Scaling back the scars

The gold standard for treating keloids really hasn't changed in 20 years. Intralesional cortisone injections are still the best approach to the raised, thick scars, according to Terri Dunn, M.D., of Berkeley, Calif., a dermatologist who has been in solo practice for 10 years. If large keloids are treated exclusively with intralesional cortisone injections, she says this provides about a 20 percent to 50 percent improvement in the appearance of the scar. In combination with other therapies, however, the rate of improvement increases dramatically.

Combating keloids

"With smaller keloids, we will often excise the scar. This does provide for the possibility of an even larger reformation of scar tissue, but we inject it with cortisone as it heals to prevent a recurrence."

Dr. Dunn tells Dermatology Times that this process can result in a better than 50 percent improvement.

"Larger keloids present the real challenge. They're often too firm to actually inject, so we have to find ways to soften them so the cortisone can be injected into them."

The methods used for softening keloids or hypertrophic scars include:

Those treatments require the patient to apply the gel or tape daily for several months, until the scars are soft enough that the cortisone injections can be effective. These can all be used in conjunction with the intralesional cortisone injections.

New approaches

Other treatments are slowly coming into use, and Dr. Dunn says they seem to offer some benefits over the softening agents. All indications are they should increase the improvement rate.

These options include:

Beyond those treatments, Dr. Dunn says some of the newer therapies being studied include intralesional injections of interferon, bleomycin and 5-fluorouracil, which are chemotherapy agents.

Intralesional bleomycin is commonly used to treat warts. Topical 5-fluorouracil is commonly used to treat actinic keratoses. Dr. Dunn has used bleomycin for warts, but has not tried any of these new drugs yet for keloids.

"The studies show some promising results for smaller keloids, so we're just waiting to see how that goes.

"But still, intralesional cortisone injections are really the gold standard and I tend to have success with that treatment."

Counter recurrent keloids

Because keloids can reform even a year or more after excision, Dr. Dunn may have the patient apply the agent of choice at home every day for up to a year, while coming into the office once a month for injections.

"If after seven or eight months, I'm not seeing any signs of the keloid reforming I may stop the injections, but I still follow the patient monthly. I have had patients who were keloid-free for a full year, and then the keloid started to reform - but that tends to be rare."

If that happens, and topical agents or cortisone injections are ineffective, she would recommend a re-excision and trying the process again.

Dr. Dunn says some doctors will not even attempt to excise keloids because they feel recurrence rates are too high.

"It is an area that requires a lot of diligence, with the patient being compliant with all of the visits and with keeping an eye on the scars to keep the keloids from reforming. In large keloids, injections alone proffer about a 20 percent to 50 percent success rate. In smaller keloids excision, combined with cortisone injections, may offer a better than 50 percent chance the keloid will not reform. If we can get that to around 70 percent to 80 percent, it would be great."