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The Latest on Handling Keloids and Scars

In the morning on the third day of the 2020 Winter Clinical Dermatology Conference, Brian Berman, MD, PhD, updated attendees on the latest in treating keloids and scarring. His presentation, titled “New and Emerging Treatments for Excessive Scarring & Keloids,” covered therapies with the potential to reduce recurrence rates.

The recurrence rate of keloids is 71%, a staggering number 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.

One suggested treatment is imiquimod 5% cream. In two studies published in the early 2000s, imiquimod 5% cream was applied immediately after keloid excision. The cream was then applied once a day for two months following the procedure. These two studies found that 0 of 11 and 1 of 15 keloids recurred, though 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 procedure shaving the keloid as well as 24 hours afterward, saw 3 of 20 ear keloids recurred at 1 year and 4 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% 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 has demonstrated improvement in texture but not much improvement in dyschromia. When it comes to planning to use AFR laser with topical corticosteroids, however, Dr Berman noted this combination therapy is “not a homerun for using it on keloids.”

Botulinum toxin A is also a viable option for surgical scars. In a split facial surgical scar study, half of the scar was injected with saline and the other with botulinum toxin. The halves that received the toxin were narrower and had significantly lower height scores of 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, ixekizumab);
  • Antagonizing IL-17 receptor (brodalumab);
  • Neutralizing IL-6 (siltuximab); and
  • Antagonizing IL-6 Receptor (tocilizumab).

Dupilumab has also a single case report with success at reducing keloid appearance. This patient with severe eczema also had two keloids; after 7 months of 300 mg doses with dupilumab to treat his atopic dermatitis, the patient’s larger keloid shrunk and his smaller one completely disappeared.

But, in the meantime, clinicians should give their patients a realistic hope to reducing their appearance of their keloids.

Reference
Berman B. New and emerging treatments for excessive scarring and keloids. Presented at: 2020 Winter Clinical Dermatology Conference; Kohala Coast, HI; January 20, 2020.

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