Our Experience at Tertiary Medical College—Intralesional Injection of Triamcinolone Acetonide Versus Injection Verapamil Following Keloidectomy with Fillet Flap in Auricular Keloids

Abstract

Keloid, which forms as an excessive tissue response to trauma to the skin, is a benign, hyperproliferative, recurrent growth of dermal collagen without a quiescent or regressive period throughout the process of wound healing. The aim of this study was to evaluate patient satisfaction with treatment and to compare the efficacy of intralesional injection of triamcinolone acetonide against verapamil after keloidectomy with fillet flap in auricular keloids. Our study was Duration based prospective observational study with a Duration of two years from June 2021 till May 2023 with study population inclusive of 50 patients aged between 20 and 70 years having recurrent keloid(s) over the pinna of any size or site. Keloidectomy with fillet flap and intralesional injection of trimcinolone acetonide was performed on 25 patients (30 keloids) in Group A, and keloidectomy with fillet flap and intralesional injection of verapamil was performed on 25 patients (30 keloids) in Group B. With a recurrence rate of 27%, eight keloids in Group A patients had an early recurrence three months following surgery. At nine months, nine more mixed-type cases with a 30% recurrence rate resurfaced. Recurrence seen in eight keloids out of 28 showed a 28.57% recurrence rate 12 months following surgery. Three people in Group B with three sessile keloids experienced an early recurrence at three months after surgery, with a recurrence rate of 10%. At nine months, four more cases of mixed kind returned, with a recurrence rate of 13%. A recurrence rate of 14.28% was found in 4 of 28 keloids at 12 months postoperatively. The Patient and Observer Scar Assesment Scale scores (POSAS scores) were consistently higher than Beausang scores at 1 year, indicating high patient satisfaction compared to physician assessment in both groups A and B. A keloid recurrence-free interval of 11.36 months was obtained by the Kaplan–Meier survival test (p < 0.05) in group A. Keloid recurrence-free interval of 10.98 months was evaluated by the Kaplan–Meier survival test (p < 0.05) in group B. Among Keloidectomy with fillet flap surgery with intralesional injection of triamcinolone acetonide (group A) and keloidectomy with fillet surgery with intralesional injection of verapamil (group B), at each follow-up the success rate of group B was higher than group A indicating better trend of success in this group in terms of both absence of recurrence and absence of complications without statistically significant difference between them which shown both procedures more or less similar.

Introduction

Keloid is a benign, hyperproliferative and recurrent growth of dermal collagen without quiescent or regressive phase during the process of wound healing which develops as a excessive tissue response to skin trauma which is differentiated from hypertrophic scars by its peculiar features such as pseudotumour growth pattern beyond the borders of the original wound with tissue distortion. The term keloid was coined by Alibert cheloide in 1806 from Greek word meaning as crab claw like to differentiate keloids from cancerous overgrowths [1]. Areas most commonly involved are the ventral aspect of chest, shoulders, anterior surfaces of extremities and the ears. Studies have shown that, the incidence of keloids found to be 2.5% of all ear piercing with higher incidence found in patients who have done ear piercing after the age of 11 years [2, 3]. They may also follow ear pinna trauma repair, auricular haematoma drainage, recurrence in excised keloids. The primary aims during planning a management protocol should be a low recurrence rate, significant aesthetic and symptomatic improvement with minimal adverse effects [4].

Treatment for the keloids includes multitreatment approach such as surgical excision, post excision methods to prevent recurrence and reconstruction modalities. The gold standard treatment for the keloid is a surgical excision which decreases the mass of the lesion and corrects the obvious distortion of the pinna. Various treatments have been described in the literature to prevent recurrence of keloids after surgery, ranging from mechanical compression, silicon occlusive dressing, intralesional steroid injection, verapamil, imiquinode 5% cream, 5-fluorouracil, and interferon alpha, beta and gamma [1]. Reconstruction can be done by any of the method, such as primary closure, secondary closure, skin grafting, or flaps. Excision of the skin over the keloid mass as a flap is known as a “keloid fillet flap” and the keloid mass is completely removed [5, 6]. Excision alone has shown recurrence rates of 45% to 100% [7, 8].

There are three approaches for using corticosteroid injections to treat keloids: as adjunctive therapy used in conjunction with surgery, as keloid specific monotherapy, and as symptomatic therapy as a part of multimodal therapy [6]. In addition to inhibiting pro-inflammatory mediators, corticosteroids reduce fibroblast proliferation, collagen and glycosaminoglycan synthesis. Triamcinolone acetonide is the most commonly used corticosteroid. It is administered at doses of 10–40 mg/ml for 3–6 weeks [9]. Verapamil, a calcium channel blocker, has been demonstrated to increase procollagenase synthesis in keloids while inhibiting the production or release of extracellular matrix components such as collagen, glycosaminoglycans, and fibronectin, which alters cell shape, depolymerizes actin filaments, and decreases the development of fibrous tissue. Verapamil hydrochloride (2.5 mg/ml) was injected locally, intraoperatively, before applying the pressure dressing. The amount of injection varied from 1 to 2.5 ml per session, depending on the size of the wound [10]. Early non-randomized clinical trials using intralesional verapamil alone or as an adjuvant after surgery have shown encouraging results [10, 11].

The aim of this study was to compare the effectiveness of Intralesional injection of triamcinolone acetonide versus verapamil following keloidectomy with fillet flap in Auricular keloids and to assess patient satisfaction with treatment& to compare effectiveness of Intralesional injection of triamcinolone acetonide versus verapamil following keloidectomy with fillet flap in Auricular keloids in terms of recurrence & complications.

Material and Methods

Our study was Duration based prospective observational study with a Duration of 2 years from June 2021 till May 2023 with study population inclusive of 50 patients(60 keloids) aged between 20 and 70 years having recurrent keloid(s) over the pinna of any size or site diagnosed on the basis of clinical presentation. We have included those patients who had not received any treatment within the last 6 months and were ready for regular follow‑up at ENT Department of our Tertiary Institution. All patients with benign or malignant tumours of the pinna, otitis externa, insect bite, atopic dermatitis, eczema, food or drug allergy, patients less than 20 years and more than 70-year age were excluded from the study. All patients underwent a detailed history for age, sex, clinical features, previous surgery, any trauma, family history and clinical examination. Patients who were falling in inclusion criteria were administered an informed consent and written consent was obtained from those who agreed to participate in the study. A case record (Proforma) form was filled by the patient. The study used a randomized, single blind, parallel design with a total of 50 patients (60 keloids), which were randomly allocated to receive fillet flap keloidectomy with intralesional injection of trimcinolone acetonide, a 10 mg/ml steroid administered at 1 ml/cm² after dilution to an equivalent volume with 2% lignocaine (group A) in 25 patients (30 keloids) and keloidectomy with fillet flap with intralesional injection of 2.5 mg/ml of verapamil with amount varied from 1 to 2.5 ml per session, depending on the size of the wound (Group B) in 25 patients (30 keloids) at the edges of the keloid incision during surgery before applying the pressure dressing.

Surgical technique in both groups involved keloidectomy with fillet flap using Kim et al. approach [5]. The term “keloid fillet flap” refers to the excision of the skin over the keloid mass as a flap, along with the total removal of the keloid mass. All operations were performed under local anesthesia in a minor operating room, following strict aseptic precautions. According to the location of keloid over the pinna, the flaps were marked so that the pedicle was facing to the other side (Fig. 1) After contouring the incision line so that the edges of the mass were not obscured, a local anesthetic (2% lidocaine with 1:100,000 epinephrine) was infiltrated into the incision site. The major keloid mass was then completely removed from the cutaneous compartment with curved blunt iris scissors, leaving normal skin around. Sharp scissors were used to separate the mass from the base without penetrating the normal skin on either side (Fig. 2). If perforation occurred, it was closed with 5–0 nylon interrupted sutures. Bleeding was controlled by pressure. An electrocautery was used to control the bleeding only when needed to avoid possible flap necrosis. A skin flap was placed over the underlying tissues for closure after excising excess skin. The wound was carefully palpated from all sides and from the bottom before starting the wound closure to ensure not leave fibrous tissue behind. The wound was closed with interrupted nylon 5–0 sutures. No subcutaneous sutures were used. Special attention was paid to tension-free closure, accurate joining of skin edges, proper hemostasis, atraumatic tissue handling and aseptic handling (Fig. 3). The removed keloids were sent for histological confirmation. At each follow-up visit, the surgical site was evaluated for the response to treatment and possible complications after surgery. Patients were followed up postoperatively at day 14, day 21, 6 weeks, 9 weeks, and 12 weeks, 6 months, 9 months, 12 months. With each recurrence at follow-up, triamcinolone acetonide and verapamil were injected locally into the wound and suture line in groups A and B respectively until the lesion was satisfactorily regressed. A pressure bandage was applied for the first 48 h, the stitches were removed 14 days later. Antibiotics and anti-inflammatory drugs were given for one week after surgery.

Fig. 1.

A 18 years female with sessile left ear pinna keloid before treatment with marking at the site of incision

Fig. 2.

Intraoperative appearance during elevation of the fillet flap and keloidectomy

Fig. 3.

postoperative photograph showing suturing of skin flap with underlying soft tissue after cutting extra skin using 5–0 interrupted sutures

Both subjective and objective scar assessment were used to measure outcome. Serial photographic documentation and measurements of the largest dimension of the scar in two perpendicular planes were used to analyze the patients. Subjective and objective assessment, also known as patient and physician satisfaction was performed using the Patient and Observer Scar Assesment Scale (POSAS) which consisted of six items (vascularity, pigmentation, thickness, relief, pliability and surface area). All items were scored on a scale ranging from 1 (‘like normal skin’) to 10 (‘worst scar imaginable’). All parameters should preferably be compared to normal skin on a comparable anatomic location. The sum of the six items results in a total score of the POSAS observer scale [12]. At each follow up, the patient and an observer assessed the operated ear by looking into a mirror in the OPD under normal lighting. An objective assessment, sometimes referred to as physician satisfaction was performed using the BEUSANG SCORE, where a patient was assessed and scored by an independent observer blinded to postoperative time at each follow-up in OPD. Beausang scoring was done using the Manchester Scar Scale (MSS) for quantitative scar assessment based on clinical, photographic, and histological features. Individual scar attributes including colour, contour, radiance, texture, and distortion are evaluated and combined with a visual analog scale (pain intensity rating by placing a mark on a 100 mm line ranging from no pain to worst imaginable pain) to determine an overall score proportional to scar severity [13].

Results of groups A and B were compared for response rate, recurrence rate, keloid recurrence free interval, and complications. In our study, response was defined as a reduction in lesion area of at least 50% without recurrence at 12-month follow-up, while the appearance of growing or chronically symptomatic scar tissue after surgery was a sign of recurrence. They were informed about the negative side effects of steroids, and female patients were advised to delay pregnancy for a year. Patients were contacted by telephone and discussed about possible relapses after the 12-month period. The data obtained were statistically analyzed using the Statistical Package for the Social Sciences (SPSS) version 13. The cross-tabulations of the study subjects and matching of treatment groups based on factors such as age and gender followed by comparison of subjective and objective satisfaction levels was done. Chi-squared test of association was used to determine response rate, recurrence rate and complications by treatment group and their test of association. Descriptive statistics such as mean age and standard error of mean age were calculated using SPSS descriptive technique.

Results

The Study involved 50 patients (60 keloids) in the age group 20–70 years age group with the highest number of cases (i.e., 36) occurring in the 20–30 year age group, which made up around 60% of the study population. Among the 60 keloids in the study, 55 (92%) were female. Female to male patients ratio was 11:1, with 5 patients (80%) being male (Table 1). In 40 (80%) individuals, the lesions were unilateral, while in 10 (20%) patients, they were bilateral. In this study, we examined the pinna’s involvement by keloid and discovered that the ear helix (33 cases, or 55%) and ear lobule (27 cases, or 45%) were more commonly affected. Out of 50 patients, 46 had ear piercings and 4 had burn injuries as a contributing factor. The duration of the lesions varied from one to three years. Five (10%) people visited a doctor because of pain, while 45 (90%) patients did so because of cosmetic concerns. Out of a total of 50 patients, 22 (44%) had a family history of keloids. Compared to 14 (24%), which were second recurrences, 46 (76%) of the keloids were first recurrences. In our investigation, sessile keloids were found to account for 36 lesions, or 60% of all lesions, whereas pedunculated keloids were found in 30% of lesions and mixed keloids in 10% of lesions. Two patients were no longer being monitored after 6 and 9 months, respectively, for bilateral sessile keloids. Out of the fifty patients who started the study, 48 patients had 56 keloids by the time it was finished. At each appointment, the response was evaluated specifically to determine whether complications or recurrence had developed. Histopathology in all of our cases shown characteristic haphazard thick collagen bundles with increased fibroblasts and few vessels (Fig. 4).

Table 1.

Demographic features of the study population

Age in years	Keloidectomy with fillet flap with intralesional inj trimcinolone acetonide (group A)		Keloidectomy with fillet flap with intralesional inj verapamil (group B)		Total
	Number	Percentage	Number	Percentage	Number	Percentage
20–30 years	18	60%	18	60%	36	60%	X2 = 1.6 p = 0.449329
31–50 years	06	20%	09	30%	15	25%
51–70 years	06	20%	03	10%	09	15%
Total	30	100	30	100	60	100
Mean age ± SE	28.52 ± 14.07	29.64 ± 12.05
Minimum age	22		21		21
Maximum age	68		70		70
Sex							X2 = 0.2182 p = 0.640429
Males	02	07%	03	10%	05	08%
Females	28	93%	27	90%	55	92%
Total	30	100	30	100	60	100

Fig. 4.

Histopathological photomicrograph showing earlobe keloid with characteristic haphazard thick collagen bundles (yellow arrow) with increased fibroblasts and few vessels

With a 27% recurrence rate, eight keloids in Group A patients had an early recurrence three months after surgery. These keloids were sessile in nature and never recurred at the follow-up consultation, demonstrating a 73% success rate. At nine months, nine more mixed-type cases with a 30% recurrence rate resurfaced. It’s important to note that all of these occurred in keloids that were successfully treated with a 70% success rate after reoccurring twice. Recurrence seen in eight keloids out of 28 showed a 28.57% recurrence rate 12 months following surgery. At 12-month follow-up, 20 of 28 (71.42%) keloids responded to treatment without recurrence, indicating a 71.42% success rate (Table 2). Partial flap tip necrosis as a result of complications was found in two (7%) keloids. With conservative treatment, the extent of flap necrosis was controlled and completely healed. There was no atrophy or haematoma or pigmentary changes at the surgical site. One dose had to be delayed in two cases due to an unwanted steroid side effect (gastritis), while one patient developed menorrhagia after completing the prescribed dosing regimen and was managed conservatively. Two patients had telangiectasia and pigmentation that resolved during follow-up (Table 3). Of the 20 respondents, 15 cases (75%) showed high satisfaction, while 5 cases (25%) were moderately or slightly satisfied. POSAS scores were consistently higher than Beausang scores at 1 year, indicating high patient satisfaction compared with physician evaluation (Tables 4 and 5). The Kaplan–Meier survival test gave a keloid recurrence-free interval of 11.36 months (p < 0.05).

Table 2.

Success rate in terms of absence of recurrence in both treatment groups

Follow up days	Keloidectomy with fillet flap with intralesional inj trimcinolone acetonide (group A)			Keloidectomy with fillet flap with intralesional inj verapamil (group B)			Total			X2	p
	Sample size (n)	Recurrence absent		Sample size (n)	Recurrence absent		Sample size (n)	Recurrence Absent
		Number	Percentage		Number	Percentage		Number	Percentage
3 months post op	30	22	73%	30	27	90%	60	49	81.67%	2.7829	0.095274
9 months post op	30	21	70%	30	26	87%	60	47	78.33%	2.455	0.117152
12 months post op	28	20	71.42%	28	24	85.71%	56	44	78.57%	1.697	0.192685

Table 3.

Success rate in terms of absence of complications in both treatment groups

Follow up days	Keloidectomy with fillet flap with intralesional inj trimcinolone acetonide (group A)			Keloidectomy with fillet flap with intralesional inj verapamil (group B)			Total			X2	p
	Sample size (n)	Complications absent		Sample size (n)	Complications absent		Sample size (n)	Complications absent
		Number	Percentage		Number	Percentage		Number	Percentage
POD 7	30	28	93.33%	30	26	86.66%	60	54	90%	0.7407	0.389424
1 months post op	30	28	93.33%	30	30	100%	60	58	96.66%	2.069	0.150323
12 months post op	28	25	89.28%	28	28	100%	56	53	94.64%	3.1698	0.075011

Table 4.

Subjective assessment using patient observer scar assessment scale (POSAS) SCORE at 12 months follow up

Keloidectomy with fillet flap with intralesional inj trimcinolone acetonide (group A)		Keloidectomy with fillet flap with intralesional inj verapamil (group B)
Mean preoperative POSAS SCORE	Mean post operative POSAS SCORE	Mean preoperative POSAS SCORE	Mean post operative POSAS SCORE
88	24	86	26

The chi-square statistic is 0.103. The p-value is 0.748272. The result is not significant at p < 0.05

Table 5.

Objective assessment using BEUSANG SCORE at 12 months follow up

Keloidectomy with fillet flap with intralesional inj trimcinolone acetonide (group A)		Keloidectomy with fillet flap with intralesional inj verapamil (group B)
Mean preoperative BEUSANG SCORE	Mean post operative BEUSANG SCORE	Mean preoperative BEUSANG SCORE	Mean post operative BEUSANG SCORE
18	8	16	6

The chi-square statistic is 0.0705. The p-value is 0.790584. The result is not significant at p < 0.05

In group B, three patients with three keloids experienced an early recurrence three months after surgery, with a recurrence rate of 10% which was of sessile type and never recurred at the next appointment, with a 90% success rate. After nine months, the remaining four returned with a recurrence rate of 13% and was of mixed type. It was interesting to note that all this happened in keloids that were healed after recurring twice, with a success rate of 87%. At 12 months after surgery, 4 of the 28 keloids recurred with a recurrence rate of 14.28%. At 12-month follow-up, 24 out of 28 keloids (85.71%) responded to treatment without signs of recurrence, with a success rate of 85.71% (Table 2). Of the 24 responding cases, 18 (75%) patients were highly satisfied and 5 (20.83%) were moderate to mildly satisfied. Partial necrosis of the flap tip as a complication was found in four (13.33%) of keloids. After conservative treatment, the extent of flap necrosis was controlled and completely healed. There was no hematoma, atrophy, and pigmentary alterations at the surgical site (Table 3). POSAS scores were consistently higher than Beausang scores at 1 year, indicating greater patient satisfaction compared to physician assessment (Tables 4 and 5). The estimated recurrence-free period was 10.98 months using the Kaplan–Meier survival test (p < 0.05).

Discussion

Keloids occur in 5–15% of wounds in humans affecting both sexes equally, but women are more likely to develop them due to the cosmetic effects of disfigurement [14, 15]. The most important factor to consider when treating keloids is prevention. Categorizing keloids as small and/or single versus large and/or multiple may be a useful strategy. Surgery would play a role in the former, leading to a one-stage complete resection, while it would play a role in the latter, leading to reduction of the keloid mass. Surgical removal of keloids is difficult because the underlying three-dimensional cartilage architecture of the ear must be preserved and there is no laxity in the surrounding tissue [16]. Lee et al. after keloid core excision described a subcapsular vascular plexus-based keloid ring flap that preserved vascularity and allowed debulking effect with uneventful recovery without donor site morbidity or the need for grafts [8, 17]. Kim et al. described keloidectomy with reconstruction using the keloid fillet flap technique. In addition, the risk factors for keloid recurrence were avoided, which were the “five As and one B” (asepsis, atraumatic technique, absence of raw surface, avoidance of tension, accurate approximation of the wound edge, complete control of bleeding, which improves aesthetics by covering a defect & provides the same colour and shape like nearby tissues [5].

Previous studies shown that surgical excision alone has a recurrence rate of 45% to 100%, while combined with corticosteroid injections has a lower rate. Corticosteroid injections can be used as adjunctive therapy, keloid-specific monotherapy, or part of a multidisciplinary approach. Postoperative wounds shown reduced pro-alpha 1 collagen transcripts, reducing fibroblast proliferation, collagen and glycosaminoglycan synthesis, and inhibiting pro-inflammatory neurotransmitters. Thus, the intraoperative dose was shown to be the most important dose to stop hypertrophy and keloid development. The most commonly used corticosteroid is triamcinolone acetonide given in doses of 10 to 40 mg/ml for 3 to 6 weeks which is having side effects such as hypo- and hyperpigmentation, skin shrinkage, telangiectasia and ulcers [1, 4, 7–9]. In a pilot study, Al Aradi et al. used keloidectomy with core fillet flap and intralesional steroid injection to treat 21 earlobe keloids. The efficacy of the clinical outcome was 87.6% with an average follow-up time of 21.9 months and an immediate recurrence of 9.5% while, 82.3% of patients reported that they were very satisfied [18]. A calcium channel blocker, Verapamil (2.5 mg/ml) injected locally shown to increase procollagenase synthesis in keloids while inhibiting the production or release of extracellular matrix substances like collagen, glycosaminoglycans, and fibronectin. This alters cell shape, depolymerizes actin filaments, and lessens the growth of fibrous tissue [10]. Copcu et al. found a 19.04 percent recurrence rate in 21 keloids patients after total excision, W-plasty, and verapamil injection [11]. Lawrence treated 31 patients with 40 earlobe keloids using surgical excision, verapamil, and pressure earrings. The procedure had a higher recurrence rate of 51.1%, with no differences in sex, age, size, duration, or verapamil injections [19]. Margaret Shanthi et al. concluded that intralesional verapamil can be an effective substitute for triamcinolone in the treatment of keloids and hypertrophic scars, significantly improving all the clinical parameters of the studied scars, most importantly, significantly reducing the risk of recurrence [20]. Rockwell et al. suggest using silicone gels dressing for 12 h daily for scars and keloids, providing occlusion, hydration, and reducing redness, itching, and discomfort [14].

Agbenorku et al. found that triple keloid treatment reduces recurrence by 12.5% after 13 months, but was difficult, time-consuming, and expensive. Another study showed improvement after five weeks with steroids [21]. Since referral to outpatient radiotherapy was not possible, radiotherapy was not used in our study.

Comparing our results with the previous literature, marginally lower recurrence rates were found in both groups, while group A was found to have a lower recurrence rate than group B, but a higher response rate in group A than in group B. POSAS scores were consistently higher than Beausang scores at 1 year, indicating high patient satisfaction compared to physician assessment in both groups A and B. The keloid recurrence-free interval was 11.36 months using the Kaplan–Meier survival test (p < 0.05) in group A. The keloid recurrence-free interval of 10.98 months was evaluated by the Kaplan–Meier survival test (p < 0.05) in group B. In our study, the recurrence free success rates of both groups were approximately 73% and 90% at 3 months postoperatively for keloidectomy with fillet flap with intralesional trimcinolone acetonide injection (Group A) and keloidectomy with fillet flap with intralesional injection. of verapamil (Group B) respectively with a p-value of 0.095274. At 9 months, it was 70% and 87% in both groups, with a p value of 0.117152. At 12 months, it was 71.42% and 85.71% in both groups, with a p value of 0.192685. At each follow-up, the success rate of group B was higher, indicating a better trend of success in this group. However, the difference in success rate was not statistically significant. Thus, the final interpretation of the success rate in terms of no recurrence is that both procedures were more or less similar. The success rate in terms of absence of complications of group A was 93.33% on postoperative day 7, followed by 93.33% at 1 month postoperatively, which fell to 89.28% at 12 months. While group B had a success rate of 86.66% on the 7th postoperative day, it increased to 100% at 1 month and 12 months. At each follow-up, group B had a higher success rate, indicating better success in this group. However, the difference in success rate was not statistically significant. Thus, the final interpretation of the success rate in terms of no complications is that both procedures were more or less similar. Thus, both groups had almost similar success rates in terms of absence of complications without a statistically significant difference between them was the final conclusion of this study.

To the best of our knowledge, no study has been published so far comparing group A with group B. Thus, we have compared keloidectomy with fillet flap surgery with intralesional injection of trimcinolone acetonide (group A) and keloidectomy with fillet flap with intralesional injection of verapamil (group B) and found that at each follow-up the success rate of group B was higher than group A indicating better trend of success in this group in terms of both absence of recurrence and absence of complications without statistically significant difference between them shown both procedures more or less similar. Limitation of our study was the small number of cases. Further studies are needed in future with more number of cases.

Conclusion

The Patient and Observer Scar Assesment Scale scores (POSAS scores) were consistently higher than Beausang scores at 1 year, indicating high patient satisfaction compared to physician assessment in both groups A and B. The keloid recurrence-free interval was 11.36 months using the Kaplan–Meier survival test (p < 0.05) in group A. The keloid recurrence-free interval was 10.98 months as assessed by the Kaplan–Meier survival test (p < 0.05).) in group B. Among Keloidectomy with fillet flap surgery with intralesional injection of trimcinolone acetonide (group A) and keloidectomy with fillet surgery with intralesional injection of verapamil (group B), at each follow-up the success rate of group B was higher than group A indicating better trend of success in this group in terms of both absence of recurrence and absence of complications without statistically significant difference between them which shown both procedures to be more or less similar while on comparing our results with the previous literature, marginally lower recurrence rates were found in both group A and B.

Funding

Not applicable.

Declarations

Conflict of interest

All the authors declare that they have not any conflict of interest.

Ethical Approval

All procedures performed in study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration. Ethical approval taken from institutional ethical committee of Ashwini Rural Medical College & Hospital Solapur as per ICMR guidelines.

Informed Consent

Informed consent was obtained from all individual participants involved in the study.