Surgeon provides clinical pearls for treating keloids, erosions

November 1, 2005

He warned physicians not to use the 75 percent silver nitrate stick because it is caustic.

Los Angeles - For stubborn keloids that do not respond to intralesional Kenalog, especially post-CABG sternal keloids, William V. R. Shellow, M.D., has successfully used Depo Medrol, which is normally used by orthopedists for injecting joints. Dr. Shellow is professor of medicine (dermatology) at the David Geffen School of Medicine at the University of California, Los Angeles.

"The crystals in Depo Medrol (Bristol-Meyers Squibb) are much less soluble than those of Kenalog (Upjohn Pharmaceuticals)," Dr. Shellow tells Dermatology Times.

Depo Medrol is available as 40 mg/ml and 80 mg/ml. He recommends first trying the 40 mg/ml dose. If that doesn't produce the desired result, move to the 80 mg/ml dose.

Benefits of silver nitrate solution

Dr. Shellow's second pearl involved the use of silver nitrate solution. When a curettage and electrodesiccation crust is thicker than expected and is slow to fall off by itself, it often requires removal with forceps and usually leaves a macerated, oozy base. "I have found that there is nothing better than 10 percent silver nitrate solution (available from Delasco)," he says.

He recommends painting it on with a cotton applicator. There will be instant sealing of the erosion or the raw area where the crust was removed. Application may sting, and it is important to warn the patient that the silver may make the area black.

The pain from the erosion will disappear quickly, and the surgical wound base will develop a thin crust that will fall off. Any slight bacterial infection will be controlled by the antibacterial properties of the silver. Weak silver nitrate is also excellent for treating tender, superficial erosions, such as those seen on the penis. A 25 percent solution is also available.

He warned physicians not to use the 75 percent silver nitrate stick because it is caustic.

Dressing wounds

After performing a tangential excision of a nevus on the face, many dermatologists tell patients to clean the site daily, to apply double or triple antibiotic ointment and to change the dressing daily for approximately 10 days. This is done because moist wounds heal more quickly.

"Unfortunately, bacitracin was the 'allergen of the year' for 2002, and there has been increasing sensitivity to double and even single antibiotic ointments. Even if the patient does not develop an allergic contact dermatitis, why make him or her go to all this trouble?" he says.

For both shave excisions and curettage and electrodessications, Dr. Shellow applies a Coverlet and tells patients to keep the area dry until the next morning. At this point, he recommends leaving the wound open to the air.

At bedtime, the patient should apply an antibiotic ointment. "I believe there is much less risk of contact sensitization when antibiotic ointments are used in this manner, because the area is not occluded by the dressing (Band-Aid or Coverlet), and there is much less fuss for the patient. The final result is the same after the crust comes off," he says.

For patients who like to wear a dressing for a small wound, he recommends putting on a small piece of Extra-Thin DuoDerm or Restore dressing. "Be sure to round the edges of the dressing so the patient does not catch an edge on something and pull the dressing off," he says.

Patients leave the dressing in place until it falls off. There is no need to change dressings. However, in case a dressing change is needed for some reason, he recommends giving patients an extra piece of DuoDerm or Restore to take with them.

Monsel's solution

Dr. Shellow believes that Monsel's solution is superior to aluminum chloride. "People stopped using it because it supposedly causes tattooing, but I have used it for almost 40 years and I have never seen tattooing. I think this is a nonissue, and it certainly is a better hemostatic agent than aluminum chloride," he says.