Keloid treatment with intralesional cryosurgery: proposal of a low-cost device

Received on: 28 June 2011
Approved on: 6 December 2011

This study was carried out at the Universidade Federal Fluminense – Niterói (RJ), Brazil.

Conflicts of interest: None
Financial support: None

Abstract

Cryosurgery is an established technique for treating keloids. The development of intralesional cryosurgery has been an important advance in that technique. In addition to producing better results in large and refractory keloids, intralesional cryosurgery presents a lower rate of complications. The authors present a new low-cost device for use in intralesional cryosurgery that allows easy handling in practically all body areas.

Keywords: KELOID, CRYOSURGERY, SURGICAL EQUIPMENT

INTRODUCTION

Keloids and hypertrophic scars result from the hyperproli- feration of fibroblasts, which leads to the excessive production of collagen. Unlike hypertrophic scars, keloids exceed the limits of the injury. Among the many proposed treatments, 1-3 cryosurgery is currently a very good therapeutic option, especially if combined with intralesional injections of corticosteroid. Intralesional cryosurgery is a recent technique that has some advantages compared to the superficial technique. It requires fewer sessions and results in less frequent recurrences and occur- rence of hypopigmentation.

Cryosurgery was initially used to treat keloids and hyper- trophic scars by Shepherd and Dawber in 1982. 4 Their results demonstrated significant improvement (80%) in a single session, but a considerably high recurrence rate (33%). In 1987, Mende5 and Zoubolis, and in 1990s, Orfanos 6 used the technique in repeated sessions, obtaining excellent outcomes with recurrence rates of 2%.

In 1993, Weshahy7 described the use of intralesional cryo- surgery to treat keloids for the first time, using a curved hypo- dermic needle that was introduced into the deepest part of the lesion. Liquid nitrogen flowed through the needle, and the free- zing-thawing process reduced the lesion. In 2001, Gupta and Kumar8 improved the technique by using peripheral intrave- nous catheters numbers 18 and 20, and needles for lumbar puncture in a 12-case study, concluding that intralesional cryo- surgery was the best option for large and refractory keloids.

Studies published by Har Shai 9-12 were carried out with a new device (CryoShapeT, US Patent Number 6,503,246; European Patent Number 1299043, FDA 510(k) Number K060928) that consists of a long dual lumen needle with a safe- ty opening and sharp tip that perforates the lesion, which is atta- ched to the nitrogen source, allowing continuity to the process (Figure 1) .

The authors present a new accessory for intralesional cryo- surgery and analyze its use in the treatment of keloids. Due to the difficulty of positioning the cryosurgery device when trea- ting some areas of the body (strong men''''''''s thorax or those of women with large breasts or silicone implants), an accessory with a flexible hose was developed that allows any area of the body to be treated.

METHODS

After carrying out local antisepsis and positioning the sur- gical fields, the lesion was injected with a 0.2-0.5% lidocaine solution, with the addition of triamcinolone at 8-10 mg/ml. Small lesions could be transfixed by a 25x7 mm needle, while larger ones required a 30x8 mm needle. The accessory, which was attached to the liquid nitrogen source in its proximal sec- tion, was connected to the needle (Figure 2), thus promoting a continuous flow up to the beginning of the whitening of the lesion. Using this process, the lesions were frozen from the insi- de out, allowing a higher intensity in the core of the keloid – the most important place to be treated – and partially preserving the lesion''''''''s surface. The freezing cycle was interrupted when the initial signs of the whitening of the keloid become perceptible. There was intense elimination of cloudy and viscous, possibly serosanguineous, material in the post-operative period. A less intense exudation often occurs on the surface of the lesion.

RESULTS

The ear keloids presented important regression in almost all patients who underwent the treatment. Sternal lesions sho- wed little improvement. When compared to the open spray, the intralesional technique offers improvement with far fewer appli- cations. Some pre- and post-operative results are shown in Figure 3.

DISCUSSION

Cryosurgery is an important technique for the treatment of keloids and hypertrophic scars, with well-established efficacy and safety. 9 The conventional technique consists of freezing the surface of the lesions with liquid nitrogen. The effectiveness of this technique is limited, since often the freezing cannot reach the base of the keloid. In addition, it is possible to observe inten- se side effects in the overlying skin. 8

In order to overcome these adversities, Weshahy 7 first used intralesional cryosurgery to treat keloids in 1993. In this techni- que, the freezing occurs from the core of the lesion, allowing a more intense and better distributed concentration (Figure 4). As freezing becomes less intense close to the periphery, the surface is less affected, producing fewer adverse effects – such as pain during the procedure, hypopigmentation and ulcerations – in this area. 11

In clinically stable and cooperative patients, intralesional cryosurgery of lesions of various sizes can be performed on an outpatient basis.

The technique presented in this study uses an accessory that allows its use in lesions that are more difficult to access, thus promoting greater flexibility in the method. The use of disposa- ble needles – adjusting their caliber according to the size of the lesion – allows a safer and more cost-effective treatment with good applicability.

This study represents five years of personal experience of one of the authors (FBL), rather than a controlled study. Therefore, its results must be viewed with caution. Nonetheless, the results seem to be superior to those obtained with open spray cryosurgery; the number of sessions required is considera- bly lower than those necessary using the intralesional technique. The accessory presented in this study demonstrates high reliabi- lity and cost effectiveness, given that the authors have given up the patent; the technology is now in the public domain.

CONCLUSION

Intralesional cryosurgery is a promising technique for trea- ting keloids, and apparently offers advantages over the conven- tional technique, both in efficacy and in reduced side effects. The accessory presented in this paper seems to be an improve- ment over previous devies. Controlled studies with larger sam- ples are still necessary to clarify the role of this technique in the treatment of keloids.

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