RSS-Feed abonnieren
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.5999/aps.2020.01914
Management of keloid scars: noninvasive and invasive treatments
![](https://www.thieme-connect.de/media/10.1055-s-00051611/202102/lookinside/thumbnails/10_5999_aps_2020_01914_149-1.jpg)
Scars vary from mature linear scars to abnormal excessive scars such as hypertrophic scars and keloid scars. Keloid scars are fibro-proliferative disease entities that reflect an abnormal process of wound healing. They can cause pain, itching, stiffness, and psychological distress, all of which can affect quality of life. Various treatment options have been advocated as ways to prevent and treat keloid scars. These include noninvasive treatments such as use of silicone gel sheeting and compression therapy, and invasive treatments such as intralesional corticosteroid injections, surgery, and radiotherapy. Novel treatments include chemotherapy, immunotherapy, and anti-inflammatory therapies. Unfortunately, keloids continue to pose a significant challenge due to the lack of efficacious treatments. Therefore, clinicians should be familiar with various therapeutic options and apply the most suitable treatment plan for patients. In this review, we introduce the current therapeutic options for the management of keloid scars.
Publikationsverlauf
Eingereicht: 25. September 2020
Angenommen: 11. Februar 2021
Artikel online veröffentlicht:
07. März 2022
© 2021. The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonCommercial License, permitting unrestricted noncommercial use, distribution, and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes. (https://creativecommons.org/licenses/by-nc/4.0/)
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
REFERENCES
- 1 Monstrey S, Middelkoop E, Vranckx JJ. et al. Updated scar management practical guidelines: non-invasive and invasive measures. J Plast Reconstr Aesthet Surg 2014; 67: 1017-25
- 2 Bailey JN, Waite AE, Clayton WJ. et al. Application of topical mitomycin C to the base of shave-removed keloid scars to prevent their recurrence. Br J Dermatol 2007; 156: 682-6
- 3 Mari W, Alsabri SG, Tabal N. et al. Novel insights on understanding of keloid scar: article review. J Am Coll Clin Wound Spec 2016; 7: 1-7
- 4 Alster TS, Tanzi EL. Hypertrophic scars and keloids: etiology and management. Am J Clin Dermatol 2003; 4: 235-43
- 5 Bayat A, McGrouther DA, Ferguson MW. Skin scarring. BMJ 2003; 326: 88-92
- 6 Juckett G, Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician 2009; 80: 253-60
- 7 Poetschke J, Gauglitz GG. Current options for the treatment of pathological scarring. J Dtsch Dermatol Ges 2016; 14: 467-77
- 8 Huang C, Liu L, You Z. et al. Managing keloid scars: from radiation therapy to actual and potential drug deliveries. Int Wound J 2019; 16: 852-9
- 9 Wilson AM. Eradication of keloids: surgical excision followed by a single injection of intralesional 5-fluorouracil and botulinum toxin. Can J Plast Surg 2013; 21: 87-91
- 10 Huang C, Akaishi S, Hyakusoku H. et al. Are keloid and hypertrophic scar different forms of the same disorder? A fibroproliferative skin disorder hypothesis based on keloid findings. Int Wound J 2014; 11: 517-22
- 11 Arno AI, Gauglitz GG, Barret JP. et al. Up-to-date approach to manage keloids and hypertrophic scars: a useful guide. Burns 2014; 40: 1255-66
- 12 Ashcroft GS, Horan MA, Ferguson MW. Aging alters the inflammatory and endothelial cell adhesion molecule profiles during human cutaneous wound healing. Lab Invest 1998; 78: 47-58
- 13 Gauglitz GG, Korting HC, Pavicic T. et al. Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. Mol Med 2011; 17: 113-25
- 14 Love PB, Kundu RV. Keloids: an update on medical and surgical treatments. J Drugs Dermatol 2013; 12: 403-9
- 15 Bell L, McAdams T, Morgan R. et al. Pruritus in burns: a descriptive study. J Burn Care Rehabil 1988; 9: 305-8
- 16 Bakker A, Maertens KJ, Van Son MJ. et al. Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature. Clin Psychol Rev 2013; 33: 361-71
- 17 Meaume S, Le Pillouer-Prost A, Richert B. et al. Management of scars: updated practical guidelines and use of silicones. Eur J Dermatol 2014; 24: 435-43
- 18 Gold MH, Berman B, Clementoni MT. et al. Updated international clinical recommendations on scar management: part 1: evaluating the evidence. Dermatol Surg 2014; 40: 817-24
- 19 Gold MH, McGuire M, Mustoe TA. et al. Updated international clinical recommendations on scar management: part 2: algorithms for scar prevention and treatment. Dermatol Surg 2014; 40: 825-31
- 20 Lv K, Xia Z. Chinese consensus panel on the prevention and treatment of scars. Chinese expert consensus on clinical prevention and treatment of scar. Burns Trauma 2018; 6: 27
- 21 Ogawa R, Akita S, Akaishi S. et al. Diagnosis and treatment of keloids and hypertrophic scars-Japan Scar Workshop Consensus Document 2018. Burns Trauma 2019; 7: 39
- 22 Mustoe TA, Cooter RD, Gold MH. et al. International clinical recommendations on scar management. Plast Reconstr Surg 2002; 110: 560-71
- 23 Macintyre L, Baird M. Pressure garments for use in the treatment of hypertrophic scars: a review of the problems associated with their use. Burns 2006; 32: 10-5
- 24 Goldenberg G, Luber AJ. Use of intralesional cryosurgery as an innovative therapy for keloid scars and a review of current treatments. J Clin Aesthet Dermatol 2013; 6: 23-6
- 25 Huang C, Ogawa R. Roles of lipid metabolism in keloid development. Lipids Health Dis 2013; 12: 60
- 26 Fette A. Influence of silicone on abnormal scarring. Plast Surg Nurs 2006; 26: 87-92
- 27 Ripper S, Renneberg B, Landmann C. et al. Adherence to pressure garment therapy in adult burn patients. Burns 2009; 35: 657-64
- 28 Anzarut A, Olson J, Singh P. et al. The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: a meta-analysis. J Plast Reconstr Aesthet Surg 2009; 62: 77-84
- 29 Mustoe TA. Evolution of silicone therapy and mechanism of action in scar management. Aesthetic Plast Surg 2008; 32: 82-92
- 30 Berman B, Maderal A, Raphael B. Keloids and hypertrophic scars: pathophysiology, classification, and treatment. Dermatol Surg 2017; 43 Suppl 1: S3-18
- 31 Butler PD, Longaker MT, Yang GP. Current progress in keloid research and treatment. J Am Coll Surg 2008; 206: 731-41
- 32 de Oliveira GV, Nunes TA, Magna LA. et al. Silicone versus nonsilicone gel dressings: a controlled trial. Dermatol Surg 2001; 27: 721-6
- 33 Saulis AS, Mogford JH, Mustoe TA. Effect of Mederma on hypertrophic scarring in the rabbit ear model. Plast Reconstr Surg 2002; 110: 177-83
- 34 Wong TW, Chiu HC, Chang CH. et al. Silicone cream occlusive dressing: a novel noninvasive regimen in the treatment of keloid. Dermatology 1996; 192: 329-33
- 35 Kikuchi K, Kadono T, Takehara K. Effects of various growth factors and histamine on cultured keloid fibroblasts. Dermatology 1995; 190: 4-8
- 36 Kupietzky A, Levi-Schaffer F. The role of mast cell-derived histamine in the closure of an in vitro wound. Inflamm Res 1996; 45: 176-80
- 37 Hosnuter M, Payasli C, Isikdemir A. et al. The effects of onion extract on hypertrophic and keloid scars. J Wound Care 2007; 16: 251-4
- 38 Ho WS, Ying SY, Chan PC. et al. Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: a prospective randomized controlled trial. Dermatol Surg 2006; 32: 891-6
- 39 Wolfram D, Tzankov A, Pulzl P. et al. Hypertrophic scars and keloids: a review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg 2009; 35: 171-81
- 40 Hochman B, Locali RF, Matsuoka PK. et al. Intralesional triamcinolone acetonide for keloid treatment: a systematic review. Aesthetic Plast Surg 2008; 32: 705-9
- 41 Atiyeh BS. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods. Aesthetic Plast Surg 2007; 31: 468-92
- 42 Robles DT, Moore E, Draznin M. et al. Keloids: pathophysiology and management. Dermatol Online J 2007; 13: 9
- 43 Sadeghinia A, Sadeghinia S. Comparison of the efficacy of intralesional triamcinolone acetonide and 5-fluorouracil tattooing for the treatment of keloids. Dermatol Surg 2012; 38: 104-9
- 44 Khan MA, Bashir MM, Khan FA. Intralesional triamcinolone alone and in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. J Pak Med Assoc 2014; 64: 1003-7
- 45 Gupta S, Kalra A. Efficacy and safety of intralesional 5-fluorouracil in the treatment of keloids. Dermatology 2002; 204: 130-2
- 46 Bijlard E, Steltenpool S, Niessen FB. Intralesional 5-fluorouracil in keloid treatment: a systematic review. Acta Derm Venereol 2015; 95: 778-82
- 47 Darougheh A, Asilian A, Shariati F. Intralesional triamcinolone alone or in combination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. Clin Exp Dermatol 2009; 34: 219-23
- 48 Nanda S, Reddy BS. Intralesional 5-fluorouracil as a treatment modality of keloids. Dermatol Surg 2004; 30: 54-6
- 49 Jones CD, Guiot L, Samy M. et al. The use of chemotherapeutics for the treatment of keloid scars. Dermatol Reports 2015; 7: 5880
- 50 Crooke ST, Bradner WT. Bleomycin, a review. J Med 1976; 7: 333-428
- 51 Perdanasari AT, Lazzeri D, Su W. et al. Developments in the use of intralesional injections keloid treatment. Arch Plast Surg 2014; 41: 620-9
- 52 Espana A, Solano T, Quintanilla E. Bleomycin in the treatment of keloids and hypertrophic scars by multiple needle punctures. Dermatol Surg 2001; 27: 23-7
- 53 Saray Y, Gulec AT. Treatment of keloids and hypertrophic scars with Dermojet injections of bleomycin: a preliminary study. Int J Dermatol 2005; 44: 777-84
- 54 Payapvipapong K, Niumpradit N, Piriyanand C. et al. The treatment of keloids and hypertrophic scars with intralesional bleomycin in skin of color. J Cosmet Dermatol 2015; 14: 83-90
- 55 Shin JY, Yun SK, Roh SG. et al. Efficacy of 2 representative topical agents to prevent keloid recurrence after surgical excision. J Oral Maxillofac Surg 2017; 75: 401
- 56 Ogawa R, Akaishi S, Huang C. et al. Clinical applications of basic research that shows reducing skin tension could prevent and treat abnormal scarring: the importance of fascial/subcutaneous tensile reduction sutures and flap surgery for keloid and hypertrophic scar reconstruction. J Nippon Med Sch 2011; 78: 68-76
- 57 Berman B, Flores F. Recurrence rates of excised keloids treated with postoperative triamcinolone acetonide injections or interferon alfa-2b injections. J Am Acad Dermatol 1997; 37: 755-7
- 58 Akita S, Akino K, Yakabe A. et al. Combined surgical excision and radiation therapy for keloid treatment. J Craniofac Surg 2007; 18: 1164-9
- 59 Sclafani AP, Gordon L, Chadha M. et al. Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature. Dermatol Surg 1996; 22: 569-74
- 60 Lee KK, Mehrany K, Swanson NA. Surgical revision. Dermatol Clin 2005; 23: 141-50
- 61 Mourad B, Elfar N, Elsheikh S. Spray versus intralesional cryotherapy for keloids. J Dermatolog Treat 2016; 27: 264-9
- 62 Gupta S, Kumar B. Intralesional cryosurgery using lumbar puncture and/or hypodermic needles for large, bulky, recalcitrant keloids. Int J Dermatol 2001; 40: 349-53
- 63 Hochman B, Isoldi FC, Furtado F. et al. New approach to the understanding of keloid: psychoneuroimmune-endocrine aspects. Clin Cosmet Investig Dermatol 2015; 8: 67-73
- 64 Levy DS, Salter MM, Roth RE. Postoperative irradiation in the prevention of keloids. AJR Am J Roentgenol 1976; 127: 509-10
- 65 Keeling BH, Whitsitt J, Liu A. et al. Keloid removal by shave excision with adjuvant external beam radiation therapy. Dermatol Surg 2015; 41: 989-92
- 66 van Leeuwen MC, Stokmans SC, Bulstra AE. et al. Surgical excision with adjuvant irradiation for treatment of keloid scars: a systematic review. Plast Reconstr Surg Glob Open 2015; 3: e440
- 67 Shen J, Lian X, Sun Y. et al. Hypofractionated electron-beam radiation therapy for keloids: retrospective study of 568 cases with 834 lesions. J Radiat Res 2015; 56: 811-7
- 68 McKeown SR, Hatfield P, Prestwich RJ. et al. Radiotherapy for benign disease; assessing the risk of radiation-induced cancer following exposure to intermediate dose radiation. Br J Radiol 2015; 88: 20150405
- 69 O’Kane S, Ferguson MW. Transforming growth factor beta s and wound healing. Int J Biochem Cell Biol 1997; 29: 63-78
- 70 Schrementi ME, Ferreira AM, Zender C. et al. Site-specific production of TGF-beta in oral mucosal and cutaneous wounds. Wound Repair Regen 2008; 16: 80-6
- 71 Occleston NL, O’Kane S, Laverty HG. et al. Discovery and development of avotermin (recombinant human transforming growth factor beta 3): a new class of prophylactic therapeutic for the improvement of scarring. Wound Repair Regen 2011; 19 Suppl 1: s38-48
- 72 Sherris DA, Gassner HG. Botulinum toxin to minimize facial scarring. Facial Plast Surg 2002; 18: 35-9
- 73 Xiao Z, Zhang F, Cui Z. Treatment of hypertrophic scars with intralesional botulinum toxin type A injections: a preliminary report. Aesthetic Plast Surg 2009; 33: 409-12
- 74 Gauglitz GG, Bureik D, Dombrowski Y. et al. Botulinum toxin A for the treatment of keloids. Skin Pharmacol Physiol 2012; 25: 313-8
- 75 Ardekani GS, Aghaie S, Nemati MH. et al. Treatment of a postburn keloid scar with topical captopril: report of the first case. Plast Reconstr Surg 2009; 123: 112e-113e
- 76 Iannello S, Milazzo P, Bordonaro F. et al. Low-dose enalapril in the treatment of surgical cutaneous hypertrophic scar and keloid: two case reports and literature review. MedGenMed 2006; 8: 60
- 77 Grossman E, Messerli FH. Calcium antagonists. Prog Cardiovasc Dis 2004; 47: 34-57
- 78 Margaret Shanthi FX, Ernest K, Dhanraj P. Comparison of intralesional verapamil with intralesional triamcinolone in the treatment of hypertrophic scars and keloids. Indian J Dermatol Venereol Leprol 2008; 74: 343-8
- 79 Danielsen PL, Rea SM, Wood FM. et al. Verapamil is less effective than triamcinolone for prevention of keloid scar recurrence after excision in a randomized controlled trial. Acta Derm Venereol 2016; 96: 774-8
- 80 D’Andrea F, Brongo S, Ferraro G. et al. Prevention and treatment of keloids with intralesional verapamil. Dermatology 2002; 204: 60-2
- 81 Lawrence WT. Treatment of earlobe keloids with surgery plus adjuvant intralesional verapamil and pressure earrings. Ann Plast Surg 1996; 37: 167-9
- 82 El-Kamel MF, Selim MK, Alghobary MF. Keloidectomy with core fillet flap and intralesional verapamil injection for recurrent earlobe keloids. Indian J Dermatol Venereol Leprol 2016; 82: 659-65
- 83 Aggarwal A, Ravikumar BC, Vinay KN. et al. A comparative study of various modalities in the treatment of keloids. Int J Dermatol 2018; 57: 1192-200
- 84 Wu CS, Wu PH, Fang AH. et al. FK506 inhibits the enhancing effects of transforming growth factor (TGF)-β1 on collagen expression and TGF-β/Smad signalling in keloid fibroblasts: implication for new therapeutic approach. Br J Dermatol 2012; 167: 532-41
- 85 Kim A, DiCarlo J, Cohen C. et al. Are keloids really “gliloids”? High-level expression of gli-1 oncogene in keloids. J Am Acad Dermatol 2001; 45: 707-11
- 86 Viera MH, Caperton CV, Berman B. Advances in the treatment of keloids. J Drugs Dermatol 2011; 10: 468-80
- 87 Berman B, Villa A. Imiquimod 5% cream for keloid management. Dermatol Surg 2003; 29: 1050-1
- 88 Martin-Garcia RF, Busquets AC. Postsurgical use of imiquimod 5% cream in the prevention of earlobe keloid recurrences: results of an open-label, pilot study. Dermatol Surg 2005; 31: 1394-8
- 89 Berman B, Harrison-Balestra C, Perez OA. et al. Treatment of keloid scars post-shave excision with imiquimod 5% cream: a prospective, double-blind, placebo-controlled pilot study. J Drugs Dermatol 2009; 8: 455-8
- 90 Cacao FM, Tanaka V, Messina MC. Failure of imiquimod 5% cream to prevent recurrence of surgically excised trunk keloids. Dermatol Surg 2009; 35: 629-33
- 91 Edwards L. The interferons. Dermatol Clin 2001; 19: 139-46
- 92 Tredget EE, Wang R, Shen Q. et al. Transforming growth factor-beta mRNA and protein in hypertrophic scar tissues and fibroblasts: antagonism by IFN-alpha and IFN-gamma in vitro and in vivo . J Interferon Cytokine Res 2000; 20: 143-51
- 93 Leventhal D, Furr M, Reiter D. Treatment of keloids and hypertrophic scars: a meta-analysis and review of the literature. Arch Facial Plast Surg 2006; 8: 362-8
- 94 Lee JH, Kim SE, Lee AY. Effects of interferon-alpha2b on keloid treatment with triamcinolone acetonide intralesional injection. Int J Dermatol 2008; 47: 183-6
- 95 Kinzbrunner B, Ritter S, Domingo J. et al. Remission of rapidly growing desmoid tumors after tamoxifen therapy. Cancer 1983; 52: 2201-4
- 96 Clark CP, Vanderpool D, Preskitt JT. The response of retroperitoneal fibrosis to tamoxifen. Surgery 1991; 109: 502-6
- 97 Chau D, Mancoll JS, Lee S. et al. Tamoxifen downregulates TGF-beta production in keloid fibroblasts. Ann Plast Surg 1998; 40: 490-3
- 98 Mikulec AA, Hanasono MM, Lum J. et al. Effect of tamoxifen on transforming growth factor beta1 production by keloid and fetal fibroblasts. Arch Facial Plast Surg 2001; 3: 111-4