Flashcards in Keloid management Deck (93):
Keloids are a hyperproliferative response to trauma.
Keloids appear most commonly in areas of high skin tension.
T Jawline, ant chest, upper back, deltoid
Genetic predisposition does not play a role in the development of keloids.
Darkly pigmented individuals form keloids 2-19 times more frequently than Caucasians.
New keloid formation is relatively less common in the very young and the elderly.
Keloids may regress after the menopause.
Significant keloids can occur after minor trauma.
Deeper and significant surgical wounds are often more likely to keloid than minor abrasions, burns, insect bites, varicella and zoster, vaccinations and tattoos.
Chronic oedema in response to the trauma of ear piercing (and subsequent reaction to the presence of a metal foreign body) could result in increased incidence of keloid formation
Infectious agents themselves are likely to cause keloids, accounting for their development following varicella for example.
F Most likely to trauma, oedema, incr wound tension that occurs from infection.
Keloids may grow more readily or appear de novo during pregnancy.
Keloids are more common before puberty.
Melanocyte-stimulating hormone does not play a role in keloid formation.
Collagen synthesis is 20 times greater in keloids than in normal skin.
The absolute number of fibroblasts within keloids is increased.
Keloids develop rapidly after surgery, whereas hypertrophic scars may occur months after the inciting trauma.
F Hypertrophic scars develop rapidly, keloids develop slowly over months.
Hypertrophic scars may subside with time, whereas keloids generally progress until such time as they become stable.
Hypertrophic scars stay within the initial wound footprint, whereas keloid exceed the size of the initial trauma
Keloids are more likely to occur in areas prone to excessive motion, whereas hypertrophic scars are most often found in areas with limited or no motion.
F Hypertrophic in areas of motion (eg joints), keloid in areas with less motion (eg chest and back)
Postoperative keloid recurrence is frequently better than the initial lesion.
F Frequently worse.
Stable mature keloids tend to be symptomatic with itching, burning and pain.
F This occurs in progressing lesions.
Keloids of the jaw, neck and anterior chest can cause dysfunction.
There are 5 types of earlobe keloids – anterior button, posterior button, dumbbell, wraparound and lobular.
Button earlobe keloids have a core component within the lobe.
F This is true for dumbbell keloids.
Wraparound keloids form a cuff around the lobe from one side to the other.
Lobular earlobe keloids can be shaved off in their entirety.
F This is true for button keloids.
Pedunculated keloids, particularly when they occur on soft, mobile skin, are amenable to simple excisional surgery.
Intralesional corticosteroids are generally the first line treatment for keloids.
When used as solo therapy, corticosteroids are most useful in peunculated or raised lesions.
F Most useful in sessile, flat and broad keloids.
The most common cause of intralesional steroid injection failure is the use of overly dilute concentrations.
T Most require 40mg/mL.
The current standard of care with intralesional TCA injection is not to inject more than 80mg per session.
F 40mg per session, so as not to suppress HPA axis.
40mg of triamcinolone is the equivalent of 50mg prednisone
Intralesional TCA should not be performed more frequently than every 4-6 weeks.
F Every 2-4 weeks (depending on total dose of steroid used and size of keloid).
Mixing lignocaine with triamcinolone makes the injections less painful.
F Pain of injection is over before lignocaine takes effect. But good for post-injection pain.
Intralesional triamcinolone can be used for prevention of keloids, with injection occurring on the day of surgery.
T One regimen = day of surgery, then at 2, 4 and 6 weeks.
Intralesional corticosteroids can be combined with any other treatment modality to improve keloid treatment outcome
Hypopigmentation is an uncommon side effect of intralesional corticosteroid injection.
After treatment, the atrophic footprint of the keloid may appear wrinkled or shiny and have telangiectasias. This is unlikely to improve with time.
F Often improves with time.
Large bulky keloids respond well to solo treatment with injectables.
F Surgical removal is often necessary.
Pedunculated keloids with narrow bases can be excised and closely primarily with little wound tension.
Surgery is best used as a solo method of treating keloids.
F Must use adjunctive techniques.
When using surgery to treat keloids, the incision should be as long as possible in order to reduce tension.
F Small as possible.
When excising keloid scars, removal of all keloid material should be attempted.
When excising keloid scars, monofilament buried sutures should be used.
F Avoid buried sutures – may serve as nidus for keloid reformation.
Sutures need to be left in longer than usual after keloid scar excision in order to prevent dehiscence, especially when steroids are injected postoperatively.
After surgical excision of keloid, the wound should never be left to heal by secondary intention
F Often results in better cosmetic outcome and lower incidence of recurrence.
Surgical treatment of earlobe keloids result in high recurrence rates.
F Have lower rate of keloid recurrence.
Anterior and posterior button earlobe keloids are most easily removed by simple shave followed by secondary intention healing.
Dumbbell keloids are anterior and posterior button keloids connected by a smaller core of keloid tissue.
With dumbbell keloids, the core can be punched out using a punch at least 1mm larger than the core itself, after shave excision of the anterior and posterior buttons.
T Defect then close horizontally on front and vertically on back of lobe (to prevent pointed lobe).
Small lobular and wraparound keloids are best excised in a wedge and closed primarily.
If a large lobular, multilobular, or wraparound keloid earlobe scar has been completely resculpted to leave an earlobed-shaped keloid, there is no need for further treatment.
F Often need XRT + silicone gel + ILCS + IFN injection + pressure to prevent recurrence.
Recurrence rate following CO2 laser of keloid scars is low.
PDL may improve hypertrophic scar symptoms, decrease scar height, and improve skin texture.
XRT alone is often effective in existing keloids.
F Ineffective. Excision of needed prior.
XRT treatment of keloids is associated with a long-term risk of malignancy of the skin or underlying structures.
F Numerous large studies report 0% carcinogenesis.
Common side effects of XRT treatment of keloid scars are skin atrophy, radiation dermatitis, abnormal skin pigmentation and local alopecia.
XRT of keloids can be used safely in children.
F Not recommended, or use metaphyseal shields.
Compression therapy for keloids involves applying pressure greater than that of capillary pressure (24mmHg).
T Causes reduced soft tissue cellularity. Should be less that a pressure that would diminish peripheral blood circulation
Compression is applied for 18-24hours a day for a minimum of 4-6months up to 2 years
Pressure alone is effective in the treatment of existing keloids.
Dressings which apply more than 24mmHg, worn 24hrs a day for 4-6months, after often successful in reducing keloid recurrence rates postoperatively.
With regards to the use of silicone gel sheeting for the treatment of keloid scars, it is possible that wound hydration, not the presence of silicone, is responsible for the clinical effect.
Interferon- is highly effective in the treatment of keloids.
F Trial results disappointing not used.
Interferon injections improve existing mature and stable keloids.
F Best for young keloids, or for prevention.
IFN-2b is best done on the day of surgery, then 1 week postoperatively directly into the wound.
IFN-2b is used in volumes of 1 million units per linear cm into the wound base and margins
Side effects of IFN-2b are reduced by limiting total dose to less than 10 million units per treatment,
F 5 million units.
Side effects of IFN-2b include a flu-like syndrome, which can be reduced or eliminated by prophylactic use of paracetamol.
T Give 1g 1hr pre-op, then repeat every 4 hrs for first 24hrs.
Topical imiquimod is most effective for earlobe keloids.
Imiquimod application results in a significant improvement in existing keloids or hypertrophic scars.
Cryotherapy for the treatment of keloid scars is used with 30-second freeze times repeated 2-3 times per cycle.
T This method has lower recurrence rates (ie 2%)
Cryotherapy has been show to be effective only in combination therapy
F Alone or in combination
Younger keloids respond better to cryotherapy.
Side effects of cryotherapy in the treatment of keloid scars include pain and a prolonged healing phase of more than one month.
Combination of cryotherapy and corticosteroids is superior to either modality alone.
Likelihood of hypopigmentation resulting from melanocyte sensitivity to cold makes cryotherapy less applicable in dark skinned patients
5-FU can be applied topically to keloid scars.
F Studies are for intralesional injection.
Small amounts of 5FU are injected at 1cm intervals along the scar
T Eg 0.05ml of 50mg/ml
Total dose of 5-FU per sessions doesn’t exceed 50mg in case series reported
F 2-50mg usually used, 100mg max
The side effects of 5-FU for the treatment of keloid scars rarely include ulceration, pain and hyperpigmentation.
F Occur in virtually all patients.
Younger, more symptomatic scars show most improvement with 5FU
Side effects of 5FU include ulceration, pain and hyperpigmentation
T In almost all patients
Combination of 5FU and triamcinolone improves efficacy and decreases pain
T No telangiectasia as side effects (vs corticosteroids)
Vitamin E topically has been shown to improve or prevent hypertrophic scars.
F No evidence to support this.
Bleomycin use in the treatment of keloid scars involves topical application of 1.5IU/ml to the keloid surface that is then punctured repeatedly with a 25-G needle.
Prevention of keloid recurrence or occurrence can be greatly improved when all available modalities are utilised simultaneously.
Ears from which keloids have been removed can be re-pierced.
F Should avoid this.
Multiple lesions in patients in whom acne lesions tend to form keloids are an indication for oral antibiotics or a course of isotretinoin.
Keloid patients should be followed-up for at least 1 year after therapy to monitor for recurrence.
Keloids can rarely become malignant.
F This has never been reported.
Bleomycin is used by applying to the surface of the keloid which is then punctured repeatedly with 25G needle
T 1.5IU/ml used. Treatment regimen – 2-5 treatments at 1-4 month interval