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Dr. Andrew Rynne

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What is the cause and treatmemt for keloids?

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Dr. Shafi Ullah Khan

General & Family Physician

Practicing since :2012

Answered : 3614 Questions

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Posted on Thu, 7 Aug 2014 in Skin Hair and Nails
Question: Hello. I have a keloid from a vaccination for about 6 years now and I have never had keloids before even though I have had surgery for certain reasons and also had very bad injuries but never turned into keloids... The keloid I have is from a very bad injection (tuberculosis) and I have tried infiltrations as well as laser treatment. My question is, I'm so desperate, is there a possibility for me to have surgery combined with radiation? I think it's the only thing that will work out. If so, what's the percentage for the keloid to coming back? Thank you. I'm so desperate and depressed I can't even go to the beach because I'm so ashamed.
doctor
Answered by Dr. Shafi Ullah Khan 2 hours later
Brief Answer:
keloid not likely just a hypertrophic scar

Detailed Answer:
Thank you for asking
What you are considering a keloid seems like a hypertrophic scar of a tuberculosis vaccine which is pretty much normal and day t k day happening to any one who get tb vaccine.
Had it been keloid every wound site would have been a victim as keloid are fibroproliferatove tumors bening in nature and does not discriminate in where to occur and where not to. keloid is an abnormal proliferation of scar tissue that forms at the site of cutaneous injury (eg, on the site of a surgical incision or trauma); it does not regress and grows beyond the original margins of the scar. Keloids should not be confused with hypertrophic scars, which are raised scars that do not grow beyond the boundaries of the original wound and may reduce over time
If you still doubt me seek a plastic surgeon and he will sooth your nerves and also make sure the scar looks less ugly and will make is cosmetically compromised.
I hope it helps. Take good care of yourself and don't forget to close the discussion please.
May the odds be ever in your favour.
Regards XXXXXXX
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Shafi Ullah Khan 11 hours later
I know it's a keloid I went to a doctor and he told me so! Just because the rest of the wounds I have didn't turn into keloids doesn't mean this one isn't. It is a keloid because it hurts, it's itchy and it's way more big than the original wound. I would really like to know thhe percentage of recurrence if I do surgery combined with radiation and steroids. I'm so scared I don't want this anymore on my back. This may be my only and last solution because laser and steroid injections didn't ho so well on me. With that being said, and waiting your last and hopefully helpful answer I'll close the discussion afterwards. Thank you, and sorry for the disturbing
doctor
Answered by Dr. Shafi Ullah Khan 42 minutes later
Brief Answer:
odds of recurrence explained

Detailed Answer:
thank you for asking
well now that you insist let me explain the odds for recurrence and different options for you. but before that let me explain the odds for recurrence.
Recurrence rates with surgery alone range from 45-100%. The combination of surgical excision with other modalities, such as corticosteroid injection, steroid injection with pressure dressing, x-ray therapy, interstitial radiation, single fraction radiation, teletherapy radiation, and brachytherapy have revealed relatively good results, with 5-year recurrence rates reported from 8-50%
1)Occlusive dressings
Silicone gel sheets and silicone occlusive dressings have been used with varied success in the treatment of keloids. The sheets can be worn for as long as 24 h/d for up to 1 year, with care to avoid contact dermatitis and skin breakdown. The silicone does not appear to enter the skin; therefore, the antikeloid effects appear to be secondary to both occlusion and hydration. Studies have demonstrated that silicone gel increases the temperature of the scar, possibly increasing collagenase activity. Increased pressure, hydration of the stratum corneum, and direct pressure on the wound also may be modes of action. In some studies, the response rate has been as high as 79%, showing substantial reduction in erythema, scar elevation, and pruritus. However, complete resolution has not been noted.
2)Compression
Mechanical compression dressings have long been known to be effective forms of treatment of keloid scars, especially with ear lobe keloids. Compression devices are usually custom-made for the patient and are most effective if worn 24 h/d. Pressure devices include garments made of Dacron spandex bobbinet fabric, shaped Tubigrip support bandages, or zinc oxide adhesive plaster. The patient should start wearing the pressure garment as soon as re-epithelization occurs and continue wearing it until scar maturation is evident. The recommended level of pressure is 25 mm Hg, but good results have been observed with pressures as low as 5-15 mm Hg.

The mechanism of action is unknown; however, by reducing the oxygen tension in the wound through occlusion of small vessels, subsequent reductions in tissue metabolism, fibroblast proliferation, and collagen synthesis result. Studies have demonstrated that with button compression devices on the earlobe, no recurrence was noted from 8 months to 4 years.

3)Corticosteroids
Pharmacological therapy has long been a mainstay and relatively effective first-line therapy of treatment of keloids, either as sole treatment or in combination with other therapies.[9] Intralesional steroid injections apparently act by diminishing collagen synthesis, decreasing mucinous ground substance, and inhibiting collagenase inhibitors that prevent the degradation of collagen, thus significantly decreasing dermal thickening. This is accomplished by uniform injection of 10-40 mg/mL of triamcinolone acetonide (Kenalog) into the fresh site of scar excision with a 25- to 27-gauge needle at 4- to 6-week intervals until the scar flattens and discomfort is controlled. The steroid should be injected into the papillary dermis (where collagenase is produced). Avoid injection into the subcutaneous tissues, which causes fat atrophy and undercuts the intended purpose.

Studies examining the effects of corticosteroid injections alone show a 5-year response rate of 50-100% and recurrence rates of 9-50%. When surgical excision is combined with steroid injection, the response rate increases to 85-100%. A typical treatment program of surgery combined with steroids involves injecting Kenalog into the wound edges after excision and repeating injections into the scar at 6-week intervals for a total of 6 months.

Adverse effects of corticosteroid injections include atrophy of the skin or subcutaneous tissue, hypopigmentation, telangiectasia, necrosis ulceration, visible deposition of steroid in the form of white flecks in the scar, and systemic effects resulting in cushingoid habitus. Most of these adverse effects can be avoided by confining injections of the lowest possible dose of steroid to the dermal layer.

4)Excisional surgery
Simple excisional surgery should involve the least amount of soft tissue handling to minimize trauma; also, plan the closure with minimal skin tension along relaxed skin tension lines. In an effort to reduce wound tension, both full- and split-thickness skin grafts have been used, but these have been only partially successful. Make all attempts to remove any source of postoperative inflammation, such as trapped hair follicles, foreign material, hematomas, or infectious areas

5)Radiation
Radiation can be used as monotherapy or in combination with surgical excision in order to prevent recurrence. Success with monotherapy has not been acceptable, with recurrence rates reaching 100%. Some success has been shown with large doses of monotherapy; however, this may lead to malignant transformation 15-30 years later. Thus, large-dose monotherapy has fallen out of favor.

The most effective time to give radiation therapy is the first 2 weeks after excision, while fibroblasts are proliferating. A typical regimen is 300 Gy every other day for 4 days or 500 Gy every day for 3 days, starting the day of surgery. Postoperative radiation is just as effective as combination preoperative and postoperative radiation. Some newer studies have shown that high-dose brachytherapy combined with surgical excision can achieve good-to-excellent cosmetic results with an 80-94% prevention of recurrence. However, some residual hyperpigmentation (5%) and telangiectasias (7%) can occur.

6)Cryosurgery
Cryotherapy uses liquid nitrogen to cause cell damage and to affect the microvasculature, causing subsequent stasis, thrombosis, and transudation of fluid, which result in cell anoxia. Studies that have evaluated cryotherapy used a protocol of 1-3 freeze cycles lasting from 10-30 seconds, repeating the therapy every 20-30 days. The most common adverse effects of treatment are pain and depigmentation. The therapy was quite effective, as the rate of no recurrence with significant flattening of the scar ranges from 51-74%. Cryotherapy used in combination with intralesional steroids has an even greater response rate, with objective success reported in 84% of patients.

7)Laser therapy
The advantage of laser therapy is that it is a precise, hemostatic excision with minimal tissue trauma, thereby eliminating an excessive inflammatory reaction. The different modes of laser therapy are flash lamp pulse-dyed laser, carbon dioxide laser, argon laser, and the Nd:YAG laser. The carbon dioxide laser and argon laser work by similar mechanisms (ie, by inducing collagen shrinkage through the laser heat). The pulse-dyed laser induces microvascular thrombosis, and the Nd:YAG laser appears to selectively inhibit collagen metabolism and production. Many studies have been done with these types of lasers over the past 40 years, but none of them have proven to be efficacious. All 3 forms of laser therapy, according to multiple studies, have recurrence rates upward of 90%

8)Interferon therapy
One of the newest therapeutic modalities is intralesional injection of INF-alpha, INF-beta, and INF-gamma. Numerous studies have demonstrated that these interferons reduce fibroblast synthesis of collagen types I, III, and, possibly, VI; reduce mucinous ground substance production; and increase collagenase activity. These mechanisms act by reducing the steady-state levels of mRNA. Studies examining the effects of intralesional injections of INF-alpha 2b and INF-gamma found them effective if injected immediately postoperatively into the excision site. INF-alpha 2b appears to normalize the increased collagen synthesis and glycosaminoglycan production by keloid fibroblasts, resulting in a reduction in the size of the keloid by approximately 50%.

This is performed immediately after surgery by injecting 1 million U to each linear centimeter of the skin surrounding the postoperative site. Another injection should be done 1-2 weeks later. INF-gamma injected weekly reduces the size and elevation of keloids, but the highest reduction obtained was 50% at 18 weeks.

9)5-Fluoruracil
5-fluorouracil (5-FU) injected intralesionally has been successfully used to treat small keloids. A mixture of 0.1 mL of triamcinolone acetonide (10 mg/mL) with 0.9 mL of 5-FU (50 mg/mL) produces the best results. It is injected into the keloid 3 times per week initially. Then, the frequency is adjusted according to response. Small keloids usually require 5-10 total injections given weekly. Painful injections are often the limiting factor.

10)Imiquimod therapy
Imiquimod induces local production of interferons at the site of application. It comes as a 5% cream and is started immediately after surgery and continued daily for 8 weeks. Patients with large surgical sites, flaps, grafts, or wounds closed with tension should not start imiquimod therapy for 4-6 weeks. The major side effect is mild-to-marked irritation at the site of application. Often, therapy must be stopped for several days then restarted. Hyperpigmentation develops in 50% of treated wounds.

11)Miscelleneous options
Flurandrenolide tape (Cordran) used on a formed keloid will cause it to soften and flatten over time. This is placed on the keloid for 12-20 hours a day. It is also good at eliminating pruritus. Prolonged use will cause cutaneous atrophy.

Bleomycin (1 mg/mL) is used with success to treat small keloids.

Tacrolimus is a new treatment for keloids given twice a day. This is based on the data that it may mute the gil- 1 oncogene.

Methotrexate has proven quite successful in preventing recurrences when combined with excision. Dosing is 15-20 mg given in a single dose every 4 days, starting a week before surgery and continuing for 3 months.

Pentoxifylline (Trental) 400 mg 3 times a day has had some impact on decreasing recurrence. The mechanism is not fully known.

Colchicine inhibits collagen synthesis, microtubular disruption, and collagenase stimulation, and is thus used in the treatment of keloids.

Other medical therapies used with limited success include topical zinc, interlesional verapamil, cyclosporine, D-penicillamine, relaxin, and topical mitomycin C.

Because of the high recurrence rate of keloid scars, a follow-up period of at least 1 year is required to enable the start of treatment of recurrences as expediently as possible and to evaluate long-term success. Losing patients during follow-up care, only to have them return with full keloid recurrence, is not unusual.

Of the many therapies listed, nothing is reliably definitive. The failure of these treatments just highlights the essential problem in keloids, ie, that no clear molecular mechanism is defined for keloid development. Increased understanding at the molecular level will lead to development of new therapies. Several of the therapies listed are promising; however, studies thus far have been relatively small in scope, and further investigation is needed in regard to safety, adverse effects, and effectiveness of the therapy.

good luck and visit your plastic surgeon and discuss what is best for you.
take care and dont forget to close the discussion please,
regards XXXXXXX

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Shafi Ullah Khan 41 minutes later
thank you!
doctor
Answered by Dr. Shafi Ullah Khan 2 hours later
Brief Answer:
:)

Detailed Answer:
You are welcome please.
Don't forget to close the discussion please.
Regards XXXXXXX
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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