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Keywords:

  • keloid;
  • lasers and 32P radiation;
  • therapy

Abstract 

  1. Top of page
  2. Abstract 
  3. Introduction
  4. Patients
  5. Report of two cases
  6. Procedure
  7. Discussion
  8. References

Keloid is one abnormal wound healing that occurs commonly in predisposed individuals. Many treatment modalities have been tried, either alone or in variety, including surgical removal, laser therapy, radiation therapy, silicone cream or gel application, cryosurgery, and intralesional injection of various agents. These treatment options have been practiced with largely transient and limited success. In the present study, the present authors prospectively assessed the efficacy of combination methods of the treatment of recalcitrant keloid. One hundred fifty-one sites of keloids in 122 patients were chosen, age of patients varied between 15 and 60 years, size of scar more than 2 cm2 with pain, itch, or other discomfort, and duration of more than 2 years. Keloids were treated with combination methods of lasers and 32P radiation on originating scars. One hundred eleven of 151 evaluated sites scored “excellence” and 40 belonged to “effectiveness”. These patients demonstrated local control and have remained free of local recurrence for more than 2 years. In addition, there were only 21 and 32 sites with pigmentation and depigmentation, respectively. Over the past 5 years, we established a treatment protocol combining laser with 32P-patch contact brachyradiotherapy, which represents a safe and effective option in the treatment of keloids.


Introduction

  1. Top of page
  2. Abstract 
  3. Introduction
  4. Patients
  5. Report of two cases
  6. Procedure
  7. Discussion
  8. References

Hypertrophic scars and keloids are the major forms of excessive cutaneous scarring that occur in predisposed individuals after skin injury [1, 2]. Although keloids look similar to a hypertrophic scar, keloids continue to grow encroaching upon normal tissue. Keloids are notoriously difficult to treat, with recurrences commonly seen when compared to hypertrophic scars. Clinicians always find it difficult to treat hypertrophic scars and keloids. Various treatment modalities are available; intralesional corticosteroids, topical applications, cryotherapy, surgery, laser or pulsed-dye laser therapy, pressure therapy, and silicone sheeting are options that have been extensively used [3, 4]. Recently, contact brachyradiotherapy has been successfully used to treat keloids and hypertrophic scars [5]. However, there are no specific protocols for the treatment of hypertrophic scars and keloids, and the treatment has to be individualized depending on the distribution, size, thickness, and consistency of the lesions and associated inflammation. Treatment also depends on the patient's age, individual differences, and overall health. Currently, the most effective treatment strategy is to determine the patients' specific case and use the appropriate means of comprehensive treatment [6]. In the present study, the present authors prospectively assessed the efficacy of combining different treatment modalities with CO2 laser and 32P radiation on recalcitrant keloids, which had been treated with two or more treatment modalities (excision, laser, cryotherapy, pressure garments, and radiation) and duration of more than 2 years.

Patients

  1. Top of page
  2. Abstract 
  3. Introduction
  4. Patients
  5. Report of two cases
  6. Procedure
  7. Discussion
  8. References

The present authors studied 151 keloids sites in 122 patients (see Table 1). The present authors' inclusion criteria were as follows: treated with two or more treatment modalities (excision, laser, cryotherapy, pressure garments, radiation), patient age between 15 and 60; size of scar more than 2 cm2 with pain, itch or other discomfort, and duration of more than 2 years.

Table 1. Clinical characteristics and curative effect of treated keloid patients
SitePatient (M/F)Number of keloidsCurative effect
Excellence (M/F)Effectiveness (M/F)Inefficiency (M/F)
Breast41(19/22)4935(14/21)14(7/7)0
Back19(8/11)3124(6/18)7(4/3)0
Upper extremity18(6/12)2115(4/11)6(2/4)0
Lower extremity12(6/6)139(3/6)4(3/1)0
Ear16(7/9)1612(5/7)4(2/2)0
Face and neck9(5/4)129(7/2)3(1/2)0
Abdomen7(2/5)97(1/6)2(1/1)0
Total122(53/69)151111(40/71)40(20/20)0

Based on therapeutic effective criteria, 111 of 151 evaluated sites scored “excellence,” and 40 scored “effectiveness” (see Table 1). The included patients have demonstrated local control and have remained free of local recurrence for more than 2 years. In addition, 21 and 32 sites had pigmentation and depigmentation, respectively. Only two of all the patients complained of itching and pain at the location of the lesion, but no complications, such as ulcer formation, occurred.

Report of two cases

  1. Top of page
  2. Abstract 
  3. Introduction
  4. Patients
  5. Report of two cases
  6. Procedure
  7. Discussion
  8. References

Case 1

A 53-year-old woman presented with keloids that developed from a scald in 2006 is shown in FIG. 1. The size of the left chest keloid was 15.0 × 6.0 × 0.7 cm. The keloid was initially excised by laser. One week later, the de novo granulation tissue was excised by pulse laser. One month later, 32P-patch contact brachyradiotherapy was preformed three times. There was no recurrence of the keloid at this location when we examined the patient after 3 years.

figure

Figure 1. Case 1 before and after treatment. (A) Left chest keloid before therapy; (B) Three-year follow-up appearance after the combinative treatment.

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Case 2

A 38-year-old woman presented with a left waist keloid after skin grafting. The keloid, 20 × 5 × 0.6 cm in size in 2002, is shown in FIG. 2A. At first, the patient was treated with CO2 laser, which removed proliferative tissues of the scar. After 5 days, CO2 laser ablation was performed again. One month later, the wound had healed and 32P-patch contact brachyradiotherapy was applied at 1MBQ/cm2 for 96 hours. It was repeated in 2-month intervals with three continuous therapies. This patient did not show any signs of recurrence of the keloid at 3 (FIG. 2B) and 7 years (FIG. 2C) after completion of the therapy.

figure

Figure 2. Case 2 before and after treatment. (A) Keloid presented on left waist before therapy; (B) evolution of the core domain after 3 years of the combinative treatment; (C) Seven-year follow-up appearance after the treatment.

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Procedure

  1. Top of page
  2. Abstract 
  3. Introduction
  4. Patients
  5. Report of two cases
  6. Procedure
  7. Discussion
  8. References

First, continuous-wave CO2 laser was used as a scalpel to eliminate the proliferation of scar tissue, and drain infections preparing the site for subsequent treatments. In addition, continuous-wave CO2 laser (or such treatment) can reduce pain and swelling. However, this method can also cause damage to the surrounding normal tissue and enlarge the scar to a greater extent than surgical removal of the scar. Second, the destruction of angiogenesis is essential, as hypertrophic scars and keloids have a larger number of blood vessels, increased thickness of the papillary dermis and reticular. Five to seven days after laser surgery, another line of ultra-pulse CO2 laser treatment of fresh wounds created significant growth of granulation tissue around capillaries, thereby slowing the rapid proliferation of capillaries and preventing the proliferation of scar tissue. Finally, fibroblast growth and collagen synthesis were inhibited by 32P application. During the regeneration period, the scar has a relatively loose organizational structure, which enables the penetration of topical medications and 32P applicator treatment. Based on the patient's age, individual differences, physical conditions, and the scar thickness and size, the localized keloids were treated twice or three times with 32P-patch contact brachyradiotherapy at 1–0.5 MBQ/cm2 for 72–96 hours at 1- or 2-month intervals. The results were gratifying. There was no recurrence, but also, there were no radiation-related systemic adverse reactions. We have follow-up data for 53 of the patients from 2 to 7 years after the procedure. These included anyone who was involved with the radiation therapy, including the three physicians who worked on the treatment protocols for over 10 years.

According to a study by Hintz et al. [7], the following subjective scale from one to three was employed to score the therapeutic effect: 1 – Excellence, no noticeable scar or scar apparent with cosmetically satisfactory result; 2 – Effectiveness, obvious, hypertrophied scar with unsatisfactory cosmetic appearance; and 3 – Inefficiency, disfiguring scar as large or lager than prior to treatment.

Discussion

  1. Top of page
  2. Abstract 
  3. Introduction
  4. Patients
  5. Report of two cases
  6. Procedure
  7. Discussion
  8. References

Keloids are common benign tumors that are caused by dermal fibroproliferative disorders [8, 9]. Because of the complex pathogenesis and variability in responsiveness, it is very difficult to treat keloids, resulting in a high recurrence rate regardless of therapy, and, to date, no effective treatment exists for permanent keloids removal [10]. Currently, the treatments include silicone sheeting, pressure dressings, and corticosteroid injections. Postoperatively, one or two methods are selected, including pulsed-dye laser, radiation, and potentially imiquimod cream. Intralesional injections of verapamil, fluorouracil, bleomycin, and interferon alfa-2b have been shown to be beneficial for treatment of established keloids [11].

Recently, the indications for CO2 laser has been expanded to include keloid excision and has shown promising results in increasing the secretion of basic fibroblast growth factor and decreasing the release of transforming growth factor β1 (TGF-β1), thereby suppressing the formation of granulation (proliferation) tissue [12]. Studies have also shown good results when adding 32P chromic phosphate or silicon 32P-patch to the local treatment for solid tumors or keloids [13, 14]. The topical paste 32P, causes local irritation, similar to radiation dermatitis, and suppresses fibroblast proliferation. 32P continues to release β-ray and affects the regeneration period of scar tissue, resulting in significant reduction of fibroblasts and synthesis of collagen fibers. It also allows fibroblast cell degeneration and inhibits procollagen synthesis and excretion by collagen fibers resulting in the flattening and softening of scar tissue [15]. Laser and isotope combination therapy achieved a curative effect in 69% of all patients.

In one word, the methods of treatment of keloids are numerous, but there is no single therapy that has been proven to be vastly superior or universally efficacious. The best success rates for treatment of keloids are combination therapies [16]. Over the past 5 years, we established a treatment protocol combining laser with 32P-patch contact brachyradiotherapy, which represents a safe and effective option in the treatment of keloids.

In conclusion, there is no therapeutic modality considered to be universally effective; the laser and 32P radiation combination therapy seems to be more effective than any single mode of treatment program for recalcitrant keloid. These results are encouraging in developing an efficacious therapeutically strategy for recurrence of keloids.

References

  1. Top of page
  2. Abstract 
  3. Introduction
  4. Patients
  5. Report of two cases
  6. Procedure
  7. Discussion
  8. References
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