Abstract
This cohort study assesses whether shaving of the keloid scar followed by cryosurgery is associated with decreased scar volume.
There is currently no consensus regarding the best treatment of keloid scars. Earlier studies report a decreased scar volume and a substantial reduction of recurrence in keloid scars treated by cryosurgery.1,2 In this study, our objective was to assess whether intramarginal excision (shaving) of the keloid scar followed by an immediate single session of contact cryosurgery is associated with decreased scar volume.
Methods
A single-center cohort study was conducted between March 2014 and May 2020 in a population of patients with keloid scars, previously treated or not, in University Hospital of Brest, France. Patients with a range of self-reported Fitzpatrick skin types were included.3 Patients were excluded if they had received treatment with immunosuppressive therapy. This study was approved by the Committee for the Protection of Persons and the National Commission for Information Technology and Liberties (ClinicalTrials.gov NCT02886091). All participants provided written informed consent. The STROBE reporting guideline was followed.
Keloid scar volume was measured using the Vancouver scar scale4 after 12 months (eMethods in the Supplement). Secondary outcomes were assessment of pruritus and pain during treatment. Statistical analyses were performed using pvalue.io software (Medistica) and included t test or the Mann-Whitney U test for continuous variables, Fisher exact or χ2 test for categorical variables, and Wilcoxon rank sum test for the matched pairs. The significance criterion for all tests was set at P = .05.
Results
A total of 31 patients with 40 keloid scars were included, with all Fitzpatrick phototypes (Table). Four patients were lost to follow-up; 27 patients (mean [SD] age, 23.9 [11.2] years; 21 were female [60%]) with 35 keloid scars were analyzed.
Table. Demographic and Clinical Characteristics of Patients and Keloid Scars.
| Characteristic | No. (%) |
|---|---|
| No. of keloid scars | 35 |
| Age, median (IQR), y | 21.0 (17.0-27.5) |
| Skin type according to the Fitzpatrick scalea | |
| I | 0 |
| II | 8 (23.0) |
| III | 8 (23.0) |
| IV | 5 (14.0) |
| V | 5 (14.0) |
| VI | 9 (26.0) |
| Patient sex | |
| Male | 14 (40.0) |
| Female | 21 (60.0) |
| Age of scar occurrence, mean (SD), y | 17.6 (8.8) |
| Scar duration, median (IQR), y | 4.0 (3.0-7.0) |
| Location of keloid scar | |
| Head and neck except ears | 3 (8.6) |
| Ear | 24 (69.0) |
| Chest | 8 (23.0) |
| Recurrence/past treatment | 5 (14.0) |
| Volume, median (IQR), cm3 | 5.0 (0.7-13.1) |
| Largest diameter, median (IQR), cm | 2.0 (1.0-3.0) |
| Length, median (IQR), cm | 3.2 (2.5-5.5) |
| Thickness, median (IQR), cm | 0.6 (0.3-1.0) |
| Physical symptoms | |
| Pruritus | 20 (57.0) |
| Pain | 11 (31.0) |
| Vancouver scar scale, mean (SD)b | 7 (1.5) |
The Fitzpatrick scale is described in the Figure caption.
The scale is based on 4 values: flexibility, height, vascularity, and pigmentation. The score is between 0 and 13, with 0 for normal skin and 13 for a very pathological scar.
Nineteen keloid scars (54%) exhibited a major reduction in scar volume, defined as an 80% to 100% volume reduction. Six keloid scars (17%) had a substantial reduction in scar volume, defined as a 50% to less than 80% volume reduction. Seven keloid scars (20%) experienced no reduction. The volume reduction after treatment across all keloid scars was significant with a median volume decrease of 81.9% (IQR, 33.5%-96.1%; P < .001) (Figure).
Figure. Clinical Outcomes Associated With Shaving the Keloid Scar Followed by Contact Cryosurgery.
A, Mean scar volume according to their localization: ear (lobes and retroauricular area), face/neck, and chest. B, Mean scar volume subdivided according to Fitzpatrick classification3 into phototypes I (pale white skin, blue or green eyes, and blonde or red hair) and II (fair skin and blue eyes); phototypes III (darker white skin) and IV (light brown skin); and phototypes V (brown skin) and VI (dark brown or black skin). C, Pruritus and pain before and 12 months after treatment.
Among the 24 ear scars (lobular and retroauricular), 21 (84%) showed a major or substantial reduction in scar volume. In contrast, among the 8 scars localized on the chest, 6 (60%) showed a moderate reduction in scar volume or a recurrence, defined as a 0% to 50% reduction in scar volume. The mean (SD) Vancouver scar scale score was significantly reduced in 25 scars (71.4% reduction from 7 [1.5] before treatment vs 5 [2.9] after treatment; P < .001).
Discussion
Multiple therapeutic combinations are described for the management of keloid scars, but no reference standard currently exists. This cohort study presents results of shaving and contact cryosurgery in a patient population including a range of Fitzpatrick skin types, with scars in various locations during a 12-month follow-up.
In this study, 71% of the scars treated decreased in volume by at least 50% compared with their initial volume. These results are consistent with Litrowski et al,2 who used several contact cryosurgery sessions and with Azzam and Omar,5 who used surgical excision followed by contact cryosurgery and injection of platelet-rich plasma, combined with a corticosteroid injection in case of early recurrence to obtain major and substantial improvement, with the same follow-up.
The recurrence rate in this study of 20% was lower than other published studies with the same follow-up.2,5,6 Study limitations include a single-center location with observational and uncontrolled conditions. In addition, the 12-month follow-up could underestimate the recurrence rate.
Conclusions
Results of this cohort study suggest that shaving and contact cryosurgery may be a technique with utility in decreasing keloid scar volume.
eMethods
References
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Associated Data
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Supplementary Materials
eMethods
