Two other options are cyclosporine and mycophenolate. “Cyclosporine clearly works,” said Dr Lebwohl, and he continued to explain that his usual dosage of mycophenolate is 4000 mg per day, though the literature has shown doses as high as 6000 mg per day.
Omalizumab (Xolair) has demonstrated great success for the various phenotypes of urticaria (autoimmune, non-autoimmune, chronic spontaneous, recalcitrant physical, angioedema, antihistamine-refractory). A 300-mg dose can be administered, but dermatologists should make patients aware that the therapy can take 5 days to take effect. While mild to moderate treatment-emergent adverse effects (eg, headache, arthralgia, and injection site reactions) have been documented, omalizumab is well tolerated and safe.
However, Dr Lebwohl emphasized, many dermatologists seem to fear the black box warning associated with biologics. “The number [for anaphylaxis frequency] is 0.2%, but why is that?” he said. “Well, [omalizumab] is treating the symptoms of anaphylaxis. You’re treating wheezing, urticaria, and angioedema. It doesn’t work for a few days…so patients could blame the injection for the symptoms they’ve had all along.” So, the potential side ffects of omalizuma may not be as stressful as the dermatology field fears.
With use of omalizumab, urticaria can recur after a median of 5 weeks, so Dr Lebwohl has patients come back every 4 weeks for a maintenance dose. After 6 months, he suggested making a quick scratch on the patient’s arm; if the patient does not get dermographism, then the injection can be delayed as spontaneous remission may have occurred.
The Latest on Handling Keloids and Scars
Brian Berman, MD, PhD, updated attendees on the latest in treating keloids and scarring.5 His presentation covered therapies with the potential to reduce recurrence rates.
The estimated recurrence rate of keloids is 71%, despite careful suturing techniques following excision. Oftentimes, the keloid will grow back larger than its original pre-excision size. Recurrence can be a frustrating experience for patients as well as dermatologists, and it can affect the patient-provider relationship. Multiple previous trials have attempted to study postexcisional therapies to find the best preventative treatment.
One suggested treatment is imiquimod 5% cream. In two studies published in the early 2000s, imiquimod 5% cream was applied immediately after kelo id excision. The cream was then applied once a day for 2 months following the procedure. These two studies found that zero of 11 and one of 15 keloids recurred; these results need additional long-term testing to confirm efficacy due to only a 6-month follow-up period. Another study, which used imiquimod 5% cream immediately following a shaving procedure of the keloid as well as 24 hours afterward, saw three of 20 ear keloids recurred at 1 year and four of 20 recurred in 5 years.
X-ray radiation therapy may also have benefits. A retrospective chart review of 96 keloidectomy with superficial radiation therapy (SRT) over a 1-year period found that 10.4% of keloids recurred, and five of those were considered clinically significant. Consensus guidelines on SRT for nonmelanoma skin cancers and keloids state:
- Multiple fractions of SRT significantly reduces keloid recurrence after postsugical treatment;
- Hyperpigmentation and other adverse events can be reduced by fractionation of the SRT dose; and
- Exposing the keloid or healthy perikeloid skin to a 3000-cGy dose of SRT does not cause skin cancer.
Dr Berman then discussed a number of new and emerging options for existing keloids and scars. The first was laser treatments, including pulsed-dye, fractional, CO₂ laser ablative fractional resurfacing (AFR). “So, we know that using pulsed-dye does help get rid of the pink blush of keloids and of hypertrophic scars,” explained Dr Berman. “But fractional ablative laser may actually help increase the range of motion of scars, especially when they go over a joint.” AFR laser therapy may also help improve topical absorption; this technique has demonstrated improvement in texture but not much improvement in dyschromia. When it comes to planning to use AFR laser with topical corticosteroids, Dr Berman noted this combination therapy is “not a homerun for using it on keloids.”
Botulinum toxin A is also a possible option for surgical scars. In a split-face surgical scar study, half of a scar was injected with saline and the other half was injected with botulinum toxin. The halves that received the toxin were narrower and had significantly lower height scores on the Vancouver Scale.
In the future, Dr Berman explained, that dermatologists will look to control the profibrotic gene expression and translation. One notably theory is to use a mimic of micro-RNA29, which is reduced in fibrotic disorders, because this gene hits six different stops in the pathway of scar formation. In addition, systemic biologics may be a viable option, including:
- Neutralizing IL-17 (secukinumab [Cosentyx], ixekizumab [Taltz]);
- Antagonizing IL-17 receptor (brodalumab [Siliq]);
- Neutralizing IL-6 (siltuximab [Sylvant]); and
- Antagonizing IL-6 receptor (tocilizumab [Actemra]).
A single case report demonstrated success in reducing
keloid appearance by using dupilumab (Dupixent). This patient with severe eczema also had two keloids; after 7 months of 300-mg doses with dupilumab to treat his AD, the patient’s larger keloid shrunk and his smaller one completely disappeared. Future studies, however, are needed to confirm the results and subsequent benefits.
But, in the meantime, clinicians should give their patients a realistic hope to reducing their appearance of their keloids.
1. Desai SR. JAK inhibitors: the new breakthroughs in the treatment of dermatologic disease. Presented at: 2020 Winter Clinical Dermatology Conference; Kohala Coast, HI; January 18, 2020.
2. Rosen T. Infectious disease update. Presented at: 2020 Winter Clinical Dermatology Conference; Kohala Coast, HI; January 18, 2020.
3. Elewaki BE. Nail tips. Presented at: 2020 Winter Clinical Dermatology Conference; Kohala Coast, HI; January 18, 2020.
4. Lebwhol M. Chronic urticaria update. Presented at: 2020 Winter Clinical Dermatology; Kohala Coast, HI; January 19, 2020.
5. Berman B. New and emerging treatments for excessive scarring and keloids. Presented at: 2020 Winter Clinical Dermatology Conference; Kohala Coast, HI; January 20, 2020.