Various therapies to control excessive scarring, including injection of a gelatin hydrogel scaffold and lasers, were highlighted by two presenters at the lst International Keloid Symposium held recently in New York City.
Although there are standards of care like injectable steroids that most clinicians use to control excessive scarring and keloids, “there is still a need for treatment that is more effective,” says Brian Berman, M.D., Ph.D., an emeritus professor of dermatology and dermatologic surgery at the University of Miami Miller School of Medicine in Miami. Dr. Berman is also co-director of the Center for Clinical and Cosmetic Research in Aventura, Fla
Dr. Berman has been involved with several studies that show that the postsurgical recurrence rate of keloids after roughly one year is 51%, compared to the literature that shows a higher composite recurrence rate of 71%.
“Even worse, is that when the keloid returns, it is often larger than the original keloid, so for that reason it is very important to make some attempts to reduce the rate of post-excision recurrence, if possible,” he says.
Interferon and imiquimod
Following surgical excision, injecting interferon at the time of surgery and again one week later during suture removal can reduce the recurrence rate from 51% to as low as 19%, Dr. Berman tells Dermatology Times.
“However, applying simply a cream (imiquimod) to the suture line immediately after keloid incision induces high levels of interferon locally that has been shown to be more efficacious,” he says.
In two smaller, three-month studies, application of imiquimod 5% cream found 0% recurrence and 6% recurrence, respectively, when applied daily for two months post-keloidectomy.
Superficial radiation therapy directed to the suture line at a biologically effective dose (BED) also achieved 0% recurrence in patients followed up to one year in one study.
At Dr. Berman’s practice, radiation is given at a dose of 6 Gy, for three consecutive days, with the first fraction scheduled within 24 hours of the excision.
“In general, though, the literature indicates that superficial radiation therapy reduces recurrence to about 20% with up to one year of follow-up, but we may want to extend the follow-up,” Dr. Berman notes. “We have not seen any recurrence, with some patients monitored for a full year.”
Emerging therapies to control excessive scarring include a single injection of a gelatin hydrogel scaffold at the completion of surgery, which has reduced the one-year recurrence to the 8% range; and injecting microRNAs that use agents to either mimic or inhibit the microRNAs to regulate a variety of genes pivotal in scarring and fibrosis.
In addition, a low-tech device is available that adheres to the skin on both sides of the keloidectomy suture line.
“Focal adhesion kinase is a cellular protein which actually is activated by mechanical forces, as when the incision site is under tension, and ultimately induces greater collagen production and inflammation, thus causing scars,” Dr. Berman explains. “When you snap the device, the tension is released from the suture line, resulting in less visible scarring.”