April 2020 HSC Section 4 - Plastic and Reconstructive Problems

F.A. Khan et al. / Journal of Pediatric Surgery xxx (xxxx) xxx

patients (2 re-recurrences). No differences in the rate of re-recurrences were noted with the treatment strategy chosen. (Fisher's exact p=1.0). These recurrences were reported over the duration of the study with a majority occurring within 2 years (median 23 months). No statistically signi fi cant effect was noted on the rate of re-recurrences related to the patient's age (p = 0.38), gender (p = 1.0), race (p = 1.0), or size of the lesion (p = 0.14). This study, to our knowledge, is the largest series evaluating out- comes and treatment of ear lobe keloids in the pediatric population. With a median follow-up of 2-years, a higher incidence of recurrences was noted in our cohort as compared to those previously reported in pe- diatric patients. [11] A possible explanation for this observed difference may be the length of follow-up; our data set suggests that the median time to recurrence postexcision is six months, and therefore longer follow-ups are necessary to accurately quantify the burden of recur- rence. In addition, we have likely captured patients who had secondary procedures with other providers owing to the telephone-based survey. There remains a paucity of evidence-based guidelines to optimally manage earlobe keloids in pediatric patients. Our data set demonstrates that while there was a high rate of recurrence, it was unaffected by the treatment strategy employed and patient characteristics, including race. This is a key fi nding, as while AAs have the highest burden of keloids, we may be selecting a subset of patients across race, gender and age that are susceptible to further keloid formation, which is suggested by the even higher rate of recurrence after a second keloid developed. An additional interesting fi nding of this study was that ear lobe keloids affected both genders equally, as females are more more likely to have ear lobe pierc- ings due to a societal bias, it can be hypothesized that males may have a higher likelihood of developing ear lobe keloids. Intralesional corticosteroids are considered a main stay of therapy of keloids owing to their ease of use and high degree of tolerability. The ef- fi cacy of corticosteroids is thought to be secondary to their ability to suppress in fl ammation, promotion of collagen degeneration and inhibi- tion of further collagen production. [2] The majority of data evaluating use of corticosteroids is several decades old and is limited to adult cases with the exception of one pediatric study. [11,14,15] The response rate in these studies for corticosteroids is reported as 50% – 100% with a 9% – 50% recurrence rate. [16] Potential for local cutaneous atrophy, hypopigmentation and pain associated with injections are other obsta- cles limiting repeated injections. In summary while there may be a po- tential bene fi t for adjuvant injection of corticosteroids the magnitude of bene fi t and optimal strategy of use are yet to be adequately de fi ned. Our data set noted no appreciable effect in reduction of recurrence rates or cosmetic outcomes related to the use of corticosteroids. Fortunately, there were no complications related to use of intralesional corticoste- roids; therefore, they may be considered as a safe adjunct to surgical therapy. There are some small series that report the use of radiation in trying to reduce the rate of recurrence [17] . Radiation theoretically works by decreasing cellular proliferation. However, the therapy may not be available at all institutions and certainly leads to an increase in the over- all expense of therapy. There were 9 cases in our report where this mo- dality was utilized. We did not see any effect on the rate of recurrences; however, given the small number in this subset no de fi nitive conclu- sions can be drawn. As this cohort was selected on the basis of having undergone a sur- gical excision of the keloid, all had an operation performed. While surgi- cal removal is likely to be the most common management approach especially for larger lesions, without a denominator of all ear lobe ke- loids presenting to our institution we cannot appropriately comment on the ef fi cacy of non-surgical approaches. Choice of technical aspects of the procedure (selection of suture type, use of cautery, etc.) is also an interesting variable and may contribute to the risk of recurrence. 3. Discussion

These aspects of the surgical care, while interesting variables, however can only be adequately controlled in the setting of a prospective study. In all cases, the choice of suture was made by the attending surgeon, but absorbable sutures were universally used. Most common was polyglactin acid (braided) suture for the deep layer, while mono fi la- ment absorbable was used in the super fi cial layer. Similarly, the postop- erative course including the use of postoperative steroids, compression earrings and radiation therapy was chosen by the patient's physician. Given the retrospective nature of this data set it is dif fi cult to adequately control for these variables. As previously discussed, given no differences in the complications when used as adjunct, there may be a role of outpatient intralesional steroids for smaller lesions in reducing the need for surgery. Further work will be needed to assess the feasibility of this approach. Our preferred approach to pediatric ear lobe keloids is excision with closure using absorbable sutures and steroid injection, which our data set suggests at least is not inferior to any other treatment plan and is rel- atively simple without requiring radiation therapy. We contend this data set suggests that pediatric ear lobe keloids are a challenging condi- tion to treat with a high rate of recurrence regardless of the treatment modality chosen. With the evidence currently available to us decision of approach should be tailored to the individual patient at the discretion of treating physician until prospectively collected data are available. There are some key limitations of this study that bear additional dis- cussion. There are inherent biases and limitations from the retrospec- tive nature of the study itself. The subsets of the patients in various treatment strategies were not controlled for baseline characteristics; similarly, the decisions involving the strategy employed were not con- trolled. Additionally, the limited number of patients in the adjuvant ra- diation therapy and compression device strategy limits any meaningful conclusion to be drawn pertaining to these strategies. The use of com- pression earrings has also not been systemically studied for children. We had limited use in our series mainly owing to patient interest and compliance; therefore, we cannot comment on its usefulness. However, despite these limitations, the strength of this report includes the dura- tion of follow up, large number of cases in the cohorts, and evaluation of multiple recurrences with telephone follow up to include patients who sought care elsewhere subsequently. Treatment of ear lobe keloids is a challenging problem among pedi- atric patients given the high rate of recurrence. Our study adds to the known literature in children and notes the lack of difference with con- comitant steroid use. Surgical management is safe, but patients should be made aware of the recurrence risk. Data from this study suggest that there are no marked differences in outcomes related to the surgical strategy employed; plans for patients should be tailored individually by the treating physician. Future studies will investigate the role of com- pression and steroids as primary therapy. While prospective studies are needed to better de fi ne the risk factors associated with recurrence, it would be reasonable because of this to consider deferring surgical in- tervention until the child is older, particularly among African American patients. 4. Conclusion

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.jpedsurg.2019.07.006 .

References [1] English RS, Shenefelt PD. Keloids and hypertrophic scars. Dermatol Surg 1999 Aug 1; 25(8):631 – 8. [2] Krakowski AC, Totri CR, Donelan MB, et al. Scar management in the pediatric and ad- olescent populations. Pediatrics 2016 Feb 1;137(2):e20142065.

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