Management of keloids draws on clinical wisdom
EXPERT ANALYSIS FROM THE COASTAL DERMATOLOGY SYMPOSIUM
WOODINVILLE, WASH. – Make decisions about whether to surgically or medically manage keloids according to features of the lesion and patient-related factors, especially likely treatment compliance, Dr. Hilary E. Baldwin advised.
"Step one when we are dealing with our patients with keloids is trying to decide what the patients actually hope for," Dr. Baldwin said at the annual Coastal Dermatology Symposium. That might be eradication of the keloid; palliation of symptoms such as itching or pain; flattening, lightening, or softening of the keloid; ability to wear clip-on earrings; or restoration of mobility.
"Most patients, in my opinion, are actually not surgical candidates, and most need to be convinced to pursue other options," said Dr. Baldwin of the dermatology department at the State University of New York, Brooklyn.
Size and shape should factor into decisions about surgical removal of keloids, said Dr. Baldwin. Larger keloids are not much more difficult to remove than smaller ones, and pedunculated keloids are generally the most amenable to surgery, she noted.
Keloid age also comes into play, as the older, mature, brown lesions are less likely to recur after surgery than the younger, pink, symptomatic ones. Location affects outcome as well, Dr. Baldwin said. Keloids on the jaw, the deltoid, mid-back, mid-chest, and upper back are most likely to recur if treated surgically, and those in low-tension areas are less likely to do so.
Surgery also may be considered for keloids that are truly unresponsive to intralesional corticosteroids, but those are uncommon as previous lack of response is usually because of an inadequate dose, Dr. Baldwin explained.
"Most important is patient commitment. They often believe that cutting is a quick fix and they are not going to have to do anything afterward, and they are poor flight risks because of that," she said. Statistics suggest that the nearly 100% of keloids recur with surgery alone, but the value falls to 50% with adjunctive corticosteroids, and 20% with adjunctive radiation therapy, she added.
When adjunctive corticosteroids are used after surgery, the steroid is injected into the base and walls of the excision site, according to Dr. Baldwin; her preference is to use 40 mg/cc triamcinolone, with injections given for at least 6 months.