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CME

Primary Care Management of Keloids and Hypertrophic Scars Reviewed

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Charles P. Vega, MD, FAAFP
  • CME Released: 8/26/2009
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 8/26/2010
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Target Audience and Goal Statement

This article is intended for primary care clinicians, dermatologists, plastic surgeons, and other specialists who care for patients with keloids and hypertrophic scars.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Identify characteristics of keloids.
  2. List first-line treatment options for keloids.


Disclosures

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MedscapeCME encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author(s)

  • Laurie Barclay, MD

    freelance writer and reviewer, MedscapeCME

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor(s)

  • Brande Nicole Martin

    is the News CME editor for Medscape Medical News.

    Disclosures

    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Charles P. Vega, MD, FAAFP

    Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine

    Disclosures

    Disclosure: Charles P. Vega, MD, FAAFP, has disclosed no relevant financial relationships.


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CME

Primary Care Management of Keloids and Hypertrophic Scars Reviewed

Authors: News Author: Laurie Barclay, MD CME Author: Charles P. Vega, MD, FAAFPFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME Released: 8/26/2009

Valid for credit through: 8/26/2010

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August 26, 2009 — Keloids and hypertrophic scars result from an exuberant healing response and are often difficult to distinguish and treat, according to a review of recommendations for family practitioners regarding treatment of keloids and hypertrophic scars, published in the August 1 issue of American Family Physician.

"Keloids are elevated fibrous scars that extend beyond the borders of the original wound, do not regress, and usually recur after excision," write Gregory Juckett, MD, MPH, and Holly Hartman-Adams, MD, from West Virginia University in Morgantown. "Hypertrophic scars are similar, but are confined to the wound borders and usually regress over time. Scar hypertrophy usually appears within a month of injury, whereas keloids may take three months or even years to develop."

Risk Factors, Development of Keloids

Risk factors for keloids are age younger than 30 years, darker skin, high-risk trauma such as burns or ear piercing, and any factor that prolongs wound healing. The areas most vulnerable to development of keloids are the sternal skin, shoulders and upper arms, earlobes, and cheeks. In contrast, hypertrophic scars may arise in any location but often occur on the extensor surfaces of joints.

Keloids and hypertrophic scars are both manifestations of abnormal responses to dermal injury. There are 3 main stages of overabundant collagen deposition: inflammation in the first 3 to 10 days after trauma; proliferation during the next 10 to 14 days; and maturation or remodeling, which begins at approximately 2 weeks and continues for years.

On histologic examination, hypertrophic scars have fewer thick collagen fibers and a scanty mucoid matrix, whereas keloids have thicker collagen fibers and a mucoid matrix. Hypertrophic scars usually flatten spontaneously in time, whereas keloids remain elevated more than 4 mm. Darkly pigmented skin is associated with a 15- to 20-fold increased risk for keloids, perhaps because of melanocyte-stimulating hormone anomalies. In contrast, hypertrophic scars are less associated with skin pigmentation.

If keloid formation is anticipated, it often can be prevented with immediate silicone elastomer sheeting, taping to reduce skin tension, or corticosteroid injections. However, keloids are challenging to treat once they have developed, and recurrence rate is high regardless of treatment.

Therapy for Keloids

Based on studies and other evidence to date, recommended first-line therapy for keloids includes silicone sheeting, pressure dressings, and intralesional corticosteroid injections. In 50% to 100% of cases, intralesional corticosteroid injections eventually flatten keloids. Use of cryotherapy to the keloid immediately before injection may improve efficacy, as well as facilitating the injection procedure.

Application of silicone sheeting is started as soon as wounds heal and is maintained for 2 to 3 months, for at least 12 hours per day. Many patients cannot use pressure dressings, which must be worn for 6 to 12 months to be effective.

Cryotherapy alone may be useful in some patients, but this should be used only for smaller lesions. Unless 1 or several of these standard treatments is used concurrently, surgical removal of keloids is likely to result in recurrence.

For refractory scars, alternative postsurgical therapies include pulsed dye laser, radiation, and possibly imiquimod cream. However, potential adverse effects of radiation therapy include growth retardation in young people and a possible risk for future cancer.

For established keloids, therapies that may be helpful include intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections.

Potential advantages of fluorouracil are that this therapy may effectively reduce keloid size without causing tissue atrophy or telangiectasias, which may occur with corticosteroid injections. Less than 5% of bleomycin injected into the keloid reaches the bloodstream, and regression rates of 84% have been reported. Although interferon alfa-2b injections may have a rapid onset of action, they may be painful and are costly.

Evidence is mixed for the use of over-the-counter herb-based creams, such as onion extracts, although they are widely used. Similarly, limited evidence supports any benefits of vitamin E, which may cause dermatitis.

Key Recommendations for Practice

Key clinical recommendations for practice, all rated level of evidence B (inconsistent or limited-quality patient-oriented evidence) are as follows:

  • For smaller lesions, such as acne keloids, cryotherapy is helpful, especially when combined with other treatment modalities.
  • For the family physician, a practical first-line approach for the prevention and treatment of keloids and hypertrophic scars is intralesional corticosteroid injections.
  • For the prevention and treatment of keloids and hypertrophic scars, silicone elastomer sheeting is a noninvasive, but time-intensive, first-line option.
  • Especially for burns, pressure dressings or garments can effectively prevent hypertrophic scars.
  • Combination therapy with surgery, silicone sheeting, and/or corticosteroid injections is an effective second-line option after failure of first-line treatments of keloids and hypertrophic scars.
  • Although there is less evidence supporting their use, intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections, as well as topical imiquimod 5% cream are reasonable alternatives to corticosteroids for keloid treatment and postoperative prevention.
  • In limited clinical trials to date, onion extract topical gel or topical vitamin E have not shown lasting improvement of established keloids and hypertrophic scars.

"The treatments for keloids and hypertrophic scars are similar, but hypertrophic scars have a better prognosis," the review authors write. "The large number of treatment options is a reflection of the poor quality of research on this topic, with no single proven best treatment or combination of treatments. First-line options include silicone sheeting, pressure treatment, and corticosteroid injections, but all of these require exemplary adherence and follow-up."

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;80:253-260.

Clinical Context

Hypertrophic scars and keloids are common problems that can promote significant distress among patients. Whereas hypertrophic scars remain within the borders of the original wound and usually regress with time, keloids extend outside these borders and do not regress. Keloids are up to 20 times more common among dark-skinned vs light-skinned individuals, and the risk for the development of keloids is greatest between ages 10 and 20 years. Delayed healing of any wound is associated with a higher risk for keloid formation, and burns are the most common wounds associated with keloids. Keloids are most commonly encountered over the sternum, shoulders and upper arms, earlobes, and cheeks.

Many keloids are also symptomatic in addition to being a cosmetic concern for patients. The current review examines the treatment of keloids.

Study Highlights

  • Reducing wound tension and promoting faster rates of healing can reduce the risk for keloid formation. Regular corticosteroid injections or the application of silicone sheeting during healing of the wound may also be helpful in preventing the formation of keloids.
  • First-line treatment options for keloids include corticosteroid injections, silicone sheeting, and pressure treatment. Surgical removal of keloids is associated with rates of regrowth of scar tissue as high as 50% to 100%.
  • Intralesional injections with corticosteroids will eventually flatten keloids in 50% to 100% of cases. Applying cryotherapy to the keloid immediately before injection may make the procedure easier and also increase the efficacy of this treatment.
  • Silicone sheeting is applied as soon as wounds heal to reduce or prevent keloids. To be effective, the sheets must be worn for at least 12 hours per day for 2 to 3 months. Silicone sheets should be washed daily with mild soap and water, and they may be reused until they begin to disintegrate.
  • Pressure dressings are impractical for many patients in the treatment of keloids, as they must be worn for 6 to 12 months.
  • In small studies, treatment with imiquimod over the excision site of a keloid has been associated with a low rate of keloid recurrence.
  • There are mixed data regarding the efficacy of pulsed dye laser treatment of keloids.
  • A limited amount of research suggests that intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections may improve keloids. Fluorouracil may shrink keloids while avoiding tissue atrophy and telangiectasias associated with corticosteroid injections. Bleomycin was associated with regression rates of 84% in 1 study, and less than 5% of the injected dose reaches the bloodstream. Interferon alfa-2b injections may work quickly but can be painful and expensive.
  • The use of radiation therapy to treat keloids is controversial, particularly among young people at risk for adverse effects on growth. There is also concern regarding the potential risk for cancer in the future associated with radiation therapy.
  • Topical vitamin E preparations have limited evidence of efficacy in the prevention of keloids, and they may promote dermatitis. Onion extracts are also of questionable efficacy in the treatment of keloids.

Clinical Implications

  • Risk factors for the development of keloids include dark skin and delayed wound healing. The risk for the development of keloids is greatest between ages 10 and 20 years, and keloids are most commonly encountered over the sternum, shoulders and upper arms, earlobes, and cheeks.
  • The current review suggests that first-line treatment options for keloids include corticosteroid injections, silicone sheeting, and pressure treatment. Topical vitamin E preparations appear to be ineffective in the treatment of keloids.

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