Management of keloids and hypertrophic scars: current and emerging options

Figures & data

Figure 1 Baseline photograph at presentation in our scar clinic before initiation of combination therapy with cryotherapy directly followed by intralesional TAC (10 mg/mL) (A and B). Result after three cycles of combined cryo/intralesional TAC therapy before initiation of PDL (C). Result after four PDL applications (D). No signs of recurrence or reactivation at follow-up 6 months after the last laser treatment (E and F).

Abbreviations: PDL, pulsed dye laser; TAC, triamcinolone acetonide.

Figure 2 Patient with keloid in the presternal area resistant to cryotherapy and TAC, silicone gel sheeting, surgery and postoperative radiotherapy (recurrence) suffering from severe pruritus at baseline (A). Significant reduction of pruritus and flattening after 1 week of injection with 5-FU (50 mg/mL) and TAC (40 mg/mL), 3:1 (B). Result at 6 months after the last injection (two injections total), with no signs of recurrence, no pruritus (C).

Abbreviations: 5-FU, 5-fluorouracil; TAC, triamcinolone acetonide.

Figure 3 With intralesional cryotherapy, a specially designed cryoneedle is inserted (under translesional local anesthesia) into the long axis and mid height of the respective keloid.

Notes: The cryoneedle is then connected by an adaptor to a cryogun filled with liquid nitrogen, which is introduced into the cryoprobe, thereby freezing the keloid. After complete freezing of the lesion, the cryoprobe defrosts and is withdrawn.

Figure 4 Result at baseline (A and C) and after 3 and 6 years, respectively (B and D) post-intralesional cryotherapy.Adapted with permission from Har-Shai Y. Intralesional cryosurgery for enhancing the involution of hypertrophic scars and keloids. A new effective technology based on experimental and clinical data. Journal of wound Technology. 2012;15:8–9.¹¹⁸

Table 1 Basic recommendations for the treatment of keloids and hypertrophic scars based on the experience of the author

Diagnosis	Start with	If no improvement	If improvement	If no improvement
1. Fresh surgical scar (patients at risk)	Silicone gel or onion extract containing gel (starting 2 weeks after wounding for 3 months)	eg, persisting erythema: PDL
2. Immature, small keloid/hypertrophic scar	TAC (10 mg/mL, women, 20 mg/mL, men)	Cryotherapy (10–15 seconds) directly followed by TAC until scar has flattened	PDL to reduce erythema	5-FU 3:1 TAC (every other week; eg, for acne keloids on the shoulders)
3. Large hypertrophic scar	If tension present: surgical relief of tension by, eg, z-, w-plasty (followed by topical agents as indicated above/main text) If no tension present: cryotherapy (10–15 seconds) directly followed by TAC until scar has flattened	5-FU 3:1 TAC (every other week)	PDL to reduce erythema	Surgical excision, ablative laser
4. Large keloid	Cryotherapy (10–15 seconds) directly followed by TAC until scar has flattened	5-FU 3:1 TAC (every other week) Intralesional cryotherapy	PDL to reduce erythema	Surgical excision (in combination with, eg, radiotherapy, intralesional TAC)

Abbreviations: 5-FU, 5-fluorouracil; PDL, pulsed dye laser; TAC, triamcinolone acetonide.

Har-ShaiYIntralesional cryosurgery for enhancing the involution of hypertrophic scars and keloids. A new effective technology based on experimental and clinical dataJournal of Wound Technology20121589

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