Keloids: Which treatment is best for your patient?

Custom pressure garments for burn patients have been used in specialized cases involving limbs and torso, face and neck, and hands and feet. For earlobe keloids, clip-on earring devices are the only practical solution. Compliance tends to wane after months of therapy, and cessation may be followed by rebound hypertrophy. The therapeutic effect of regular pressure massage has been poorly studied. Because pressure has minimal adverse effects, it is likely most useful as an adjunct therapy where practical.

Radiation has variable effectiveness
Radiation damages fibroblasts, inhibits proliferation, and may improve local oxygenation.¹³ Low megavolt electron beam radiation is used to limit depth of penetration, usually with a total dose of 10 to 20 Gy fractionated over several weeks.⁵ A dose-response effect is likely.³ Response rates vary from 10% to 94%,³ and keloid recurrence is common, making radiation a poor choice for primary treatment except in cases of a large-volume unresectable keloid (eg, post-burn keloids).¹³

Adverse effects can include nodule formation, hyperpigmentation, ulceration, pruritus, paresthesia, and wound dehiscence. Theoretical risks of malignancy with radiation treatment of keloids have not been borne out in large studies, which have shown a zero percent malignancy rate despite rare anecdotal reports.¹⁵ Nevertheless, radiation therapy for benign disease is not recommended for children or pregnant women, or in breast, thyroid, or other cancer-prone body sites.⁵

Occlusive dressings require patient compliance
An innovation in keloid treatment is the use of occlusive dressings, which started in 1981 and gained popularity in the 1990s.¹⁶ Gel, fluid, or rubbery sheeting, usually made from silicone, is applied topically for 12 to 24 hours daily for up to 18 months.^1,12,14 Gel may be practical along creases or in areas of motion where silicone sheets are obtrusive. Because long-term therapy is recommended, occlusive dressings require active patient participation. Occlusive dressings can decrease pruritic symptoms by decreasing mast cell activity,¹² and may do so by warmth, hydration, or occlusion effects.³

Although study methodology has been suboptimal and further research is required, some practitioners have reported efficacy of 86% for texture reduction, 84% improvement in color, and 68% in diminishing height of scars.¹⁴ However, silicone gel and sheeting may be most successful when applied to a wound before a keloid has formed, as a preventive measure for keloid-prone patients.¹⁴ Occlusive dressings are a relatively benign treatment because silicone rubber is inert, but adverse effects may include skin breakdown, rash, or pruritus that may require discontinuation of therapy for a few days or more.

Combination regimens may be most effective
If a keloid remains unresponsive to first-line therapies, combined therapies may reduce keloid size and prevent recurrence. Select regimens according to keloid characteristics and patient preferences.¹⁷ Corticosteroids used after surgical excision can produce cure rates exceeding 80%, making this a consistently successful management regimen for keloids and the standard of care in many primary care practices.³

Surgery and pressure are the preferred combination for earlobe keloids, as adverse effects are minimal and compliant patients may achieve response rates exceeding 80%.^3,5

Surgery followed by immediate radiation reportedly has a response rate of 65% or higher.¹⁸ This regimen may be most successful in low-tension body areas, like the neck or lower limbs, where keloids are less likely to recur.¹⁸

A combination of surgery and occlusive dressings is also promising. Early studies have had recurrence-free rates of more than 80% when patients applied the dressings for up to 24 hours daily over 4 to 6 months.⁶

Emerging therapies that require further testing

Many promising treatments lack sufficiently rigorous evidence of efficacy.

• Intralesional calcium channel blockers, which depolymerize actin¹⁹ and inhibit protein synthesis,⁵ have shown promising results in nonrandomized early clinical trials.¹⁹
• Ultraviolet light is a potentially successful noninvasive method.
• Topical retinoids (vitamin A derivatives) may be effective but must be applied twice daily for several months to reduce collagen metabolism by fibroblasts⁵; they may also cause photosensitivity and skin irritation.⁷
• Intralesional fluorouracil (5-FU) (as an antimetabolite) successfully reduced keloid size after one year of treatment in a few small trials.^5,20
• Oral lathyrogen, such as penicillamine with colchicine, can interfere with collagen cross-linking; in a small case series there was no keloid recurrence after treatment.⁵
• Topical imiquimod (Aldara) cream, an immune response modifier, showed promise in a few case reports.^5,21
• Laser procedures are less likely than scalpel procedures to produce keloid scars and have been reported to successfully improve scar color, size, and texture, although the risk of hyperpigmentation ranges from 1% to 24%.^2,3,22 (Lasers induce ischemia through blood vessel destruction and cause decreased fibroblast production and histamine release.^23,24) Red flat scars (which triamcinolone injections may cause) can be lightened with yellow light laser, which has been used in the treatment of capillary malformations.²⁵