Mature brownish keloids are less likely to recur than younger red ones. “There are no data for that, just my experience,” she continued. Keloids on the jaw, upper back, mid-chest, and deltoid are the ones most likely to recur.
During her presentation, Dr. Baldwin provided the following points about different treatments:
- Postsurgical adjunctive therapy. The options include corticosteroid injections, injectable interferon, and pressure dressings. Which to chose? Urge patients to opt for all of them. “Go for the whole kit and caboodle. There’s no reason to stop at just one. I can tell you that if you do all of these things on an earlobe keloid, no matter how big it is, that sucker’s not coming back. On the body, sometimes yes, sometimes no. That’s a much harder area to treat,” Dr. Baldwin said.
- Corticosteroids. Her personal recipe is 40 mg/cc of triamcinolone injected to the base and walls of the excision site immediately postsurgically and again every 2 weeks for 2 months, regardless of the site’s clinical appearance. “If they come in absolutely dead flat, I don’t care. I’m injecting it anyway. I have no data behind this, but I can tell you that when I do it that way, the chances of recurrence are much less,” she noted. After the first 2 months of steroid injections, she switches to a once-monthly schedule for another 6 months, with the dose and concentration selected based upon appearance.
- Radiation therapy. “Many of you don’t use it and many patients refuse it, but if you’ve got a patient who’ll do it, it’s by far the single best adjunctive therapy for the treatment of keloids,” Dr. Baldwin said. This is ineffective on existing keloids, and she advises to cut first, then irradiate the base. All forms of radiotherapy are effective, she added, so she leaves the details to the radiotherapist. “I say, ‘Here’s the patient, do your thing.’ Most of them do it immediately postop, others do it a day or 2 or a week later,” she said.
- Interferon. The regimen is 1.5 million U/linear cm injected into the base and walls of the excision site on days 1 and 7. The maximum is 5 million U/session in order to minimize the interferon-induced flulike syndrome. Pretreatment with 1 g of acetaminophen before the interferon injections and every 4 hours for 24 hours posttreatment is also helpful in preventing the flulike symptoms, which can sometimes be formidable. “I tell patients to be able to take the next day off from work if they have to and also not to have any obligations that night for child or elderly care,” Dr. Baldwin noted.
- Pressure dressings. For these to be effective, they have to exert considerable pressure, and they must be worn 24/7 for 4-6 months. The only location in which pressure dressings make sense is on the earlobes. Dr. Baldwin mentioned two producers: Delasco makes silicone pressure earrings, and NBN Products makes a variety of the devices.
- The nonsurgical alternatives. For the many patients who aren’t good surgical candidates, the workhorse therapy for existing keloids is intralesional triamcinolone at 40 mg/cc. This works best for sessile lesions. Dr. Baldwin doesn’t hesitate to give 50-100 mg/treatment session. “Ask, ‘Where do you want to start?’ We do a tiny area with a huge amount of triamcinolone and then that spot will get better. If you spread it around over a large area, nothing’s going get better,” she advised. 5-fluorouracil is a less attractive alternative. It’s painful, less effective, and it can cause ulceration.