Intralesional Injection of Keloids and Hypertrophic Scars with the ...

Clinical ResultsRelief of symptoms.An analysis of the 4 patients seeking onlyrelief of symptoms proved interesting.1. A 38-year-old woman had had a hysterectomythrough a lower vertical mid-abdominalincision 2 years previously. She developed araised, hypertrophic, reddish brown scarmeasuring 2 in. by 9 in. The scar wasextremely sensitive and painful. She wasunable to wear a girdle or other tight clothingover the scarred area. The entire scar wasinjected with the Dermo-Jet initially, and thepatient had complete relief of symptoms within48 hr. after the injection. The patientsubsequently had 2 additional series ofinjections with complete flattening of the scarand permanent cessation of the symptoms.2. A 70-year-old man had had a colon resectionthrough a lower vertical mid-abdominalincision 10 months previously. He developed araised, painful, hypertrophic, reddish brownscar measuring % in. by9 in. This patient alsohad complete relief of symptoms after theinitial injection. He subsequently had 2additional series of injections with completeflattening of the scar.3. A 42-year-old woman had a similar raisedhypertrophic scar on the right flank resultingfrom a nephrectomy operation 18 monthspreviously. This patient was very apprehensiveand had been under psychiatric care for adepressed state. This scar measured 3/8 in. by8 in. Her symptoms were relieved after 2 seriesof injections. A major portion of her scar wasflattened. This patient was one of a few whocomplained of severe pain during the injectionand also persistent burning pain for severalhours after the injection.4. A 19-year-old girl complained of severe painto pressure over a small localized area ofsubcutaneous scarring on the sole of the leftfoot following removal of a plantar wart 2years previously. This patient had 1 injectionwith the Dermo-Jet. The scar softened andcompletely disappeared with cessation ofsymptoms within a month after treatment.Of the other 10 with symptoms, 9 hadcomplete relief of symptoms within 48 hr. after theinitial series of injections. The remaining patient was a33-year-old woman with multiple hypertrophic scars onthe palm of the left hand resulting from a crush injury 5months previously. She had 5 series of injections withsoftening and leveling of the scars and markedimprovement of symptoms. She still complained ofmoderate pain to pressure over a tight scar on theproximal crease of the palm.Appearance of the scarAnalysis of the appearance of the scars afterinjection indicated a very favorable response to thetherapy. Nine patients are still under treatment. Of theremaining 19 patients, 14 had complete leveling of thekeloid or hypertrophic scars. Of the 14, 4 were smallkeloids averaging 1,4 in. in diameter resulting fromvaccination. The other 10 were hypertrophic scarsresulting from surgery or injury. Of the 5 of the 19 whoshowed incomplete leveling of the scar, 2 had 80 to 90per cent leveling.1. The patient was a 17-year-old girl with a largerecurrent keloid on the left shoulder measuring2½ in. in diameter. It was of 3 years’ durationand resulted from the surgical excision andgraft of another keloid resulting fromvaccination. X-ray therapy was also given atthe time of the surgical excision. She had atotal of 8 series of injections over a period of10 months.2. An 18-year-old boy had a keloid over the leftmastoid area resulting from a car accident. Thescar measured 3/8 in. by 1 in. He had a total of3 series. Three showed a 60 to 75 per centleveling of the scar.3. A 21-year-old man had multiple keloids on hischest resulting from acne. Hehad a total of 7 series of injections.4. A 42-year-old woman had a hypertrophic scaron the right flank following a nephrectomy.She had a total of 2 series of injections.5. A 14-year-old boy had a large keloid on theleft side of the neck resulting from injury. Hehad had a surgical excision with Z-plastyrepair 1 year previously with markedrecurrence of the keloid which measured 1 1/2in. by 5 in. He had a total of 10 series of injectionsover a period of 12 months with about75 per cent flattening of the scar.

Pain experienced during and after injection.The Dermo-Jet has proven itself to be a veryuseful instrument in the injection treatment of keloidand hypertrophic scars primarily because of the ease ofadministration. of the drug. No form of anesthesia isnecessary with the Dermo-Jet.A controlled amount of solution is given witheach injection, and there is visible evidence in the formof pale white wheals to indicate whether the entire scarhas been injected. An analysis of the amount of painresulting from the injections with the Dermo-Jet provedinteresting. I have used this instrument on myself andsome of my fellow workers. The pain noted during theinjection into normal skin on the arm was minimal andinsignificant. It felt like a tiny transient “pinch” in theskin. There was no after pain.Of the 27 patients treated, 18 complained ofminimal or insignificant pain during the injection. Moststated that it felt like a tiny mosquito bite, and theywere able to tolerate several injections during eachseries without any complaint. Six complained ofmoderate pain with the initial series of injections. Theydescribed it as a momentary sting. They were also ableto tolerate multiple injections, and most of them hadminimal pain with subsequent injections. Threecomplained of severe pain during the injection.1. A 21-year-old girl had a large keloid burn scarof the right cheek of 7 months’ duration. Thispatient had had a total of 6 previous Kenaloginjections with a needle and syringe and alsoradiation therapy elsewhere. She wasextremely agitated, and treatment had to besuspended after only a few injections with theDermo-Jet. When this patient returned for hersecond treatment 1 month later, 1 part of 2 percent Xylocaine was added to the 6 parts ofKenalog and Wydase. She was assured that thepain would be negligible, and she was able totolerate about 15 injections with only minimalto moderate complaints of pain.2. A 42-year-old maiden lady had a painfulhypertrophic scar on the right flank 18 monthsafter a nephrectomy. She had been underpsychiatric treatment for a chronic depressedstate. This patient stated that the injectioncaused a sharp painful stinging sensation.However, she did tolerate 5 injections with thefirst series and then came back a month laterfor a second series at which time she had 10injections. This patient also complained ofpersistent stinging pain in the scar for severalhours post injection.3. A 10-year-old boy had a large recurrenthypertrophic scar on his left arm measuring 1in. by 6 in. This boy had had 2 previousoperative procedures for gradual partialexcision of a much larger scar. He complainedof severe pain during the multiple injections.He returned 1 month later for a second seriesof injections. Again, 1 part 2 per centXylocaine solution was added to 6 parts ofKenalog and Wydase, and this time hetolerated the treatment with minimal complaintsof pain.Rees 6 has tried the Dermo-Jet for injectingKenalog solution into hypertrophic scars, and he hasnoted that his patients have complained of very severesensations of pain and burning in the scar for severalhours following treatment. In fact, he has found it morepainful than direct injection by needle. My experiencehas shown that the great majority of patients complainof minimal pain. I believe that the addition of theWydase markedly lessens any post injection pain. Theaddition of a small amount of local anesthetic to theKenalog solution would also diminish any post injectionpain in patients who complain initially. Reassurance ofthese patients and their acquaintance with thisinstrument before treatment help considerably in minimizingany discomfort.Discussion and SummaryThis paper has been principally written toacquaint the medical profession with a useful newinstrument, the Dermo-Jet. The DermoJet has beenemployed for the intralesional steroid injection ofkeloids and hypertrophic scars in a total of 28 patients.A definite improvement evidenced by disappearance ofthe symptoms and leveling or flattening of the scars wasnoted in all cases. Some scars showed a faster and morespectacular response than others. The most dramatic responsewas noted in the hypertrophic scars resultingfrom surgery or injury. Complete flattening of thesescars resulted after only 1 to 4 series of injections.The true keloids, especially the larger ones, showed aslower response. Softening and flattening proceededslowly, and a large number of doses were needed over alonger period of time. The small keloids resultingfrom vaccination showed a quick, dramatic response toonly 1 or 2 series of doses.In the hypertrophic operative scars of theabdomen, the principal complaint was burning pain and

itching. In these patients, contact of their clothing overthe scar caused discomfort. It was gratifying that theirsymptoms were quickly relieved after just a fewinjections.Most patients experience minimal pain whenthe solution is injected into the scar. They tolerate theprocedure well without the need for any type ofanesthetic. Most of the patients have someapprehension with the first series of injections.However, subsequent injections are taken with minimaldiscomfort. The few who complained acutely during theinitial injection tolerated subsequent ones quite well.This method of treatment is not beingproposed for all scars that come to a surgeon’sattention. In many patients, surgical excision, whenindicated, is still the quickest and most efficient form oftreatment. Intralesional injection of steroids into araised scar will level the scar and smooth it out but itwill not narrow it. This technique does not replace thetried and proven techniques of the plastic surgeon. Itshould be used as an aid to surgery to be done when thesurgeon begins to notice even the slightest recurrence ofhypertrophy or keloid formation after surgery. Inknown keloid formers who are undergoing surgery, thetechnique of Griffith’ of injecting Kenalog with aregular syringe into the wound at the time of thesurgery appears to have merit. Intralesional injectioncould also be used for most true keloids when thesurgeon feels that surgery would be of no avail. Thismethod may be used in cases that have already had asurgical attempt at correction. It has proven to beespecially effective in patients who are more concernedwith the symptoms caused by the scar than with theappearance.Other Uses of the Dermo-Jet for the PlasticSurgeonThere are a number of situations in medicinewhere the Dermo-Jet has already proven itself quiteuseful, e.g., in mass vaccinations. I have found it veryuseful in removing plantar warts under local anesthesia.The Dermo-Jet is used for the subtopical injection of alocal anesthetic. Greater depth can be achieved byinserting a needle with additional anesthetic solutionpainlessly into the wheal center. I have also beenexploring the possibility of the intralesional injection ofthe plantar wart itself with a solution that would resultin resolution of the wart.Another possible use of the Dermo-Jet which Ihave also been considering is the injection of asclerosing solution into some of the smaller raisedhemangiomas. Its use in the larger hemangiomas wouldbe limited since the scierosing solution would not penetratemore than 5 to 6 mm.ConclusionThe Dermo-Jet, a needleless pressure injectioninstrument, has proven to be of great value for theintralesional injection of keloids and hypertrophic scars.The technique is simple and quick with minimaldiscomfort to the patient.41 Ocean StreetLynn, Massachusetts 01902REFERENCES1. Conway, H., and Stark, R. B.: ACTH in plasticsurgery. Plast. & Reconstruct. Surg., 8: 354— 377,1951.2. Murray, R. D.: Kenalog and the treatment ofhypertrophied scars and keloids in Negroesand whites. Plast. & Reconstruct. Surg., 31:275—280, 1963.3. Griffith, B. H.: The treatment of keloids withtriamcinolone acetonide. Plast. & Reconstruct.Surg., 38: 202—208, 1966.4. Ketchum, L. D., Smith, J., Robinson, D. W., andMasters, F. W.: The treatment of hypertrophicscar, keloid and scar contracture by triamcinoloneacetonide. Plast. & Reconstruct. Surg., 38: 209—2 18, 1966.5. Cornbleet, T.: Treatment of keloids with hyaluronidase.J. A. M. A., 154: 1161—1163, 1954.6. Rees, T. D.: Personal communication.