Keloids in the ears: follow-up of 41 patients who had surgery and intralesional corticosteroid injections

Received on: 13/06/2011
Approved on: 21/06/2011

This study was carried out at the Instituto
Lauro de Souza Lima, São Paulo (SP), Brazil.

Conflicts of interests: none
Financial support: none

Abstract

Introduction: Surgery combined with post-operative intralesional corticosteroid injections is considered a good treatment for keloids that occur in the ears, yet the recurrence rate for this procedure is not yet well established. There is no consensus about the minimum number of corticosteroid infiltrations needed to decrease the number of recurrences.
Objective: To correlate the rate of recurrence among patients who had surgery and postoperative intralesional corticosteroid injections to treat keloids in the ear lobe with the number of injections.
Methods: Retrospective study of 41 patients who underwent surgical excision of ear keloids combined with up to two (Group A) or 3 or more (Group B) triamcinolone ace- tonide intralesional injections sessions.
Results: The total recurrence rate was 37% (13% in patients from Group A and 24% in patients from Group B). Results were not more effective when the number of injections was equal to or higher than 3 (p = 0.74).
Conclusions: There was no statistical significance in the number of post-operative corticosteroid intralesional injections in the treatment of ear keloids. Further studies are necessary to corroborate these results.

Keywords: KELOID, ADRENAL CORTEX HORMONES, AMBULATORY SURGICAL PROCEDURES

INTRODUCTION

Keloids result from an abnormal response to healing in predisposed individuals. Factors linked to its occurrence are: genetic predisposition, with a higher incidence in Hispanics, Asians and blacks (in rates from 5:1 to 15:1 compared to Caucasians), 1,2 age (more common in young individuals), endocrine factors (pregnancy and menopause), and location in body areas with a greater number of melanocytes and trauma. 3 In patients with lesions in the earlobe, keloids appear mainly after piercing the ears The diagnosis is clinical and a number of techniques – combined or not with surgical interventions – are proposed for treating this condition, including intralesional cor- ticosteroids, 5-fluoruracil, alpha and gamma interferon bleomycin or verapamil injections; the use of topical substances such as clobetasol, silicone gel or sheets , immunomodulators, retinoids and onion extract; cryotherapy, radiotherapy, the use of pressure earrings, ligature of sessile keloids and pulsed dye laser, among others. 1,4,5-7

OBJECTIVE

To evaluate the recurrence rate among patients who underwent surgery and corticosteroids injections (CI) for the removal of keloids in the earlobe , making correlation with the number of injections carried out in the post-operative period.

MATERIALS AND METHODS

This was a retrospective study analyzing 41 patients'''''''' records (21 men and 20 women, aged 9-66) amounting to 46 operated keloids (five patients presented bilateral lesions). The study was approved by the Instituto Lauro de Souza Lima''''''''s ethics committee. Patients who had either never undergone treatment or had already been treated with cryosurgery or bleomycin injections but presented a recurrence of lesions or therapeutic failure, were included. The intramarginal excision and simple suture of the keloids, as well as the monthly triam- cinolone (20-40 mg) CI (started on the 15th day of the post- operative period up to a total of six sessions), were carried out by the same assistant physician. The initial dose was 20 mg, and was increased to 40 mg in case there was a progression of the keloid between sessions. Due to the great number of patients who abandoned the treatment during the infiltrations period, two follow-up groups were established: A – operated patients who had up to two sessions of CI, and B – patients who had three or more CI sessions. After a minimum of one year from the end of the treatment, the patients were called and asked about the recurrence of the operated lesion. Reincidence was considered to have taken place if the patient described any recurrence, regardless of the lesion''''''''s size.

RESULTS

The total corresponds to the number of operated keloids. In Group A there was recurrence in six patients, correspon- ding to 13% of the total number of lesions. Recurrence was observed in 11 patients from Group B, corresponding to 24% of the total number of lesions.

Comparing Groups A and B (See Table 1) ), there was no statistically significant difference between the number of infil- tration sessions and the lesion recurrence e when the Chi- square test corrected by Fisher''''''''s exact test was used.

c 2 = 0.1048; p = 0.7462; 95% confidence interval (CI) (0.3682 – 1.684); Fisher: 95% CI (0.3682 – 1.684); p = 0.5546.

DISCUSSION

Keloids have a high rate of recurrence: according to which methodology is used, the rate varies from 0 to 100%. 1,3,7 Surgery using intramarginal excision is a treatment option, however it is associated with reincidence rates of 45-100%. 7 The combination of corticosteroids and infiltration in the post-operative period as an adjuvant therapy is one of the most established options, since corticosteroids inhibit collagen synthesis by increasing alpha-2 macroglobulins and alpha-1 antitrypsin. 8,9

Although the effectiveness of combining surgery and post- operative infiltrations has been demonstrated, there is no con- sensus on doses or duration of treatments; several treatment plans have been suggested. Chowdri, Mattoo and Darzi propose two to five weekly injections of triamcinolone, followed by monthly injections for four to six more months. 5 In a review on keloids and hypertrophic scars, English and others suggest administering 20 mg/ml triamcinolone once every two or three weeks, repeated if necessary, combined with a brief cryotherapy jet prior to the procedure. 8

A less aggressive approach was proposed by Rosen, Patel, Freeman and Weiss, consisting of one intra-operative and two post-operative infiltrations of 40 mg/ml triamcinolone ace- tonide. In cases with no recurrence, the follow-up was observa- tional only. That study involved 92 keloids in the ears of 64 patients, with a reincidence rate that ranged from 14% (first time treatment) to 40% (recurrent keloids). 11

In the post-operative period of 11 patients, Aköz, Gideroglu and Akan used pressure earrings combined with sili- cone gel, in addition to one session of CI with 20-40 mg/ml triamcinolone in the borders of the incision, after the 14th day after the procedure. The follow-up lasted 28 months on average, presenting a 89% cure rate. 1

Triamcinolone is also Wolfram, Tzankov, Pulzl and Piza- Katzer''''''''s drug of choice. Their treatment plan consists of smaller doses (5 to 10 mg/ml) in intervals of three to six weeks, continuing until the scar stabilizes, until a new surgical intervention is necessary or until side effects appear. 3

In the present study, a total reincidence rate of 37% was observed after surgery and infiltration. Aligned to the average results found in the literature describing the combination of those procedures, suggesting it is reasonably effective when compared to the date found in the literature for the isolated sur- gery. Nevertheless, when comparing these results to the recur- rence rates in groups with fewer or greater numbers of infiltra- tion sessions, no statistical significance was found. In fact, a greater recurrence rate was verified for the group with a greater number of infiltrations (13% in the group treated with up to two infiltrations and 24% in the group that received three or more infiltrations). This can be linked to the fact that recurrent keloids that had already been treated – thus implying a situation where recurrence rates tend to be higher – were indiscriminate- ly included in the study. 11 There is also the hypothesis of a high- er patient adherence to longer treatments in cases where the post-operative outcome was less favorable, for example with the fast growth of a new lesion or with previous recurrences.

Therefore, it is not possible to establish a minimum num- ber of post-operative infiltrations. Factors other than the num- ber of sessions and the corticoid dosage can have a decisive influence in the recurrence of a keloid, explaining, for instance, why some patients with bilateral lesions treated in the same way present recurrence in only one side.

CONCLUSION

Corticosteroids present side effects such as the risk of sec- ondary infection, atrophies, telangiectasias, hypopigmentation and Cushing''''''''s syndrome. 8 The attempt to establish effective infiltration treatment plans of the shortest possible duration are, therefore, justified.

Although the adjuvant therapy was found to be efficient, there was no statistical significance between the two groups, meaning it is not possible to state that long infiltration schemes are necessary or possibly more efficient in the prevention of recurrences. Further studies to corroborate such results and identify new risk factors for the recurrence of keloids are, there- fore, necessary.

References

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