Management of Keloid Scars


Often these scars are quite a challenge. If you wish to make an enquiry it is helpful if you can send me a picture and I can give you a better idea?

Protocol

In general red active keloids respond to the usual injection of steroid. We use 10mg/ml Triamcinolone (Adcortyl) and based on work from the Institute of Dermatology in New York mix it 50:50 with 50mg/ml 5-FU (Fluorouracil) and inject monthly for three sessions, and then depending on response. I tend to inject active scars - so itching or thickened. In some cases this treatment programme can take 10 years before the scar is finally quiescent. It is important not to blanch the scar in the early treatments. This can result in ischaemia necrosis and ulceration when the scar is hard and tight. From January 2016 we have changed to the higher concentration of steroid at 40mg/ml (Kenalog) for trunk and limb scars and the rapidly proliferating ear keloids. There has been no changed in the side effect profile and the results are much better with faster resolution of the scarring.
You only really know you have won when you are two years after the last injection. Compliance from the patient is important, as otherwise this programme will not be very effective. Appointment intervals increase as the scar settles, but some will need monthly injections for a year to get on top of things. Scar telangiectasia is a risk after the sixth injection, but I no longer worry about this, as we can usually sort these out with laser treatment.
As the scar resolves the inflammatory component will settle, and there is less for the steroid to do. We then reduce the ratio adding more 5-FU to the mix.
So far the most we have injected in one session is 4cc, which is 200mg. The daily maximum adult dose of Adcortryl is 1000mg, and Kenalog is 80mg.
If the scar is too large, then it may be better to accept defeat and excise and start with a fresh scar. I inject once the wound is closed, and start with the above regime from fresh. Sometimes it is necessary to excise flaps of skin off the scar tissue, leaving epidermis and 1-2 mm of dermis/scar tissue. There is less of a scar load to then treat, and the flaps are often necessary to allow primary wound closure.
If the keloid is white, mature and less than 2cm across then CO2 laser ablation in an UltraPulse mode taking of 200 micron layers in multiple passes wiping between to remove the eschar. I think that it works in the same way as intralesional excision, leaving a small rim of relatively undamaged scar behind that does not seem to regrow. For large confluent areas of keloid scarring some improvement in the pain and inflammatory phase seems to be helped with the injection in the scar and sub epidermal plane with washed fat (from abdominal liposuction). I think it is the prostaglandins that play a role in this, but I am not sure at the moment.
These treatments are not licensed, and only a few studies support our method. These are included with abstracts at the end of this email. Unfortunately an assessment of improvement in scars is very subjective. Only in exceptional circumstances do we follow this regime in children, and always ask female patients if there is any chance they are pregnant before carrying out the injections as this is a contraindication. There is no known link with abnormalities in the foetus, but this is taken as a position of safety, as with many treatments. There is no evidence to date regarding impact on future fertility. Side effects are painful scars for up to two days after injection. Usually the first injection is the most painful, and this becomes less with subsequent injections. Rarely patients require a local anaesthetic nerve block to reduce the pain after each injection.

References

Info as follows from relevant article:
Fitzpatrick RE. (1999). Treatment of inflamed hypertrophic scars using intralesional 5-FU. Dermatologic Surgery, 25(3): 224-232.
BACKGROUND: Hypertrophic scars and keloids may complicate wound healing secondary to trauma or surgery. A variety of treatment regimens have been used with a range of success. OBJECTIVE: The purpose of this paper is to report the use of 5-fluorouracil (5-FU) intralesionally in treatment of inflamed hypertrophic scars, both as an individual agent as well as in conjunction with low-dose intralesional corticosteroids plus pulsed dye laser therapy. METHODS: The author's 9-year experience in the use of this agent in treating hypertrophic scars is summarized, and case reports are used to demonstrate its efficacy at 50 mg/cc as well as mixed with Kenalog (1 mg/cc) plus concomitant use of the pulsed dye laser. RESULTS: Frequent initial injections (once to thrice weekly) were found to be more efficacious with decreasing frequency (weekly to monthly) during a period of stabilization and resolution of the scars. The combination of 5-FU and Kenalog appeared to be more effective and less painful. The addition of the pulsed dye laser treatments simultaneous with injection therapy was found to be most effective. CONCLUSION: The use of 5-FU intralesionally for treatment of hypertrophic scars appears to be both effective and safe. Further study is warranted.

Lin Huang YJ, Cai IL, Leung BCS and Burd A. (2013). A study of the combination of triamcinolone and 5-fluorouracil in modulating keloid fibroblasts in vitro. J Plast Reconstr and Aesthetic Surgery, 66: e251-e259.
Background: Preliminary clinical trials suggest a superior effect when steroids and 5-fluorouracil are injected together for the intralesional therapy of keloids. In addition, it has been proposed that low-dose 5-fluorouracil may have advantages over conventional high dosages. We explored the molecular basis for the potential synergy involved in the combined treatment with triamcinolone and 5-fluorouracil. Methods: The effects of triamcinolone alone or in combination with low-dose 5-fluorouracil on cell proliferation, cell-cycle progression, apoptosis and regulation of p53, p21, type I collagen (Col-1), vascular endothelial growth factor (VEGF), transforming growth factor-beta1 (TGF-beta1) and matrix metalloproteinase-2 (MMP-2) production in primary cultured keloid fibroblasts were examined by MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide), flow cytometric and Western blotting assays.

Mustoe TA, Cooter RD, Gold MH, Hobbs FDR, Ramelet A, Shakespeare PG, Stella M, Teot L, Wood F and Ziegler UE. (2002). International clinical recommendations on scar management. Plast Reconstr Surg, 110(2): 560-571.

Uppal RS, Khan U, Kakar S, Talas G, Chapman P and McGrouther AD. (2001). The effects of a single dose of 5-fluorouracil on keloid scars: a clinical trial of timed wound irrigation after extralesional excision. Plast Reconstr Surg, 108(5): 1218-1224.
The possibility of altering the pathophysiology of keloid scars was investigated in 11 patients, using a single application of 5-fluorouracil solution for 5 minutes after extralesional excision was performed. Similar excisional wounds treated with phosphate-buffered saline for 5 minutes served as synchronous controls. An objective scoring system and subjective assessment were made to assay the change in the quality of the wound-healing and scar tissue produced by this treatment. A keloid scar score was used at regular time intervals after treatment to assess the quality of scar produced, thereby enabling the treated and control scars to be clinically compared. Biopsies were taken of the control and treated scars 1 month after treatment; the biopsy specimens were then subjected to immunohistochemical analysis as well as a functional assessment of cultured keloid fibroblasts. The immunohistochemical antigens assayed were Ki-67 (also called MIB-1; a marker of cell proliferation); vascular cell adhesion molecule-1 (a marker of inflammation); transforming growth factor beta-1 (a factor involved in scarring) and CD-68 (a macrophage-specific marker). Fibroblast-populated collagen lattices provided a functional assessment of fibroblast contraction. All treated and control wounds healed without any dehiscence or infection. The keloid scar score revealed that there was a perceived improvement in condition for those treated with 5-fluorouracil, compared with the control specimens, during the 6-month follow-up period in the five patients who attended all their clinic appointments; data on later recurrence are not complete as yet. The wounds treated with 5-fluorouracil produced scars that had a significant (p < 0.01) reduction in all the markers assayed, apart from CD-68. Functionally, the keloid fibroblasts from three of five of the treated patients showed reduced contractile capacity. This pilot study demonstrates that a "single-touch" technique with 5-fluorouracil can produce a change in the characteristics of the healing keloid wound after extralesional excision. Long-term studies are required to elucidate the correct dosage and time of exposure to improve the efficacy of this potential treatment.

Khan MA, Bashir MM and Khan FA. (2014). Intralesional triamcinolone alone and in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. Journal of the Pakistan Medical Association, 64(9): 1003-1007.
To compare the use of intralesional triamcinolone acetonide and its combination with 5 fluorouracil in the treatment of keloid and hypertrophic scars in terms of reduction in initial height of the scar. METHODS: The randomised controlled trial was conducted at the Department of Plastic Surgery, King Edward Medical University, Lahore, from March 2011 to December 2012. It comprised patients of both genders having keloids or hypertrophic scars (1 cm to 5 cm in size) having no history of treatment for the scars in preceding 6 months. Those who were pregnant, planning pregnancy or lactating were excluded. The subjects were divided into two groups: Group A received intralesional triamcinolone acetonide alone; and Group B received triamcinolone acetonide + 5 fluorouracil. Eight injections were given at weekly interval. Scars were assessed 4 weeks after the completion of treatment on a five-point scale. SPSS 16 was used for statistical analysis. RESULTS: The 150 subjects in the study were divided into two equal groups of 75 (50%) each. Good to excellent results were seen in 51 (68%) cases in Group A compared to 63 (84%) in Group B. Frequency of complications was 18 (24%) and 6 (8%) in Group A and Group B respectively. CONCLUSION: Combination of triamcinolone acetonide and 5 fluorouracil is superior to triamcinolone acetonide therapy in the treatment of keloids and hypertrophic scars.

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