Surgeon offers pearls for keloid tx

Los Angeles - For stubborn keloids that do not respond to intralesional triamcinolone acetonide (Kenalog, Bristol-Myers Squibb), especially post-CABG sternal keloids, William V.R. Shellow, M.D., has successfully used methylprednisolone acetate (Depo-Medrol, Pharmacia & Upjohn), normally used by orthopedists for injecting joints.

"The crystals in Depo-Medrol are much less soluble than those of Kenalog," says Dr. Shellow, professor of medicine (dermatology) at the David Geffen School of Medicine, University of California, Los Angeles.

Depo-Medrol is available as 40 mg/ml and 80 mg/ml. He recommends first trying the 40 mg/ml dose. If that doesn't produce the desired result, move to the 80 mg/ml dose, he says.

Silver nitrate benefits Another treatment Dr. Shellow uses is silver nitrate solution. When a curettage and electrodesiccation crust is thicker than expected and is slow to fall off by itself, it often requires removal with forceps and usually leaves a macerated, oozy base.

Dr. Shellow recommends painting the scar with a 10 percent silver nitrate solution, using a cotton applicator. There will be instant sealing of the erosion or the raw area where the crust was removed. Application may sting, and it is important to warn the patient that the silver may make the area black, he says.

Pain from the erosion will disappear quickly, and the surgical wound base will develop a thin crust that will fall off. Any slight bacterial infection will be controlled by the antibacterial properties of the silver. Weak silver nitrate also is excellent for treating tender, superficial erosions, such as those seen on the penis. A 25 percent solution also is available.

Dr. Shellow warns physicians against the 75 percent silver nitrate stick because it is caustic.

Dressing wounds After performing a tangential excision of a nevus on the face, many dermatologists tell patients to clean the site daily, to apply double or triple antibiotic ointment and to change the dressing daily for approximately 10 days. This is done because moist wounds heal more quickly.

For shave excisions and curettage and electrodessications, Dr. Shellow applies a Coverlet (Beiersdorf) and tells patients to keep the area dry until the next morning. At this point, he recommends leaving the wound open to the air.

At bedtime, the patient should apply an antibiotic ointment.

"I believe there is much less risk of contact sensitization when antibiotic ointments are used in this manner, because the area is not occluded by the dressing, and there is much less fuss for the patient. The final result is the same after the crust comes off," he says.

For patients who like to wear a dressing for a small wound, he recommends putting on a small piece of Extra-Thin DuoDERM (ConvaTec) or Restore dressing (Hollister).

Patients leave the dressing in place until it falls off. There is no need to change dressings.