Combined Keloid Removal Modality

One of the most commonly used combination therapies employs cold-knife excision followed by postoperative injection of intralesional steroid. The injection into the lesion typically occurs 2-3 weeks postoperatively, followed by repeat injection in 3-4 weeks. Preoperative or intraoperative steroid injection may delay wound healing and increase the possibility of wound dehiscence. The most commonly used form of steroid is triamcinolone suspension; however, dexamethasone and cortisone can also be used. A concentration of 10 mg/mL of triamcinolone is used as the starting point and can be increased to as high as 40 mg/mL for denser, more recalcitrant keloids. The lower dose is preferred because of the potential complications of intralesional steroids, including depigmentation and dermal atrophy. The literature, confirmed by clinical experience, reports a negligible incidence of systemic effects.

The mechanism of action of corticosteroids is inhibition of fibroblast growth and promotion of collagen degradation. Surgical excision followed by postoperative intralesional steroid injection is reported by some authors to have recurrence rates as low as 50%, while other authors report recurrence rates as high as 70%.

A combination of surgical excision and external beam radiotherapy is implemented in certain centers. Radiation therapy adversely affects fibroblast growth and collagen production. Sclafani et al conducted a randomized prospective trial comparing keloid excision followed by intralesional steroid injection with keloid excision followed by radiotherapy. Results of the study did not demonstrate statistical significance but were able to show a trend toward a lower recurrence rate in the radiated group. A second method of radiation therapy involves the use of interstitial iridium 192. The typical dosing range for external beam radiotherapy is 700-1500 cGy administered within 1 week of surgery. Some authors report that the timing of radiation therapy may actually improve patient compliance.

The disadvantages of treating a benign process with radiation include the potential of inducing thyroid or salivary gland neoplasia, which has a latency period of 15-20 years. Shielding techniques are used to safeguard against such occurrences but should not be considered foolproof. In areas where the surrounding normal structures can be adequately shielded (eg, the earlobes), radiation therapy is a reasonable and viable option.

>>>> keloid treatment approaches: keloid treatment

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