Pakistan on Apr 25,
Treatment of keloids and hypertrophic scars remains a challenging
task in the modern era of scientific reseach. Lesions that are
excised often recur larger than the original lesions but extirpation
followed soon by radiotherpy has been proved to be effective.
Surgical excision followed by intralesional steroids or interferon
is another option. Orphan patient is another challenge to deal
with. Support groups for such patients are doing an excellent
Gregory Herbich MD, Honolulu, HI, USA on Apr
I have experience alternating 5 FU injections with
585 nm. pulse dye laser monthly with good results.
She has larger keloids than I am used to treating so a debulking
seems reasonable. Treatment takes Years Also Botox injections
and Bleomycin have been tried by others.
Saraswat Abir MD, Lucknow, India on April
Intralesional liquid nitrogen cryotherapy can be a ray of hope
in such patients and I have had good results in some pretty
hopeless-looking keloids with it. (Plast Reconstr Surg. 2003
May;111(6):1841-52) I use an even simpler modification of this
technique; I use a simple lumbar puncture needle instead of
a specially designed one. It works as well. For the smaller
lesions, you could use an 18-gauge needle attached to the cryo
The only problem is the invariable depigmentation at the entry
and exit points of the needle, which is sometimes irreversible.
Mostly however, it responds to topical PUVA / NB-UVB / simple
sun exposure. All the best with this difficult problem.
Sate Hamza MD, Winnipeg, Canada on April 27,
I am wondering whether surgical excision followed by postoperative
use of imiquimod 5% cream would be helpful in a case like this.
Michael Albom MD, Clinical Professor of Dermatology,
Ronald O. Perelman Department of Dermatology, New York University
Medical Center, New York, NY, USA on May 1, 2006
There are two issues that are predominant in this very difficult
case. The first is that of the orphan patient. If possible,
it would be very helpful to have one physician provide treatment
to this patient. When treating chronic conditions, it is important
to establish a supportive relationship in which the patient
can develop trust especially when the outcomes are uncertain.
In my experience, I have had the best results with a combination
of deep cryotherapy and Kenalog intralesional injections. Here
is what I do: the area(s) to be treated must be anesthetically
blocked outside the perimeter of the keloid using slow injections
with a 30 gauge needle to minimize the discomfort of the administration
of anesthetic solution. I use a combination of Lidocaine and
Marcaine. After waiting about 10 minutes, I completely freeze
the keloid with a spray device and a thin probe. Then I allow
the frozen keloid to thaw and allow another 5 minutes or so
to elapse. I then slowly inject the edematous keloid with Kenalog
40mg per cc with a 20 guage needle. It is important to inject
deeply and entirely through the keloid with multiple passes
of the needle. I also insure that I remain within the keloid
itself and not inject beyond its deep or lateral borders. Sometimes
I have found, but not consistently,that surgically debulking
the keloid to just below the surface of the skin has helped
followed by immediate injection of steroid. Monthly injections
of Kenalog must be done to prevent recurrence of the keloid.
Therefore in recent years, because surgery has not necessarily
provided me with results superior to the combination of cryosurgery
and Kenalog, I have just about abandoned surgery. Since the
patient has several keloids, treatment will have to done monthly
over many months to over a year. Clearly, one wants to avoid
adrenal-pituitary axis depression with the use of high dose
steroids. She may need to be monitored in conjunction with an
endocrinologist. As was mentioned by another commentator (in
the comment section of this case), there will probably be hypopigmentation
which can be permanent. Therefore, treating one of the smaller
keloids to start, would be advised and then monitor her progress.
If she is truly upset with altered pigmentation, then other
modalities may have to be chosen. Although there is no guarantee,
the patient will more likely accept the ultimate results of
any given treatment if she is educated, prior to treatment,
about the advantages and disadvantages of the treatment that
may be utilized.
Roger Ceilley first published this concept of combined cryotherapy
and intralesional fluorinated steroid injections for reducing
keloids and hypertrophic scars in: J Dermatol Surg Oncol. 1979
Jan:5 (1): 54-6.
Lastly, I have concerns in regard to your reference about radiation
therapy. There is no question that radiation therapy has been
effective in the treatment of keloids. However, the referenced
case indicated that radionecrosis of tissue occurred even though
the patient is free of keloids for two years. One wonders what
potential there is for cancerous changes at the treatment site
over the long term. I would venture to say that pigmentary alteration
of the skin would eventually occur in your 26 year old patient.
However, more importantly, I wonder what her risk would ultimately
be for developing a radiation-induced skin cancer after 15,
20, or more years post treatment. Radiation treatment for keloids
seem to be given in a shortened schedule as compared to the
treament of skin cancers in which fractionation is extended
over a 6 week course. Many articles lump the treatment of hypertrophic
scars and keloids together. This is not helpful because keloids
are much more resistent to any treatment as compared to hypertrophic
scars. There are too many variables to mention here that could
affect the long term outcomes. Most importantly, published data
is lacking for long term followup in these types of patients
who have undergone radiation therapy. It is important to recall
that skin cancers have occurred 60 or more years after treatment
in some patients at sites of previous radiation therapy.
Whatever treatments are chosen, the patient must understand
that there is an element of uncertainty in what will actually
occur. The fact that treatments will go on potentially for a
year or two or perhaps even longer must be shared up front by
the physician who hopefully "adopts" this ophaned
young woman. I believe that if her physician is truly available
to her over the long term, she will be better able to contend
with the uncertainties of treatment and their ultimate outcomes.
Lastly, a positive and patient attitude is most useful in managing
the tribulations that will occur during the course of treatment.
I wish you well as you manage this young woman's dilemma.
Pakhi Pereira MD, Bangalore, India on May
I have treated a case where the keloid had recurred within
a few months of excision. The patient had a single large cosmetically
disfiguring keloid on the left ear lobe after ear piercing.
I treated the case with excision and oral antibiotics for a
week . This was followed by Inj. triamcinolone 10mg every three
weeks into the borders of the excision scar. 9 months later
there was no recurrence. The patient was lost to follow-up thereafter.
The cosmetic result achieved was highly satisfactory as there
was apparently no difference between the two lobes. Hope this
helps your 'orphan' case. Best of luck.
Hussain Mahdi MD Sanabis, Bahrain on May 12,
I guess imiquimod may help after surgical removal
Ref: Stashower ME. Successful treatment of earlobe keloids
with imiquimod after tangential shave excision. Dermatol Surg.