A Novel Treatment for Keloid Scars

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Intralesional Cryosurgery: A Novel Treatment for Keloid Scars Intralesional cryosurgery appears to allow for focused destruction of keloid scar tissue with minimal damage to the surface of the skin.

By Adam Luber, BA and Gary Goldenberg, MD

eloid scars—fibrous overgrowths that occur in sites of previous skin injury—are composed of excess collagen and often extend beyond the borders of the original wound (Figure 1). Keloids often develop soon after inju- Kry but can also occur up to several years following the initial traumatic insult. Common causes include surgical procedures, piercings, vaccinations, lacerations, and burn injuries.1 There is potential for all individuals (except albinos) to develop keloid scars; however, the greatest incidence is seen in patients of darker skin color. Keloids are most common in the second to third decades of life, and susceptibility decreases with age.2,3 Lesions are firm, pink to purple, and mildly tender. The most common anatomic sites to develop keloid scars include the anterior chest, shoulders, ear lobes, cheeks, and skin overlying joints. After development, keloid lesions con- tinue to persist without spontaneous regression and have Figure 1. Keloid with hypereosinophilic, thickened collagen no malignant potential. Patients often complain of itchiness, bundles in the dermis (4X). pain, and abnormal sensitivity to touch. These symptoms, along with the contractures created from excessive scar for- Current Therapies mation, can be extremely uncomfortable for patients.2,3 While multiple treatment modalities exist for treating keloid The cause of keloid scar development is multifactorial, scars, no single method is proven to be widely effective. with a strong genetic component. Uncontrolled scar forma- Steroid injections directly into keloids (intralesional) are the tion is due to aberrant wound healing following any injury mainstay treatment method and are usually well tolerated to the deep dermis. Normal wound healing depends on the by patients; however, approximately 50 percent of lesions fine balance between extracellular matrix deposition and recur after treatment.1,4 Alternatively, contact cryosurgery degradation. However, in keloid scars, there is overexpres- using liquid nitrogen to “freeze” the lesion is moderately sion of specific growth factors and inflammatory molecules effective, but patients may require up to 20 treatments.5-9 that stimulate fibroblasts to increase collagen synthesis.1-3 Often, these two methods (contact cryosurgery and intrale-

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month, the wound is healed with a flat, slightly thinned scar. Since the surface of the skin is mostly spared from the intralesional cryosurgery technique, there are minimal cosmetic side effects (Figure 2).9,12 Several studies9,13-16 have examined the safety and efficacy of intralesional cryosurgery for treating keloid scars. There is

Photos courtesy of Z. Paul Lorenc, M.D a significant reduction in objective parameters, such as scar volume, deformity, hardness, and redness. Microscopically, the scar architecture is transformed into a more organized arrangement.9 Notably, this treatment also decreases subjec- tive concerns including tenderness, itching, and aesthetic discomfort.14 Patients experience better results and shorter healing time compared to the contact cryosurgery technique.11

Conclusion The treatment of keloid scars continues to be a challenging clinical scenario. Intralesional cryosurgery is shown to reduce the size of keloid scars and eliminate the symptoms associat- Figure 2. Baseline keloid on chest (A); S/P 2 treatments with ed with abnormal scar formation. Intralesional cryosurgery is CryoShape 18 months later (B); Baseline keloid behind ear (C); S/P a novel, safe, and highly efficacious technique recommended 1 treatment with CryoShape 24 months later (D). for clinicians and patients striving to minimize both the appearance and discomfort of these physically and psycho- sional steroid injections) are used in combination to achieve logically damaging lesions. n better results.10 Surgically revising the scar is typically unsuccessful, with The authors have no relevant disclosures. recurrence rates between 45 to 100 percent.1 Laser and Adam Luber, BA is a Clinical Research Fellow at the Mount radiotherapy can be used with variable efficacy, in addition Sinai School of Medicine Department of Dermatology. to injections with 5-fluorouracil (5-FU) or interferon-alfa-2b. Gary Goldenberg, MD is an Assistant Professor Other minimally invasive regimens with mediocre results of Dermatology and Pathology at the Mount Sinai include silicone gel sheets, silicone occlusive dressings, and School of Medicine Departments of Dermatology pressure devices.4 and Pathology.

Har-Shai Y, Mettanes I, Zilberstein Y, et al. Keloid histopathology after intralesional cryosurgery treatment. J Eur Acad Intralesional Cryosurgery Dermatol Venereol. 2011;25(9):1027–1036. as a Novel Treatment Gauglitz GG, Korting HC, Pavicic T, et al. Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. Mol Med. 2011;17(1-2):113–125. Intralesional cryosurgery, introduced in the early 1990s, is Thomas DW, Hopkinson I, Harding KG, Shepherd JP. The pathogenesis of hypertrophic/keloid scarring. Int J Oral Maxillofac Surg. 1994;23(4):232–236. a treatment that allows for a focused destruction of keloid Berman B, Zell D, Romagosa R. Keloid scarring. In: Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I, eds. Treatment of scar tissue with minimal damage to the surface of the skin.11 Skin Disease Comprehensive Therapeutic Strategies. 2nd ed. Philadelphia, PA: Elsevier Limited; 2006:314–317. Mende B. Treatment of keloids by cryotherapy. Z. Hautkr. 1987;62(18):1348, 1351–1352, 1355. Most recently, a uniquely designed needle probe has been Zouboulis CC, Blume U, Büttner P, Orfanos CE. Outcomes of cryosurgery in keloids and hypertrophic scars: A prospective developed (CryoShape®).9 After proper local anesthesia consecutive trial of case series. Arch Dermatol. 1993;129(9):1146–1151. Rusciani L, Paradisi A, Alfano C, et al. Cryotherapy in the treatment of keloids. J Drugs Dermatol. 2006;5(7):591–595. is achieved, the probe is inserted into keloid scars and Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol Surg Oncol. 1993;19(6):529–534. Har-Shai Y, Amar M, Sabo E. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. Plast attached to a liquid nitrogen source (a cryogun). As liquid Reconstr Surg. 2003;111(6):1841–1852. nitrogen passes through the needle, a lethal zone (<22°C) is Lawrence WT. In search of the optimal treatment of keloids: report of a series and a review of the literature. Ann Plast Surg. 1991;27(2):164–178. created around the inserted probe which is situated deep Weshahy AH. Intralesional cryosurgery. A new technique using cryoneedles. J Dermatol Surg Oncol. 1993;19(2):123–126. Har-Shai Y, Dujovny E, Rohde E, Zouboulis CC. Effect of skin surface temperature on skin pigmentation during contact and in the scar tissue, thereby directly destroying the cells that intralesional cryosurgery of keloids. J Eur Acad Dermatol Venereol. 2007;21(2):191–198. produce keloids.12 This is in contrast to traditional contact Har-Shai Y, Brown W, Pallua N, Zouboulis CC. Intralesional cryosurgery for the treatment of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;126(5):1798–1800. cryosurgery, which forms a lethal zone on the surface of the Har-Shai Y, Brown W, Labbé D, et al. Intralesional cryosurgery for the treatment of hypertrophic scars and keloids follow- skin, often leading to blistering, loss of pigmentation, and ing aesthetic surgery: the results of a prospective observational study. Int J Low Extrem Wounds. 2008;7(3):169–175. Har-Shai Y, Sabo E, Rohde E, et al. Intralesional cryosurgery enhances the involution of recalcitrant auricular keloids: a new 7,9 inadequate penetration to the deeper tissue structures. clinical approach supported by experimental studies. Wound Repair Regen. 2006;14(1):18–27. Mirmovich O, Gil T, Goldin I, et al. Pain evaluation and control during and following the treatment of hypertrophic Immediately after treatment, patients experience redness, scars and keloids by contact and intralesional cryosurgery--a preliminary study. J Eur Acad Dermatol Venereol. swelling, and blister formation. After approximately one 2012;26(4):440–447.

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