Abstract
Background
Keloids, pathological scars with complex etiology including genetic predisposition and trauma, remain a therapeutic challenge due to high recurrence rates. This study intends to conduct a retrospective study on the patients who received punch drilling therapy for keloid in our hospital to provide a new method and objective basis for the treatment of keloid.
Methods
A retrospective analysis of 13 patients (20 keloids) treated at Dermatology Hospital of Southern Medical University was conducted. Outcomes were assessed using Vancouver Scar Scale (VSS) and Visual Analogue Scale (VAS) scores preoperatively and scar image data were collected, alongside complication rates and patient satisfaction surveys.
Results
Significant reductions were observed in both scar scores: Median VAS decreased from 3.5 (range: 2.0–8.0) to 1.5 (1.0–4.0), and VSS from 7.0 (3.0–12.0) to 5.0 (1.0–8.0) (P < 0.001). Postoperative complications were minimal, with 95 % of patients reporting marked improvement in scar appearance and satisfaction.
Conclusion
The combination of punch drilling, adjuvant radiotherapy, and intralesional steroids injection demonstrates high efficacy in keloid treatment, characterized by low invasiveness, rapid recovery, and reduced recurrence. This protocol provides a promising strategy for refractory keloid management.
Keywords: Keloid, Punch drilling, Superficial radiation therapy, Intralesional drug injection
Introduction
Keloids are abnormal proliferations of skin tissue following injury, characterized by excessive fibroblast proliferation, invasive growth, and overproduction of extracellular matrix.1,2 In susceptible individuals, even minor skin injuries such as vaccinations or insect bites, can induce keloid formation. Current treatments include intralesional drug injections, surgical excision, radiotherapy, and laser therapy.3 However, conventional methods face limitations: high steroid dosages in conservative therapy, surgical challenges due to skin tension in multiple keloids, and poor efficacy of radiotherapy alone for keloids older than three months. Thus, a novel combined therapeutic approach is urgently needed.
Punch drilling, a tool for skin biopsy, removes keloid tissue via rotating circular blades, reducing volume and tension. Combined with superficial X-ray radiotherapy, it induces apoptosis of hyperactive fibroblasts, inhibits proliferation, and lowers recurrence.4 On this basis, combined with Intralesional drug injection, suppressing myofibroblast growth, reducing collagen synthesis and ameliorating inflammatory factors secretion, leading to keloids softening and shrinking. The synergy of these three modalities achieves rapid flattening and softening of keloids with minimal recurrence.
This retrospective study evaluates the efficacy of punch drilling combined with superficial X-ray radiotherapy and intralesional drug injection for multi-site keloids, aiming to provide a new therapeutic strategy and objective evidence.
Patients and methods
Subject selection
Ethical approval was granted by the institutional ethics committee of Dermatology Hospital, Southern Medical University and the trial was performed in accordance with the principles of the Declaration of Helsinki. Each patient signed a written informed consent form before enrollment.
Recruitment was performed from September 2022 to June 2023. 13 patients were male or female patients aged 18 to 60 years, who underwent keloids and required punch drilling combined with superficial X-ray radiotherapy and intralesional drug injection. Treatments were operated in all subjects by the same team of senior surgeons. The surgical sites included the mandibles, the anterior chest and the dorsal shoulder. Postoperative follow-up lasted from 3 to 6 months. Patients who were not treated with punch drilling or Non-compliance with radiotherapy or drug injection protocols were excluded. Patients with severe systemic infections, acute infectious diseases, severe heart disease, liver, kidney, lung, brain and other organ dysfunction were excluded. Patients who had received prior X-ray radiotherapy (≥4 sessions) at the same site were excluded. Pregnancy or lactation were also excluded.
Treatment protocols
Punch drilling procedure
Local infiltration anesthesia or general anesthesia can be selected according to size of keloids and patient's requirements. For general anesthesia, a tumescent solution (2 % lidocaine 10 mL + 100 mL normal saline + 1 mg epinephrine) was injected subcutaneously. Patients with local anesthesia were replaced with 1 % lidocaine solution. After anesthesia was completed, the drilling points were designed on the scar surface with a marking pen. According to the design point and scar width, different sizes of trephine instruments [Model: ZKQ-HZ, Optical Applied Medical Technology (Guangzhou) Co., LTD.] were selected. A 2 mm, 3 mm or 4 mm punch drill (ZKQ-HZ, Guangying Medical Technology, China) was used to penetrate the full thickness of the keloid. Excised tissue was removed with forceps and curved scissors. Drill holes were spaced 2–3 mm apart. The residual scar tissue between punch holes can be excised by drilling in an oblique or horizontal direction. The keloid core tissue should be removed as much as possible. After treatment completed, the area below the ring drilling should be wedge-shaped cavity, as shown in Fig. 1. The primary goal of treatment is focused on transforming the scar texture from hard to soft.
Figure 1.
Punch drilling procedure. For general anesthesia, a tumescent solution (2 % lidocaine 10 mL + 100 mL normal saline + 1 mg epinephrine) was injected subcutaneously. Patients with local anesthesia were replaced with 1 % lidocaine solution. After anesthesia was completed, the drilling points were designed on the scar surface with a marking pen. According to the design point and scar width, different sizes of trephine instruments [Model: ZKQ-HZ, Optical Applied Medical Technology (Guangzhou) Co., LTD.] were selected. A 2 mm, 3 mm or 4 mm punch drill (ZKQ-HZ, Guangying Medical Technology, China) was used to penetrate the full thickness of the keloid. Excised tissue was removed with forceps and curved scissors. Drill holes were spaced 2–3 mm apart. The residual scar tissue between punch holes can be excised by drilling in an oblique or horizontal direction. The keloid core tissue should be removed as much as possible. After treatment completed, the area below the ring drilling should be wedge-shaped cavity, as shown in Figure 1. The primary goal of treatment is focused on transforming the scar texture from hard to soft. Drill holes were spaced 2–3 mm apart. Larger wounds (4 mm) were sutured with 4–0/5–0 Mersilk sutures. Postoperatively, wounds were covered with Vaseline gauze and dressed.
Drill holes were spaced 2–3 mm apart. Larger wounds (4 mm) were sutured with 4–0/5–0 Mersilk sutures. Postoperatively, wounds were covered with Vaseline gauze and dressed. Cat ear deformity is easy to occur during the operation. However, the surface of wound area can be modified according to the tension direction to eliminate the cat ear deformity. Do not trim cat ears unless necessary.
Superficial X-ray radiotherapy
The X-ray machine is the superficial X-ray radiotherapy instrument (SRT-100, SENSUS Company, USA). Using the SRT-100 system, a total dose of 20 Gy (5 Gy per session) was delivered at 70 kV. The first session executed within 24 h post-surgery, followed by weekly sessions for four weeks.
Intralesional drug injection
Triamcinolone acetonide (40 mg) mixed with 2 % lidocaine (3 mL) was injected into the keloid core during surgery. Monthly injections continued until complete flattening and softening.
Evaluation metrics
Postoperative assessments at 3–6 months utilized the Vancouver Scar Scale (VSS: pigmentation, vascularity, pliability, height; total score 0–14) and Visual Analogue Scale (VAS: 0–10). The evaluation indexes of Vancouver Scar Scale included four aspects: color (0∼3 points), blood vessels (0∼3 points), softness (0∼5 points) and thickness (0∼3 points). The higher the score is, the more serious the scar condition is. Two independent plastic surgeons evaluated outcomes. Adverse events were recorded.
Statistical analysis
GraphPad (GraphPad Software, San Diego, CA) 8.4.3 was used for analysis. Quantitative data are expressed as mean ± SD; qualitative data as frequencies. Intergroup differences were assessed via t-test. Statistical significance was considered for values of P < 0.05.
Result
VAS scores
To evaluate the clinical efficacy of combination therapy, pre- and post-treatment Visual Analog Scale (VAS) scores were analyzed. Pre-treatment VAS scores ranged from 2.0 to 8.0 (median: 3.5; mean ± SD: 4.00 ± 2.10). Following combination therapy, scores decreased significantly to a range of 1.0–4.0 (median: 3.0; mean ± SD: 2.55 ± 1.05; p = 0.0006). Treatment outcomes were categorized based on score differences (pre-treatment minus post-treatment): Ineffective treatment (difference < 0): 1 case (5 %). Improvement (difference 0–2.0): 15 cases (75 %). Excellent effect (difference > 2.0): 4 cases (20 %), all of whom exhibited pre-treatment VAS scores ≥ 6.0. Subscale analysis demonstrated limited improvements in vascularity and pigmentation (median difference: 0 for both), whereas scar pliability and height showed greater reductions (median differences: 1.5 and 1.0, respectively). Vascular distribution and pigmentation items were not improved well in patients VSS score, and the median difference was 0. The median difference between hardness and scar height was 1.5 and 1.0, respectively.
VSS scores
Vancouver Scar Scale (VSS) assessments revealed significant improvements after combination therapy. Pre-treatment scores ranged from 3.0 to 12.0 (median: 7.0; mean ± SD: 8.00 ± 2.49), which decreased post-treatment to 1.0–8.0 (median: 5.0; mean ± SD: 4.85 ± 2.05; *p* < 0.0001). Outcome categorization based on VSS score differences (post-treatment minus pre-treatment): Ineffective treatment (difference < 0): 0 cases. Improvement (difference 0–3.0): 12 cases (60 %). Excellent effect (difference > 3.0): 8 cases (40 %) (Fig 2).
Figure 2.
VAS scores. To evaluate the clinical efficacy of combination therapy, pre- and post-treatment Visual Analog Scale (VAS) scores were analyzed. Pre-treatment VAS scores ranged from 2.0 to 8.0 (median: 3.5; mean ± SD: 4.00 ± 2.10). Following combination therapy, scores decreased significantly to a range of 1.0–4.0 (median: 3.0; mean ± SD: 2.55 ± 1.05; p = 0.0006). Treatment outcomes were categorized based on score differences (pre-treatment minus post-treatment): Ineffective treatment (difference < 0): 1 case (5 %). Improvement (difference 0–2.0): 15 cases (75 %). Excellent effect (difference > 2.0): 4 cases (20 %), all of whom exhibited pre-treatment VAS scores ≥ 6.0. Subscale analysis demonstrated limited improvements in vascularity and pigmentation (median difference: 0 for both), whereas scar pliability and height showed greater reductions (median differences: 1.5 and 1.0, respectively). Vascular distribution and pigmentation items were not improved well in patients VSS score, and the median difference was 0. The median difference between hardness and scar height was 1.5 and 1.0, respectively.
Typical case
A young female patient presented with multiple recurrent keloids on the shoulder and back, persisting for over four years. Previous treatment with intralesional corticosteroid injections (details unspecified) yielded unsatisfactory outcomes (Fig. 3).
Figure 3.
Typical case in our retrospective Study: Preoperative treatment photos. A young female patient presented with multiple recurrent keloids on the shoulder and back, persisting for over four years. Previous treatment with intralesional corticosteroid injections (details unspecified) yielded unsatisfactory outcomes.
The patient underwent "bilateral scapular and back scar punch drilling" under general anesthesia. Punch drilling devices (3 mm and 2 mm) were utilized to perform scattered perforations across the scarred areas. The first session of superficial X-ray radiation therapy (SRT-100) was administered within 24 h postoperatively, followed by weekly sessions for a total of 4 treatments (Fig. 4). Dressing changes were performed every 48 h until complete epithelialization. The surgical site was kept dry to avoid water exposure. One month postoperatively, monthly intralesional injections were initiated using a combination of triamcinolone acetonide (40 mg) and 2 % lidocaine hydrochloride (3 mL). Postoperative follow-up at 6 months revealed reduced height, softening, and no recurrence. (Fig. 5).
Figure 4.
Typical case in our retrospective Study: Intraoperative treatment photos. The patient underwent "bilateral scapular and back scar punch drilling" under general anesthesia. Punch drilling devices (3 mm and 2 mm) were utilized to perform scattered perforations across the scarred areas. The first session of superficial X-ray radiation therapy (SRT-100) was administered within 24 h postoperatively, followed by weekly sessions for a total of 4 treatments.
Figure 5.
Typical case in our retrospective Study: Postoperative follow-up photos. Postoperative follow-up at 6 months revealed reduced height, softening, and no recurrence.
Discussion
The rapid and effective treatment of multiple keloids has long been a challenging clinical issue. Conventional intralesional corticosteroid injection therapy is associated with prolonged treatment cycles, significant patient discomfort during administration, and adverse effects such as localized skin atrophy and telangiectasia. Long-term, multi-site corticosteroid use leads to higher cumulative doses compared to single keloid treatment, posing risks of complications like Cushing's syndrome. Furthermore, multiple keloids often present as clustered lesions within the same anatomical region, making complete surgical excision unfeasible due to tension-related limitations. To address these challenges, we introduced punch drilling as an intermediate therapeutic approach between conservative management and surgical excision.
The punch drill is a single-use circular cutting instrument. Its application in treating multiple keloids offers distinct advantages:
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Precise margins: Ensures clean-cut edges with customizable sizes for individualized treatment.
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Rapid and efficient: High-speed cutting significantly reduces surgical duration.
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Controlled depth: Safe operation with tactile feedback upon penetrating the keloid tissue.
The therapeutic mechanism of punch drilling involves en bloc removal of the keloid core. During the procedure, drilling is performed not only vertically beneath the circular wound but also obliquely along the peripheral regions, creating an inverted conical hollow space. This approach achieves the following:
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Reduces keloid thickness.
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Decreases volume while releasing internal tension through scar contracture relief.
A schematic diagram of the punch drilling process is illustrated in Fig. 1.
Simple punch excision surgery alone can achieve certain therapeutic effects, but when used as a solitary treatment, it carries a high postoperative recurrence rate.5 Therefore, comprehensive treatment is very important. Postoperative early-stage, standardized, and full-course superficial X-ray radiotherapy is required. Radiotherapy targets rapidly proliferating fibroblasts, mesenchymal cells, and inflammatory cells, inhibiting TGFβ release from fibroblasts to prevent collagen synthesis and fibroblast proliferation.6 According to the "Chinese Expert Consensus on Clinical Scar Prevention and Treatment," radiotherapy is recommended as a postoperative preventive measure against keloid recurrence after surgical excision. With advantages including shorter treatment duration, painless procedure, better patient experience, and higher compliance, superficial radiotherapy has become a routine postoperative treatment in our department for keloid excision. Previous studies have demonstrated the effectiveness of superficial X-ray radiotherapy in preventing recurrence of multiple chest keloids after punch excision.6
Additionally, regular postoperative follow-ups and good patient compliance are closely associated with prognosis. For some patients with preoperative keloid thickness >0.3 cm, the combination of punch excision and radiotherapy alone may fail to achieve the final treatment endpoint. Postoperative intralesional drug injections should be administered periodically, typically initiated after complete wound healing. These injections can significantly reduce scar thickness and address the limitation of punch excision in fully removing all pathological scar tissue. Studies have also demonstrated that postoperative intralesional corticosteroid injections (e.g., triamcinolone acetonide) effectively reduce keloid recurrence rates.7
Comparisons of preoperative and postoperative VAS (Visual Analog Scale) and VSS (Vancouver Scar Scale) scores have confirmed the effectiveness of this treatment protocol. Notably, keloids with more severe preoperative scores demonstrated greater improvement through this regimen, yielding substantial benefits for patients. However, a small subset of patients with initially low preoperative scores showed minimal changes, and one case even exhibited symptom exacerbation. These findings emphasize the importance of prioritizing patients with higher scar severity when selecting candidates for this treatment approach.
It is noteworthy that in the Vancouver Scar Scale (VSS) assessment, 60 % of patients showed no improvement or even worsening in pigmentation scores compared to preoperative evaluations. This phenomenon is attributed to superficial X-ray radiotherapy administered to all patients in our cohort. Post-radiotherapy, skin hyperpigmentation typically develops within the irradiated area—covering the scar surface and approximately 1 cm of surrounding skin—with larger radiation fields correlating with more pronounced pigmentation.7 Given that our shortest follow-up period was only 3 months postoperatively, and radiation-induced hyperpigmentation requires over 1 year for gradual resolution, the long-term efficacy of this outcome necessitates further investigation through extended follow-up. Additionally, improvements in scar vascularity were observed in fewer than half of the patients (35 % of cases). These findings underscore the limitations of this combined therapy in addressing scar coloration issues, highlighting an urgent need for protocol optimization in future research.
Conversely, most patients demonstrated significant improvements in scar thickness and pliability postoperatively compared to preoperative assessments. This indicates that punch excision combined with superficial radiotherapy effectively reduces keloid core volume while avoiding common complications associated with scar core removal, such as epidermal necrosis. The procedure proves safe and effective, being particularly suitable for patients with thick, firm scars. These cases represent precisely the clinical challenges that intralesional drug injections alone cannot adequately address.
Future research aims to enhance outcomes through comprehensive postoperative interventions to reduce scar hyperplasia rates. We propose that combining fractional laser therapy with superficial radiotherapy following punch drilling may not only address the high recurrence rates associated with laser therapy but also improve scar surface pigmentation. This integrated approach holds potential for optimizing both functional and aesthetic outcomes in keloid management.
In conclusion, the comprehensive treatment protocol combining punch drilling, superficial X-ray radiotherapy, and intralesional drug injections demonstrates significant efficacy in keloid management, markedly reducing scar height and hardness. Future research aims to further refine outcomes through integrated laser therapy targeting scar pigmentation abnormalities. This multi-modal approach seeks to address both keloid protrusion and aesthetic concerns simultaneously, ultimately achieving higher patient satisfaction by optimizing treatment outcomes in both functional and cosmetic dimensions.
Funding
None.
Conflict of interest
None declared.
Ethical approval
Not required.
References
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