2017-18 HSC Section 4 Green Book

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for three studies. 27 Of these articles, one described a nonrandomized controlled trial that found better results for intralesional verapamil, compared with the control group. 35 The other two level 2 evidence studies were both randomized single-blinded controlled trials that compared intralesional verapamil with intrale- sional triamcinolone acetonide, the gold standard in nonsurgical management. They used the widely used validated VSS to assess ef fi cacy of the treatments. Both studies found a comparable ef fi cacy for verapamil and triamcinolone acetonide. Intralesional triamcinolone acetonide achieved the end result faster but also showed more side effects. Another advantage of verapamil over triamcinolone, beside the lower rate of side effects, was reported to be the considerably lower cost of verapamil. This can have bene fi cial implica- tions for developing countries. 38,39 One of the shortcomings of the available literature, on ef fi cacy and adverse events, is the lack of subgroup analysis in studies that included both hypertrophic scars and keloids. The two types of pathological scars are clubbed together; yet, it is known that keloids are more recalcitrant to treatment and result in more profound recurrences after excision. In this study, both hypertrophic scars and keloids were included in the search strategy, to achieve a suf fi cient number of articles for analysis and reviewing. Another shortcoming of the available literature, on ef fi cacy and adverse events, is the use of many different nonvalidated assessment tools. Although scar evalua- tion tools are necessary for an evidence-based approach to scar treatment, there is still no generally accepted tool. 45 Many of the validated assessment tools in current use are semiquantitative scales such as the VSS or the Patient and Observer Scar Assessment Scale. 46,47 Only two studies described in this reviewused a validated tool, the VSS, whichmakes comparison of outcomes dif fi cult. Current more objective methods, which include direct casting and high-frequency ultrasound, can be complex and are not easily applied in clinical setting. 48,49 Other techniques, for example, use of a three-dimensional imaging system for volume measurement, show promising results and may be used for better scar assessments in the future. 50,51

Conclusion

An overview is presented of the current evidence for mechanismof action and for ef fi cacy and adverse events of the calcium antagonist verapamil in the treatment of hypertrophic scars and keloids. Important methodo- logical shortcomings of the available literature were identi fi ed. Further large scale, high-quality studies are needed to optimally evaluate ef fi cacy of treatment with calcium antagonists. Nevertheless, there have been interesting results reported, and further study is required to explore the effects. 1. Al-Attar A, Mess S, Thomassen JM, Kauffman CL, et al. Keloid pathogenesis and treatment. Plast Reconstr Surg 2006;117: 286 – 300. 2. Datubo-Brown DD. Keloids: a review of the literature. Br J Plast Surg 1990;43:70 – 7. 3. Rockwell WB, Cohen IK, Ehrlich HP. Keloids and hypertrophic scars: a comprehensive review. Plast Reconstr Surg 1989;84:827 – 37. 4. English RS, Shenefelt PD. Keloids and hypertrophic scars. Dermatol Surg 1999;25:631 – 8. 5. Wolfram D, Tzankov A, Pulzl P, Piza-Katzer H. Hypertrophic scars and keloids — a review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg 2009;35:171 – 81. 6. Slemp AE, Kirschner RE. Keloids and scars: a review of keloids and scars, their pathogenesis, risk factors, and management. Curr Opin Pediatr 2006;18:396 – 402. 7. Niessen FB, Spauwen PH, Schalkwijk J, Kon M. On the nature of hypertrophic scars and keloids: a review. Plast Reconstr Surg 1999;104: 1435 – 58. 8. Leventhal D, Furr M, Reiter D. Treatment of keloids and hypertrophic scars: a meta-analysis and review of the literature. Arch Facial Plast Surg 2006;8:362 – 8. 10. Juckett G, Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician 2009;80:253 – 60. 11. Monstrey S, Middelkoop E, Vranckx JJ, Bassetto F, et al. Updated scar management practical guidelines: non-invasive and invasive measures. J Plast Reconstr Aesthet Surg 2014;67:1017 – 25. 12. Lawrence WT. In search of the optimal treatment of keloids: report of a series and a review of the literature. Ann Plast Surg 1991;27:164 – 78. 13. Darzi MA, Chowdri NA, Kaul SK, Khan M. Evaluation of various methods of treating keloids and hypertrophic scars: a 10-year follow-up study. Br J Plast Surg 1992;45:374 – 9. 14. Berman B, Kaufman J. Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids. J Am Acad Dermatol 2002;47(4 Suppl l):S209 – 11. 15. Ledon JA, Savas J, Franca K, Chacon A, et al. Intralesional treatment for keloids and hypertrophic scars: a review. Dermatol Surg 2013;39: 1745 – 57. 16. Chowdri NA, Masarat M, Mattoo A, Darzi MA. Keloids and hypertrophic scars: results with intraoperative and serial postoperative corticosteroid injection therapy. Aust N Z J Surg 1999;69:655 – 9. References 9. Murray JC. Keloids and hypertrophic scars. Clin Dermatol 1994;12:27 – 37.

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