- Email: [email protected]
Successful treatment of earlobe keloids in the pediatric population
Journal of Pediatric Surgery (2009) 44, 286–288
www.elsevier.com/locate/jpedsurg
Successful treatment of earlobe keloids in the pediatric population Miller Hamrick ⁎, William Boswell, David Carney Department of Pediatric Surgery, Memorial Health University Medical Center, Savannah, GA 31406, USA Received 5 October 2008; accepted 7 October 2008
Key words: Keloid; Kenalog; Interferon alfa-2b; Fibroblast; Alpha1-antitrypsin; Proteoglycans; Hyaluronic acid; Alpha-2-macroglobulin; TGF-β; bFGF
Abstract Background: Keloid scars present a difficult treatment challenge. Recently, intralesional steroid injection has become a common treatment modality [Akoz et al. Aesthetic Plast Surg. 2002;6:184-188; Studdiford et al. JABFM. 2008;21:149-152]. Although this has become a proven treatment technique, there is no standard injection protocol to which treating physicians commonly adhere. We hypothesize that timing of steroid injection may improve outcomes using this treatment technique in combination with lesion excision. Methods: Fifteen patients with 16 earlobe keloids were treated using a standard steroid injection protocol with Kenalog (Bristol-Myers Squibb, New York, NY), in combination with lesion excision. Strict follow-up was enforced, with repeat injections as needed at any sign of abnormal scar formation postoperatively. Results: Of 16 lesions, 15 (94%) were treated successfully with no sign of lesion recurrence at 6 months of follow-up. A single lesion was lost to follow-up and presented 18 months postoperatively with recurrence. This lesion was subsequently retreated successfully. Conclusions: Kenalog injection in combination with excision is a well-tolerated and effective treatment of earlobe keloids in the pediatric population. We feel that timing of injection and adherence to a strict follow-up regimen is crucial to success. © 2009 Elsevier Inc. All rights reserved.
Keloid scars are the result of abnormal wound healing caused by genetic and environmental factors [4,5]. Although the pathogenesis for keloid development remains ill-defined, it is widely acknowledged that keloids develop from physical injury (ie, incisions, lacerations, and piercings) or from pathologic lesions (ie, acne, molluscum, and herpetic lesions)
Presented at the 39th annual meeting of the American Pediatric Surgical Association, Phoenix, AZ, May 27-June 1, 2008. ⁎ Corresponding author. Tel.: +1 478 955 0603; fax: +1 912 350 5984. E-mail address: [email protected] (M. Hamrick). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.10.058
[1,4,5]. Despite the prevalence of keloids in the general population, effective management of the symptomatic and psychosocial burden to the patient remains challenging. Although surgical excision is appealing, recurrence after excision alone exceeds 80% [1]. Recently, combination therapy has become the mainstay of treatment. The most common treatment modalities include intralesional steroid injection, surgical excision, cryotherapy, laser therapy, radiation therapy, and application of pressure with silicon gel sheets. Other less common treatment options include imiquimod, bleomycin, 5-Fluorouracil (5-FU), retinoids, mitomycin C, and interferon alfa-2b. Most data that support
Treatment of earlobe keloids in pediatric population the success of these later options are based on small study populations without blinding or placebo control [1,4,5]. Intralesional steroid injection is the most common mode of treatment to date, as it is well tolerated and has significant effectiveness in reducing symptoms. The typical therapy includes intralesional injection of triamcinolone acetonide (Kenalog, Bristol-Myers Squibb, New York, NY) at a concentration of 10 to 40 mg/mL, depending on the size of the lesion. Subsequent injections are performed at the discretion of the treating physician. This drug works by inhibiting fibroblasts and collagen synthesis. It is also thought to inhibit transforming growth factor β expression and increase basic fibroblast growth factor (bFGF). Complications of this modality include skin atrophy, hypo/hyperpigmentation, and development of telangectasias [2,4,5]. Currently, there is no injection protocol to which physicians commonly adhere. The purpose of this review was to examine the response of earlobe keloids to surgical excision with a defined regimen for perioperative intralesional Kenalog injection. We hypothesize that triamcinolone (Kenalog) injection at the appropriate time during wound healing may increase the efficacy of this treatment modality.
1. Methods Fifteen patients, 1 with bilateral keloids, presented to a single pediatric surgery office over a 3-year period for evaluation and treatment of earlobe keloids. Fifteen lesions were a result of ear piercing, whereas 1 lesion developed secondary to trauma. All patients were treated with a preoperative intralesional injection of Kenalog (0.5 mL triamcinolone 0.5%) at the time of their initial office visit. They were then scheduled for outpatient surgery in 4 weeks, where the lesion was injected again intraoperatively and subsequently excised. Excision was performed in standard fashion with care to approximated skin edges without tension. Wounds were closed with 5-0 Prolene stitches in interrupted fashion, and these stitches were removed within 10 to 14 days of the operation. No deep stitches were used in the closure, in efforts to limit foreign body exposure. Patients were scheduled for follow-up in 4 weeks, and the area of their lesion was then injected for a third time. Strict follow-up was enforced, as lesions were evaluated every 6 weeks, with injections given at any sign of abnormal scar formation. Further follow-up was dictated on a case-by-case basis with repeat injections every 6 weeks until complete resolution of the lesion.
2. Results Fourteen patients adhered to our follow-up regimen, including the patient with bilateral keloids. Of these fifteen lesions, none showed sign of keloid recurrence at 6 months. Four required a subsequent injection of Kenalog, and 1 lesion
287 required 2 subsequent injections. These repeat injections were performed because of concerns about early hypertrophic scar formation. Success was defined as minimal scar formation with no evidence for scarring extending outside of the borders of the surgical incision at 6-month follow-up. A single patient was lost to follow-up after her initial 4-week postoperative visit. She returned 18 months later with evidence for keloid recurrence. The entire injection regimen was repeated, along with reexcision. The patient then complied with follow-up requirements and subsequently had no evidence for recurrence 12 months following her keloid reexcision. Overall, 15 (94%) of 16 keloids were successfully treated with no visible sign of recurrence at 6 months. The single recurrence was retreated, and with strict follow-up, showed no sign of recurrence at 12 months. We noted no serious complications secondary to multiple Kenalog injections. We did identify a single patient who developed hypopigmentation of the earlobe, although this improved slightly over time.
3. Discussion In our experience, perioperative intralesional Kenalog injection and excision is an efficacious and well-tolerated treatment option for earlobe keloid management. The success of this treatment modality depends strongly on patient reliability and adherence to a strict follow-up regimen. We also feel that this treatment regimen optimizes the effect of Kenalog by initially decreasing inflammatory response to injury and subsequently decreasing the inhibition of collagenase at the appropriate time during collagen remodeling [6]. The single recurrence in our study was noted on follow-up at 18 months postoperatively. Upon further evaluation, this lesion began to show signs of abnormal scar formation early in the patient's postoperative course. We feel that had this patient adhered to our follow-up regimen, serial injections could have alleviated this scarring before the need for complete reexcision of the lesion. Therefore, we feel that early follow-up is mandatory, with risk of recurrence decreasing significantly after 6 months postoperatively. Although the exact pathophysiology of keloid formation is not well described, the steps of normal wound healing are well described. The 5 stages classically described are the vascular phase, inflammatory phase, reepithelialization phase, granulation tissue formation, and matrix and collagen remodeling. The final phase begins with replacement of hyaluronic acid with proteoglycans. As collagen crosslinking begins, type III collagen is replaced by type I as the collagen bundles are reoriented. Keloid collagen is thin, irregular, and cross-striations on electron microscopy suggest that it is immature. Patients with keloids have normal plasma concentrations of alphaglobulins but increased deposition of alpha-globulins, alpha1-antitrypsin, and alpha-2-macroglobulins in the keloid tissue. These substances are known inhibitors of collagenase activity [2,4]. Intralesional injection of Kenalog can reduce
288 local alpha1-antitrypsin deposits and therefore decrease keloid size by reducing collagenase inhibition and allowing normal collagen remodeling. Although this series represents a small population, a 94% success rate is comparable, if not better, than any reported literature. Intralesional steroid injection is a widely used treatment modality with few complications. By administering this treatment at the correct time during wound remodeling, the effect of the steroid can be optimized. We feel that because of its success and limited complications, this regimen is a great treatment option for the pediatric surgeon who is asked to evaluate these difficult lesions. Other treatment options have not yet proven their superior efficacy and are often complicated by serious side effects, which are avoided by our simple treatment option.
M. Hamrick et al.
References [1] Akoz T, Gideroglu K, Akan M. Combination of different techniques for the treatment of earlobe keloids. Aesthetic Plast Surg 2002;6: 184-8. [2] Al-Attar A, Mess S, Thomassen J, et al. Keloid pathogenesis and treatment. Plast Reconstr Surg 2006;117:286-300. [3] Lane J, Waller J, Davis L. Relationship between age of ear piercing and keloid formation. Pediatr 2005;115:1312-4. [4] Robles D, Moore E, Draznin M, et al. Keloids: pathophysiology and management. Derm Online J 2008;13(3):9. [5] Slemp A, Kirschner R. Keloids and scars: a review of keloids and scars, their pathogenesis, risks factors, and management. Curr Opin Pediatr 2006;18:396-402. [6] Studdiford J, Stonehouse A, Altshuler M, et al. The management of keloids: hands-on versus hands-off. JABFM 2008;21: 149-52.
www.elsevier.com/locate/jpedsurg
Successful treatment of earlobe keloids in the pediatric population Miller Hamrick ⁎, William Boswell, David Carney Department of Pediatric Surgery, Memorial Health University Medical Center, Savannah, GA 31406, USA Received 5 October 2008; accepted 7 October 2008
Key words: Keloid; Kenalog; Interferon alfa-2b; Fibroblast; Alpha1-antitrypsin; Proteoglycans; Hyaluronic acid; Alpha-2-macroglobulin; TGF-β; bFGF
Abstract Background: Keloid scars present a difficult treatment challenge. Recently, intralesional steroid injection has become a common treatment modality [Akoz et al. Aesthetic Plast Surg. 2002;6:184-188; Studdiford et al. JABFM. 2008;21:149-152]. Although this has become a proven treatment technique, there is no standard injection protocol to which treating physicians commonly adhere. We hypothesize that timing of steroid injection may improve outcomes using this treatment technique in combination with lesion excision. Methods: Fifteen patients with 16 earlobe keloids were treated using a standard steroid injection protocol with Kenalog (Bristol-Myers Squibb, New York, NY), in combination with lesion excision. Strict follow-up was enforced, with repeat injections as needed at any sign of abnormal scar formation postoperatively. Results: Of 16 lesions, 15 (94%) were treated successfully with no sign of lesion recurrence at 6 months of follow-up. A single lesion was lost to follow-up and presented 18 months postoperatively with recurrence. This lesion was subsequently retreated successfully. Conclusions: Kenalog injection in combination with excision is a well-tolerated and effective treatment of earlobe keloids in the pediatric population. We feel that timing of injection and adherence to a strict follow-up regimen is crucial to success. © 2009 Elsevier Inc. All rights reserved.
Keloid scars are the result of abnormal wound healing caused by genetic and environmental factors [4,5]. Although the pathogenesis for keloid development remains ill-defined, it is widely acknowledged that keloids develop from physical injury (ie, incisions, lacerations, and piercings) or from pathologic lesions (ie, acne, molluscum, and herpetic lesions)
Presented at the 39th annual meeting of the American Pediatric Surgical Association, Phoenix, AZ, May 27-June 1, 2008. ⁎ Corresponding author. Tel.: +1 478 955 0603; fax: +1 912 350 5984. E-mail address: [email protected] (M. Hamrick). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.10.058
[1,4,5]. Despite the prevalence of keloids in the general population, effective management of the symptomatic and psychosocial burden to the patient remains challenging. Although surgical excision is appealing, recurrence after excision alone exceeds 80% [1]. Recently, combination therapy has become the mainstay of treatment. The most common treatment modalities include intralesional steroid injection, surgical excision, cryotherapy, laser therapy, radiation therapy, and application of pressure with silicon gel sheets. Other less common treatment options include imiquimod, bleomycin, 5-Fluorouracil (5-FU), retinoids, mitomycin C, and interferon alfa-2b. Most data that support
Treatment of earlobe keloids in pediatric population the success of these later options are based on small study populations without blinding or placebo control [1,4,5]. Intralesional steroid injection is the most common mode of treatment to date, as it is well tolerated and has significant effectiveness in reducing symptoms. The typical therapy includes intralesional injection of triamcinolone acetonide (Kenalog, Bristol-Myers Squibb, New York, NY) at a concentration of 10 to 40 mg/mL, depending on the size of the lesion. Subsequent injections are performed at the discretion of the treating physician. This drug works by inhibiting fibroblasts and collagen synthesis. It is also thought to inhibit transforming growth factor β expression and increase basic fibroblast growth factor (bFGF). Complications of this modality include skin atrophy, hypo/hyperpigmentation, and development of telangectasias [2,4,5]. Currently, there is no injection protocol to which physicians commonly adhere. The purpose of this review was to examine the response of earlobe keloids to surgical excision with a defined regimen for perioperative intralesional Kenalog injection. We hypothesize that triamcinolone (Kenalog) injection at the appropriate time during wound healing may increase the efficacy of this treatment modality.
1. Methods Fifteen patients, 1 with bilateral keloids, presented to a single pediatric surgery office over a 3-year period for evaluation and treatment of earlobe keloids. Fifteen lesions were a result of ear piercing, whereas 1 lesion developed secondary to trauma. All patients were treated with a preoperative intralesional injection of Kenalog (0.5 mL triamcinolone 0.5%) at the time of their initial office visit. They were then scheduled for outpatient surgery in 4 weeks, where the lesion was injected again intraoperatively and subsequently excised. Excision was performed in standard fashion with care to approximated skin edges without tension. Wounds were closed with 5-0 Prolene stitches in interrupted fashion, and these stitches were removed within 10 to 14 days of the operation. No deep stitches were used in the closure, in efforts to limit foreign body exposure. Patients were scheduled for follow-up in 4 weeks, and the area of their lesion was then injected for a third time. Strict follow-up was enforced, as lesions were evaluated every 6 weeks, with injections given at any sign of abnormal scar formation. Further follow-up was dictated on a case-by-case basis with repeat injections every 6 weeks until complete resolution of the lesion.
2. Results Fourteen patients adhered to our follow-up regimen, including the patient with bilateral keloids. Of these fifteen lesions, none showed sign of keloid recurrence at 6 months. Four required a subsequent injection of Kenalog, and 1 lesion
287 required 2 subsequent injections. These repeat injections were performed because of concerns about early hypertrophic scar formation. Success was defined as minimal scar formation with no evidence for scarring extending outside of the borders of the surgical incision at 6-month follow-up. A single patient was lost to follow-up after her initial 4-week postoperative visit. She returned 18 months later with evidence for keloid recurrence. The entire injection regimen was repeated, along with reexcision. The patient then complied with follow-up requirements and subsequently had no evidence for recurrence 12 months following her keloid reexcision. Overall, 15 (94%) of 16 keloids were successfully treated with no visible sign of recurrence at 6 months. The single recurrence was retreated, and with strict follow-up, showed no sign of recurrence at 12 months. We noted no serious complications secondary to multiple Kenalog injections. We did identify a single patient who developed hypopigmentation of the earlobe, although this improved slightly over time.
3. Discussion In our experience, perioperative intralesional Kenalog injection and excision is an efficacious and well-tolerated treatment option for earlobe keloid management. The success of this treatment modality depends strongly on patient reliability and adherence to a strict follow-up regimen. We also feel that this treatment regimen optimizes the effect of Kenalog by initially decreasing inflammatory response to injury and subsequently decreasing the inhibition of collagenase at the appropriate time during collagen remodeling [6]. The single recurrence in our study was noted on follow-up at 18 months postoperatively. Upon further evaluation, this lesion began to show signs of abnormal scar formation early in the patient's postoperative course. We feel that had this patient adhered to our follow-up regimen, serial injections could have alleviated this scarring before the need for complete reexcision of the lesion. Therefore, we feel that early follow-up is mandatory, with risk of recurrence decreasing significantly after 6 months postoperatively. Although the exact pathophysiology of keloid formation is not well described, the steps of normal wound healing are well described. The 5 stages classically described are the vascular phase, inflammatory phase, reepithelialization phase, granulation tissue formation, and matrix and collagen remodeling. The final phase begins with replacement of hyaluronic acid with proteoglycans. As collagen crosslinking begins, type III collagen is replaced by type I as the collagen bundles are reoriented. Keloid collagen is thin, irregular, and cross-striations on electron microscopy suggest that it is immature. Patients with keloids have normal plasma concentrations of alphaglobulins but increased deposition of alpha-globulins, alpha1-antitrypsin, and alpha-2-macroglobulins in the keloid tissue. These substances are known inhibitors of collagenase activity [2,4]. Intralesional injection of Kenalog can reduce
288 local alpha1-antitrypsin deposits and therefore decrease keloid size by reducing collagenase inhibition and allowing normal collagen remodeling. Although this series represents a small population, a 94% success rate is comparable, if not better, than any reported literature. Intralesional steroid injection is a widely used treatment modality with few complications. By administering this treatment at the correct time during wound remodeling, the effect of the steroid can be optimized. We feel that because of its success and limited complications, this regimen is a great treatment option for the pediatric surgeon who is asked to evaluate these difficult lesions. Other treatment options have not yet proven their superior efficacy and are often complicated by serious side effects, which are avoided by our simple treatment option.
M. Hamrick et al.
References [1] Akoz T, Gideroglu K, Akan M. Combination of different techniques for the treatment of earlobe keloids. Aesthetic Plast Surg 2002;6: 184-8. [2] Al-Attar A, Mess S, Thomassen J, et al. Keloid pathogenesis and treatment. Plast Reconstr Surg 2006;117:286-300. [3] Lane J, Waller J, Davis L. Relationship between age of ear piercing and keloid formation. Pediatr 2005;115:1312-4. [4] Robles D, Moore E, Draznin M, et al. Keloids: pathophysiology and management. Derm Online J 2008;13(3):9. [5] Slemp A, Kirschner R. Keloids and scars: a review of keloids and scars, their pathogenesis, risks factors, and management. Curr Opin Pediatr 2006;18:396-402. [6] Studdiford J, Stonehouse A, Altshuler M, et al. The management of keloids: hands-on versus hands-off. JABFM 2008;21: 149-52.