2017-18 HSC Section 4 Green Book

Volume 134, Number 3 • Treatment of Recalcitrant Keloids

Table 1. Patient Characteristic and Results

Patient Characteristics

Results

Age (yr) Sex

Duration (yr)

Fitzpatrick

Scar

Location

Pretreatment

Cause

Score Recurrence

Side Effect

1 20–40 F

2 Shoulders

EXC, ST, SIL

Acne

V–VI III–IV

No Hypopigmentation

2 20–40 M 5 Retroauricular EXC, SIL

Surgery Surgery Trauma

No None No None No None No None No None No None No None No None No None No None No None

3 20–40 F

5 Retroauricular EXC, SIL

I–II I–II

4 20–40 M 3 Ear lobules

EXC, ST

5 20–40 F

4 Ear lobules

ST

Ear piercing I–II Ear piercing I–II

6 20–40 F 10 Ear lobules

EXC, ST

≥ 60 M 5 Limb

7

EXC, ST, SIL

Unknown Trauma Trauma Insect bite Unknown

V–VI V–VI V–VI

8 40–60 F

8 Upper back ST, SIL

9 40–60 M 8 Upper back ST, SIL

10 20–40 F 11 20–40 F

5 Ear lobules

SIL

Ear piercing I–II

6 Sternum ST, SIL

I–II I–II

12 20–40 M 18 Sternum EXC, ST, SIL 13 20–40 F 19 Sternum ST

Acne

V–VI V–VI

No Hyperpigmentation

14 40–60 M 5 Head

EXC, ST, SIL, Cryo Unknown

No None

15 20–40 F

5 Head

EXC, ST, SIL, Cryo Unknown III–IV EXC, ST, SIL, Cryo Unknown III–IV

No Hypopigmentation

16 20–40 M 5 Head

No None No None

17 20–40 F 18 20–40 F 19 20–40 F 21 40–60 F 22 40–60 F

4 Ear lobules

EXC, ST, SIL

Ear piercing V–VI

3 Other 3 Other

ST ST

Trauma Trauma

V–VI I–II III–IV I–II V–VI V–VI V–VI V–VI V–VI III–IV

Yes

None

No None No None No None No Infection No None No None No None No None No None No Infection

20 20–40 F 12 Shoulders

ST, SIL EXC, ST

Acne

1 Ear lobules

Unknown Surgery Trauma

1 Sternum ST, SIL

≥ 60 F

23

2 Ear lobules

EXC, ST, SIL

24 40–60 F 20 Sternum EXC, ST, SIL, Cryo Acne

25 20–40 F 26 20–40 F

2 Shoulders 2 Ear lobules

EXC, ST

Surgery Surgery Surgery Surgery

ST ST

27 20–40 M 2 Ear lobules 28 20–40 F 14 Sternum ST, SIL 29 20–40 M 3 Ear lobules 30 40–60 M 3 Sternum EXC, ST, SIL EXC, ST, SIL

I–II

Ear piercing V–VI

Yes

None

Surgery

I–II

No Telangiectasis No Hyperpigmentation No Hyperpigmentation No Hypopigmentation

≥ 60 F

31

4 Thorax 2 Ear lobules

EXC, ST, SIL

Acne

V–VI V–VI

32 20–40 F

EXC

Surgery

33 0–20 M 1 Ear lobules

EXC, ST

Ear piercing V–VI

34 40–60 F

2 Abdomen None

Surgery

V–VI

No None

35 20–40 M 16 Ear lobules

EXC, ST

Ear piercing I–II

Yes

None

F, female; M, male; Cryo, cryosurgery; EXC, surgical excision; ST, intralesional steroids; SIL, silicone gel/sheeting.

of 1 year. 21 In this prospective trial, we used a frequently cited recurrence definition as set by Cosman and Wolff. 20 In addition, we evaluated scars preoperatively and postoperatively using the Patient and Observer Scar Assessment Scale, which is validated for assessing keloid scars. 13–15 Recurrence After a mean follow-up of 33.6 months, we found a low recurrence rate of 3.1 percent. Previ- ous studies have stated recurrence rates ranging from 12 to 27 percent following external beam radiation therapy. 11,22,23 High-dose-rate brachy- therapy, as in this study, has been reported to yield lower recurrence rates. Veen and Kal found a 3 percent recurrence rate in a 1 × 6-Gy plus 2 × 4-Gy schedule and a 44 percent recurrence rate in a 1 × 4-Gy plus 2 × 3-Gy schedule, 24 but the lat- ter schedule included only nine patients. 24 Arneja et al. used a 3 × 5-Gy schedule in 25 patients and found an 8 percent recurrence rate, 9 whereas Guix

disfigurement and physical complaints, mainly pain and pruritus. Thus far, treatment of recalci- trant keloids has proven challenging, with high recurrence rates and even growth stimulus as the main issue. 1 Excision with adjuvant radiotherapy is considered the most efficacious treatment for keloids Comparison with Existing Literature As stated by Arneja et al., 9 brachytherapy offers several practical advantages over external beam radiation therapy, including improved dose optimization, better radioprotection to surround- ing healthy tissue, and more focused radiation distribution and delivery. Comparison between external beam radiation therapy and brachyther- apy was difficult, because most studies were ret- rospective trials, often not distinguishing clearly between hypertrophic and keloid scars, lacking a variety of Fitzpatrick skin type patients, and not always respecting the minimum follow-up term

193