Temple University School of Podiatric Medicine Journal Review Club
Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Article title: Keloid Management: A Retrospective Case Review on a New Approach Using Surgical Excision, Platelet-Rich Plasma, and In-office Superficial Photon X-ray Radiation Therapy
Authors: Michael E. Jones, MD; Cherrell Hardy, BSN, RN; and Julie Ridgway, BSN, RN
Journal name and issue: Advances in Skin & Wound Care: July 2016.
Reviewed by: Sharon Mathew, Class of 2018, Temple University School of Podiatric Medicine

Keloids are fibrous lesions made of collagen types I and III that arise from an area of wound healing, outside the margins of the original wound and are an unfortunate consequence of irregular wound healing. Treating keloids is difficult because there is limited understanding on why they arise, which is why many treatments fail to prevent their recurrence. It has been shown that no single treatment modality is effective to treat keloids; therefore, a multifaceted approach must be taken to lower recurrence rates. The authors in this study employed this principle when they investigated the efficacy of surgical excision, platelet-rich plasma (PRP), and in-office superficial photon x-ray radiation therapy as a combination therapy for keloids.

Methods

40 patients with 44 keloids were treated using the combination therapy. 4 patients who rated “poor” on the Kyoto Scar Assessment Scale were also given intralesional triamicinoloneinjections.

PRP is an autologous platelet concentrate that has been shown to induce tissue repair. It was obtained prior to the keloid excision by administering a blood draw to the patient and subsequently centrifuging the sample. Then, patients had their keloids excised under either IV or local anesthesia. After the excision, 2-3 cm3 of PRP were applied to both the wound bed, the skin flaps, as well as the incision site after suturing. In-office superficial photon X-ray radiation treatment was done within 72 hours of the excision. Keloids on the ears were treated with 70 kV, chin was treated with 50 kV, and all other sites were treated with 100 kV on a schedule of either 13, 16, or 18 Gy (Gray units). 16 keloids that received 2 treatments at 16 Gy were noted to have significant hyperpigmentation in the treatment area which prompted the investigators to change the treatment regimen. 25 of the remaining keloids were given 3 treatments of 18 Gy. The last 3 keloids were given 1 treatment of 13 Gy as a result of patients’ personal limitations.

Follow Up

Patients followed up initially at 10 days, then at 1,3, 6 and 9 months. For the first 3 months, patients were to use a proprietary scar cream known as “Keloid Care” twice daily. During follow-up, patients were evaluated for reoccurrence via examination as well as photo documentation. Signs of recurrence included significant redness, induration, and growth of the scar beyond the excision site. 4 patients who were rated “poor” on the Kyoto Scar Assessment Scale were given Triamcinolone injections.

Results

Overall, the treatment resulted in a non-recurrence rate of 95.5% at 3-11 months in the post-operative period. All patients had hyperpigmentation due to radiation therapy, but this was noted to be less in the patients who received 3 treatments. All 16 keloids that received 2 treatments did not recur while one each from the 3 treatment and 1 treatment category showed signs of recurrence.

Conclusion

The treatment of keloids is difficult and often unsuccessful due to recurrence. The treatment regimen investigated in this study seems to be quite promising because it resulted in a non-recurrence rate of 95.5%. An advantage of this procedure is that it can be done in-office at the convenience of both the doctor and the patient. One limitation of this study is that the patients had a follow up period of 3-11 months post-operative even though keloids are generally considered cured after 3-5 years without recurrence. Therefore, the patients in this study should continue to be monitored for at least 3-5 years to evaluate the true efficacy of this treatment.

About the Authors:
Sharon Mathew is a 3rd year student at Temple School of Podiatric Medicine (TUSPM) in Philadelphia, PA. She completed her undergraduate studies at Rutgers University in 2013 with a major in Cell Biology and Neuroscience and a minor in Public Health. Sharon matriculated at TUSPM in the fall of 2014 with a merit scholarship. In the future, she would like to be able to use her knowledge and expertise not only to treat patients in the US, but also to volunteer for medical mission trips and provide needed medical care to people who have limited access to it.

Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.