wound-healing-reading-chapters

Recommendations

Info

SRPS Volume 10, Number 7, Part 1 Table 9 Reports of X-ray Therapy for Keloids (Reprinted with permission from Norris JEC: Superficial X-ray therapy in keloid management: a retrospective study of 24 cases and literature review. Plast Reconstr Surg 95:1051, 1995.) Adverse reactions to the use of intralesional steroids may include local depigmentation or hypopigmentation, epidermal atrophy, telangiectasia, and skin necrosis. Systemic side effects and Cushing’s syndrome are rare and associated with improper dosages. Ketchum and colleagues 336 injected up to 120mg triamcinolone intralesionally at the time of excision, and noted 88% regression to varying degrees and disappearance of pruritus within 3–5 days. Complications included atrophy, depigmentation, and recurrence. Currently most practitioners do not administer such high doses; rather, monthly doses of ~12mg are recommended. 337 Radiation Therapy. Radiation therapy has been used for treating keloids since 1906. 296 Used alone, radiation therapy is associated with a wide range of cure rates (15%–94%). 326 Radiotherapy is best used in conjunction with surgical excision. When the lesions are first excised and subsequently radiated, the response rates increase to 33%–100%. 326 More recent studies show even better response rates (64%–98%). 326 In large keloids resistant to treatment, radiotherapy offers a reduction in recurrence rate, from 50%–80% with surgery alone, to ~25% with combined surgery and early postoperative radiotherapy (Table 9). 338,339 Success seems to depend on the number of rads delivered to the surgical site and start of RT immediately postoperatively. Preoperative irradiation does not offer any advantage. The usual dosage is 15–20Gy administered over 5 or 6 treatment sessions. Possible complications include scar hyperpigmentation and, rarely, malignant degeneration. 340 Controversy abounds regarding the safety of delivering radiation to a benign tumor, 341 fueled by anecdotal reports of malignant tumors developing after RT of a keloid. Although the recommended dose for the treatment of keloids is low, long-term follow-up is needed to put this issue to rest. Pressure Therapy. Pressure therapy is effective in the treatment of hypertrophic scars and keloids, especially after burn injury. 342 This therapeutic strategy is used in combination with other treatment modalities (eg, silicone gels or sheets). The applied pressure should be 24–30mmHg to avoid excessive compression of peripheral blood vessels. Maximum benefit is achieved from wear- 29
SRPS Volume 10, Number 7, Part 1 ing the pressure appliance for 18–24h/d for at least 4–6 months. 296,343,344 Pressure is thought to decrease tissue metabolism and increase collagenase activity within the wound. 272 Pressure techniques include various compression wraps and custom garments for large areas, or the use of large clip-on earrings after excision of earlobe keloids. 345 Pressure therapy requires patience and perseverance, as continuous application of pressure is required for several months to obtain a satisfactory result. Several authors report good response rates of 90%–100% in patients treated with keloid excision followed by pressure therapy, 296,343,344 especially when the keloid was located on the earlobe. Intralesional verapamil combined with 6 months of pressure therapy after keloid excision resulted in a 55% cure rate in one series. 346 Interferon. Interferons interfere with the ability of fibroblasts to synthesize collagen. Specifically, IFN-α-2b normalizes the collagen and glycosaminoglycan of the keloid. 347 Complications of IFN-α- 2b injection include flu-like symptoms of headache, fever, and myalgias. In a retrospective study, Berman and Flores 347 found lower recurrence rates with postexcisional IFN-α-2b (18.7%) than with either excision alone (51.1%) or postexcisional triamcinalone injections (58.4%). Conejo-Mir et al 348 report 0% recurrence at 3 years with the combination of CO 2 laser excision and IFN-α-2b injections for keloids of the earlobe. Interferon-γ is believed to work similarly to IFN-α- 2b. There have been several anecdotal reports regarding the benefits of IFN-γ in treating the keloid. Pittet et al 349 reported improvement of hypertrophic scars in 7 patients who were given human recombinant gamma-interferon in twice-weekly intralesional injections for 4 weeks. Granstein 350 and Larrabee 351 have also reported modest success with gammainterferon in a small number of patients. A small pilot study by Broker et al 352 followed the course of patients with two keloids, one of which was treated with IFN-γ injections and the other with placebo injections after excision. Only 7 patients were enrolled in the study and 3 dropped out by the 1-year follow-up examination. Both experimental and control groups had uniformly poor results, with an approximate 75% recurrence. Other researchers have used antitransforming growth factor-beta (anti-TGF-β) to decrease scarring in experimental animals. 317 Tredget 353 describes antagonizing the proliferative effects of TGF-β2 and histamine with interferon-α-2b. Imiquimod is an immune response modifier that stimulates innate and cell-mediated immune pathways, enhancing the body’s natural ability to heal. 354 Imiquimod also induces the local synthesis and release of cytokines, including IFN[alpha], IFN[gamma], tumor necrosis factor-[alpha], and interleukins-1, -6, -8, and -12 when topically applied. 355 A number of recent case reports and clinical studies document success with imiquimod under conditions where interferons are also successful. Nightly application of topical imiquimod 5% cream for 8 weeks after surgical excision of 13 keloids from 12 patients resulted in no recurrence of keloidal growth at 24 weeks. 356 Silicone Gel Sheeting. The mechanism of action of silicone gel sheeting is not known. Histologic examination reveals no evidence of silicone leakage into the tissues. Hydrocolloid dressings are occlusive and facilitate scar hydration, and are considered to be safe in the treatment of wounds in the initial stages of healing. 357 Depending on the series, between 80% and 100% of patients show significant improvement of their hypertrophic scars with silicone gel. 358–360 In patients with keloids, however, silicone gel is successful only 35% of the time. 360 Silicone gel sheeting may reduce recurrence rates after excision of keloids. It is a benign intervention that does not cause any problems and may be useful as an adjunctive measure. In human trials, topical silicone gel was used to treat 22 keloids in 18 patients, with a significant response rate of 86%. 361 Possible drawbacks to silicone gel include patient noncompliance (especially children) and occasional rashes, skin breakdown, or difficulty obtaining adherence to the scar. 362 The review by Shaffer et al 288 summarizes and compares all keloid treatments in the literature. SURGICAL TREATMENT Keloids that are resistant to corticosteroid injection, pressure therapy, or other topical therapy should be considered for surgical excision. Surgery alone is associated with recurrence rates of 50%– 30
Page 2 and 3: WOUNDS AND SCARS George Broughton I
Page 4 and 5: SRPS Volume 10, Number 7, Part 1 ap
Page 6 and 7: SRPS Volume 10, Number 7, Part 1 co
Page 8 and 9: SRPS Volume 10, Number 7, Part 1 Ru
Page 10 and 11: SRPS Volume 10, Number 7, Part 1 si
Page 12 and 13: SRPS Volume 10, Number 7, Part 1 Ep
Page 14 and 15: SRPS Volume 10, Number 7, Part 1 an
Page 16 and 17: SRPS Volume 10, Number 7, Part 1 Ta
Page 18 and 19: SRPS Volume 10, Number 7, Part 1 En
Page 20 and 21: SRPS Volume 10, Number 7, Part 1 Si
Page 24 and 25: SRPS Volume 10, Number 7, Part 1 in
Page 26 and 27: SRPS Volume 10, Number 7, Part 1 ti
Page 32 and 33: SRPS Volume 10, Number 7, Part 1 80
Page 34 and 35: SRPS Volume 10, Number 7, Part 1 Ti
Page 36 and 37: SRPS Volume 10, Number 7, Part 1 ce
Page 38 and 39: SRPS Volume 10, Number 7, Part 1 CH
Page 40 and 41: SRPS Volume 10, Number 7, Part 1 et
Page 42 and 43: SRPS Volume 10, Number 7, Part 1 gi

wound-healing-reading-chapters

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?