Dr. Jones and colleagues recently used advanced genetic sequencing technology to profile the genomes of six keloids and six normal skin samples; that profiling revealed 152 keloid specific genes. Those genes were uploaded into Ingenuity Pathway Analysis software, which led to the discovery of 10 genes that are part of biological pathways known to be important to the process of keloid development. Dr. Jones presented his findings at the International Symposium of Facial Plastic Surgery in May 2014.
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September 2014“Some of the genes we identified are unique; they haven’t yet been reported in keloids,” Dr. Jones said. “This research allows us to look at the genes identified in this study in a different light and from the standpoint of their biological significance. These genes are part of pathways, and we can study them at different points along the pathways to identify opportunities to intervene therapeutically.”
What is exciting about studying keloids is that if we understand what’s going on in keloids, we can exploit that knowledge for other uses in facial plastics.—Lamont R. Jones, MD
Current Treatment
Fortunately, many of the most common facial plastic surgery procedures are unlikely to result in keloid formation. “The places that keloids are most likely to occur are the earlobes, the shoulders, the sternum, the preauricular areas, and the neck. Within the head and neck region, the earlobes and neck are the two most common areas of keloid scarring,” said Anthony Brissett, MD, associate professor of otolaryngology–head and neck surgery and director of the Baylor Facial Plastic Surgery Center in Houston, Texas.
The middle of the face is unlikely to develop keloids, so facial plastic surgeons can feel comfortable performing rhinoplasty and blepharoplasty, said Dr. Brissett. Procedures such as otoplasty and rhytidectomy are more likely to result in keloids in at-risk patients, due to the locations of incisions.
Of course, many patients seek assistance for keloids that developed as a result of previous procedures, such as ear piercing. The most common treatments for keloids include silicone gel sheeting, intralesional corticosteroid injections, laser and light-based therapy, cryotherapy (both topical and intralesional), radiotherapy, fluorouracil (5-FU), interferon, bleomycin, imiquimod 5% cream, botulinum toxin A, and surgical excision, but none of these treatments have been found to be universally useful or effective (Burns [published online ahead of print April 22, 2014]. doi:10.1016/j.burns.2014.02.011). As a result, physicians often combine treatments for the most effective results.
According to a 2014 review, combining intralesional corticosteroid injection, a common first-line treatment, with surgery, pulsed-dye laser treatment, 5-flurouracil, and silicone gel sheeting may be a more effective first-line treatment than corticosteroid injection alone, which carries a high risk of recurrence. Keloids that don’t respond to that regimen can be treated with cryotherapy or irradiation via brachytherapy and electron beam radiation (Burns [published online ahead of print April 22, 2014]. doi:10.1016/j.burns.2014.02.011).
Recent Advances
A 2012 study of three patients suggests combining silicone gel sheeting with negative pressure. The small study examined the use of an all-in-one negative pressure/silicone dressing device; patients used the device for one month, and two patients demonstrated an improvement in keloid appearance, itching, and thickness at one month, with further improvement in thickness two months after the discontinuation of treatment. The third patient, a juvenile, dropped out of the study after one week. (Int Wound J. 2013;10:340-344).