Re-thinking the medical management of keloids: Reflections and experiences from a busy urban clinical practice in Kingston, Jamaica.

Dr. Patricia Yap B.Sc. MB.BS. Dip. Derm.¹, Dr. Jonathan Ho MB.BS., Dr.Sc. Dip. Dermpath², and Prof. Kevin A, Fenton MB.BS. (Hons) M.Sc. Ph.D. FFPH³

1. Consultant Dermatologist, Apex Skin and Laser center, Kingston, Jamaica

2. Consultant Dermatologist and Dermo-Pathologist, University of the West Indies, Mona, Jamaica

3. Honorary Professor of Epidemiology and Public Health, University College London, London UK

Corresponding Author: Dr Patricia Yap. Email: patyapja@gmail.com

Introduction

Keloids are nodular, firm, tender, movable, non-encapsulated masses of hyperplastic scar tissue, occurring in the dermis and adjacent subcutaneous tissue, usually after trauma, surgery, burns, or severe cutaneous disease such as cystic acne. Traditional treatments have largely relied on combinations of surgery, radiotherapy, chemotherapy and cryotherapy, in part reflecting the historic view of keloids as benign tumours. These treatments have relatively poor outcomes, often complicated by keloid regrowth after repeated attempts at removal. Medical management of keloids remains underutilized, so too has the use of medical treatments to prevent recurrence.

This presentation reviews the experiences of three patients that benefitted from medical treatment of confirmed keloids, all managed by Dr. Patricia Yap in her clinical practice in Kingston Jamaica.  We introduce the application and results of a novel topical treatment option which demonstrates objective improvements in clinical outcomes (reductions in the size, appearance and recurrence of keloids) with enhanced patient satisfaction.

Background

In 2002, a middle-aged female patient attended Dr. Yap’s practice for a consultation regarding multiple keloids on her back. At this time, the typical treatment would have been the painful, uncomfortable intralesional steroid treatment. Each and every keloid would have had to be injected, therefore, the volume of Triamcinolone Acetonide (TA) solution would result in systemic side effects. The patient suggested that there should be a cream (topical treatment). With this suggestion, Dr. Yap who has a first degree in chemistry, created a unique delivery system that allowed the introduction of the steroid into the dermis topically.

On commencing treatment, the decision was taken to not to use intralesional steroids on the entire back as it would have incurred side effects. Consequently, a half back approach to application was implemented.

On the left of the patient’s back, intralesional steroids along with topical therapy was used, whereas on the right side, only the topical therapy was used. The keloids on both sides decreased in thickness, even though the left side progressed much faster. The patient experienced little-to-no systematic side effects and the outcomes (Figure 1.) were satisfactory for the patient with significant reduction in reported pain, itchiness, and growth. 

Figure 1. Before and after images of Patient A. Female. Kingston, Jamaica

BEFORE TREATMENT Month 0	AFTER TREATMENT Month 3

Treatment applied: Left Back – Intralesional and Topical Therapy. Right Back – Topical Therapy only

Following this initial positive response, Dr Yap has refined and expanded the application of topical treatment for patients with keloids over the past seventeen years. The following case studies present 3 cases which demonstrate the success of topical treatments alongside or instead of intralesional injections.

Case Studies

In the three cases below and pictures that follow, it is evident that using a novel topical treatment option is beneficial to the patient. This not only gives control back to the patient but also results in decreasing the burden in the healthcare system.

Case 1: Combination therapy using topical and standard intralesional steroids.

Male, 35 years old, presented with extensive folliculitis keloidalis on the scalp involving the crown and the back of the head.  

The patient was diagnosed with both folliculitis keloidalis on the crown of the head and folliculitis keoidalis nuchae at the back of the head (occipital area). For the former, the patient was  applied the topical treatment only for one month.  The folliculitis keloidalis of the crown resolved completely after this period (see Figure 2a).

For management of the folliculitis keloidalis nuchae, the patient was prescribed both intralesional and topical treatments.  The intralesional steroid was given at the end of the first and second months of treatment to the folliculitis keloidalis nuchae. The third month only topical treatment was used. The resolution over the 3 month period is shown in Figure 2b.

Figure 2a. Before and after images of Case 1. Male. Aged 35. Kingston, Jamaica

BEFORE TREATMENT Month 0	AFTER TREATMENT Month 1

Diagnosis: Folliculitis keloidalis. Treatment applied: Topical therapy for 1 month only

Figure 2b. Before and after images of Case 1. Male. Aged 35. Kingston, Jamaica

BEFORE TREATMENT Month 0	AFTER TREATMENT Month 3

Diagnosis: Folliculitis keloidalis nuchae. Treatment applied: Topical therapy for 3 months, supported by intralesional steroids at the end of Months 1 and 2.

Case 2: Topical treatment post-surgical keloid scars

Female, 32 years old, with past history of keloids on chest and shoulder from minor injuries.

After having developed keloid scars after her first cesarean section, the patient requested post-op treatment for her second cesarean section to prevent keloid recurrence.  At two weeks post-op care, the patient’s keloid already started to develop, shown on the right. The topical treatment was then applied for two weeks which resulted in 100% flattening.

Treatment applied: Topical therapy only

Figure 3. Before and after images of Case 2. Female. Aged 32 years. Kingston, Jamaica

BEFORE TREATMENT Week 1	AFTER TREATMENT Week 2

 

Case 3: Topical treatment monotherapy

Female, 67 years old, referred from a general practitioner with chronic itching and spontaneous keloid formation on chest for the past nine years. 

This patient developed multiple keloids on her chest from scratching. The increased irritation caused loss of sleep and general discomfort. After one month of receiving the novel topical treatment, the patient was no longer uncomfortable and the keloids were flattened.

Figure 4. Before and after images of Case 3. Female. Aged 67. Kingston, Jamaica

BEFORE TREATMENT Month 0	AFTER TREATMENT Month 1

Treatment applied: Topical therapy only

Conclusions

These three cases are illustrative of the very positive treatment outcomes for keloids being achieved with medical treatment (topical applications) in Dr. Yap’s clinical practice for the past seventeen years. Unfortunately, when the patients are satisfied with the outcome, whether due to the decrease in pain, itchiness and size they often do not return to the clinic for the final picture. Further, more robust clinical studies are now planned to systematically study and document patient outcomes and improvements in patient experience.

However, from these documented case studies and clinical experience, it is evident that self-applied therapeutics can minimize healthcare burden by promoting self-treatment rather than intensive in-office treatment. The ability to self-manage with topical preparations also encourages early treatment to prevent future recurrence of keloids. They may therefore form the basis for effective first-line therapy for the medical treatment of keloids.

Please open the pdf file below

https://majdoctors.com/wp-content/uploads/2019/01/Dengue-Guidelines.pdf

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Statement from the Medical Association of Jamaica (Oct 2017) on the HPV Vaccine

Dr. Clive Lai

Cervical cancer is the 7^th commonest cancer in the world and the 4^th commonest in Jamaica.  Every year 528,000 (392 in Jamaica) new cases are diagnosed and there are approximately 270,000 deaths (185 in Jamaica). By 2050, without any intervention, cases diagnosed with cervical cancer will increase to one million per year with approximately 90% of the deaths being in developing countries. In Jamaica, cervical cancer is the second commonest cancer among our female population after breast cancer, and accounts for 63% of cancers of the female reproductive tract.  The incidence is about 25/100,000 and accounts for 15% of all female cancer deaths.

The central cause of cervical cancer is the Human Papilloma Virus (HPV), which is found in 90% of all cases.  The HPV is the most common Sexually Transmitted Disease (6 M new cases each year) and most men and women who have been or are sexually active have been exposed to HPV.  More than 75% of sexually active women tested, have been exposed to HPV by age 18-22 and 15% show evidence of current infection

The human papillomavirus (HPV) infects the cells and transforms normal cells on the cervix to cancer. It is a slow process which can take a few years (10-15) to develop. Only women with persistent HPV (sub-types 16 & 18) are at risk for cervical cancer.

Research, studies and trials have been done over the years, resulting in the formulation of a safe vaccine, which has yielded good results in other countries.  The vaccine is not new to Jamaica, as it is currently being used in some institutions and in private practice.

The Medical Association of Jamaica therefore supports the Ministry of Health in its drive to protect the country’s women from cervical cancer by making the bivalent HPV vaccine (for 16 & 18)  available to the public sector.  Jamaica has been a leader in the elimination of vaccine preventable diseases such as polio, measles and congenital rubella syndrome. With regards to cervical cancer, a vaccine preventable disease, the bivalent HPV vaccine, if administered to girls ages 9 to 14 years, will drastically reduce the risk of cervical cancer. However, this does not mean that as they get older that they should stop doing their regular screening tests like pap smears.  The HPV vaccine is safe and the MAJ is encouraging parents to get their daughters vaccinated, as it will have a significant public health impact by decreasing the incidence of cervical cancer.

The MAJ fully endorses the implementation of this program and will continue to work with the Ministry of Health in ensuring its success. However, every effort must be made to continue to educate and inform the public so that they can make an informed decision about the vaccine.

 

 Read more

http://www.jamaicaobserver.com/news/cancer-survivor-supports-ministry-s-hpv-vaccine-drive_148898?profile=1606

www.theguardian.com/science/blog/2016/jan/11/why-is-there-opposition-hpv-vaccine-cervical-cancer

www.cdc.gov/hpv/parents/vaccine.html

www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html

www.cdc.gov/std/hpv/stdfact-hpv-vaccine-young-women.htm

www.ncbi.nlm.nih.gov/pubmed/28596091

 

The Medical Association of Jamaica views with concern the statements made by the Minister of Heath Dr. The Hon. Christopher Tufton and the President of the Nurses Association of Jamaica Mrs. Carmen Johnson on the Special Feature entitled “Prescriptive Rights” aired on the TVJ Prime Time News on Wednesday 4^th July 2018.

The Minister stated that changes to the Nursing and Midwifery Act to allow prescriptive rights for Nurse Practitioners have been accepted.  Accepted by whom?  It was the Medical Council of Jamaica along with the Medical Association of Jamaica under the Medical Act, who approved the implementation of the Nurse Practitioner Program in the late 1970’s.  This was done because there was an acute shortage of doctors at the time due to migration and there was a move towards Primary Health Care with the staffing of 345 Health centers.  It was also agreed that this would be a temporary measure until more doctors were available and the policy was made very clear to the Nurses Association of Jamaica at the time, that prescriptive rights could never be given to nurses because they had not fulfilled the formal medical training to have competences necessary to practice as doctors.  However, we would like to commend the nurse practitioners who filled the gap and thank them for working in collaboration and under supervision by a medical doctor. The Minister also alluded that the change will happen before we even know it, but the Medical Association of Jamaica will be vigilant and active to ensure that this does not happen.

Fast forward forty years later and our medical school is now graduating over 300 doctors annually, some of whom cannot get a job with Government after internship.  In addition, technology has vastly improved over the years with smartphones, computers and internet services.  This would make it easier for the nurse practitioners to contact the doctors and discuss a case with them.  Prescriptions can now be countersigned online.

In this modern era, all doctors and nurses are required to continue ongoing training through continuing medical education or by attending conferences and workshops.  The President of the Nurses Association of Jamaica stated that the Nurse Practitioners do not require further training to be given prescriptive rights, which is contrary to modern day medical practice.  We are very concerned about this statement as it places the patient’s safety at risk.  The time has come to reduce the number of Nurse Practitioners being trained and to focus more on training more Critical Care nurses.

 

Sincerely,

………………………………….
Dr. Clive Lai
PRESIDENT

The Medical Association of Jamaica has taken serious note of our Minister of Justice’s announcement of the
decriminalization of ganja in Jamaica as reported in the media June 12th 2014.
Any future use of medical ganja in Jamaica must be supported by scientific evidence that has been rigorously tested locally and internationally and not emotions.
Undoubtedly, additional investment in medical research is necessary. Jamaica could benefit from the potential profits to be earned both here and overseas from a well conceived and efficient industry. The development of prescription medications such as Canasol and Asmasol by Dr. Albert Lockhart and Professor Manley West demonstrates that this can successfully be accomplished in Jamaica under the existing laws and regulations.
As Physicians we have been confronted first hand with and seen the devastating effects of the misuse of Ganja. The adverse effects of marijuana, include, but are not limited to: addiction, psychiatric disorders, and disruption of neurological development (especially in adolescents). Negative impact on all aspects of memory is also closely associated with ganja use. The ability of cannabis to negatively impact reaction time and perception plays a major role in “drugged driving” often resulting in road traffic or workplace accidents
after cannabis use. We have already seen a significant number of road fatalities in Jamaica. Cannabis withdrawal symptoms can also result in violence. Jamaica already suffers from a high violent crime rate. Many of those who smoke it are at higher risk of developing lung problems including cancer than non-smokers.
Non-communicable diseases (hypertension, diabetes, cancer, psychosis etc.) already cost our health sector billions of dollars,   approximately 30% of which is attributable to Neuro-psychiatric disorders such as depression and addiction. (WHO) The medical evidence against the social/recreational use of ganja; smoked or otherwise, is well established. Vulnerable groups like our teenagers and young person’s especially, are the most likely to pay with their health for the changes that are proposed.
Alcohol and tobacco use although legal, also cause terrible effects on the health of the user, which we are  already struggling to manage. The popularity of decisions made in other jurisdictions on this topic must be carefully studied but not necessarily followed. Our public health sector is already overburdened and underfunded. The prevention of a public health problem should be the clear focus of the Government. While we are not qualified to comment on the legal arguments around this issue, the MAJ is eminently qualified to declare that the decriminalization of ganja for personal use will cause more mental and physical health problems for Jamaicans, especially our youth.
Medical ganja development and its potential use must be pursued in a responsible, regulated and well thought out manner. It is our hope that Cabinet will reconsider its position in line with health practice and science. The issue of human rights is secondary to the right to protect life.
Dr. Shane Alexis
MAJ President

The Medical Association of Jamaica (MAJ) strongly condemns acts of violence against any citizen. Today we are all deeply saddened that a bright young colleague of ours is battling for her life in hospital.

The doctor was viciously attacked by gunmen outside her home on Friday night (May 2nd 2014).  As a member of a Profession that is dedicated to preserving and saving lives this attack has devastated many of our members.
We encourage anyone who may have information on the perpetrator(s) to share what they know with the Police so that justice may be served.
Jamaica must not continue to go down this violent path.
The MAJ wishes to thank ALL members of staff at the Cornwall Regional Hospital for their selfless hard work in attending to our friend and colleague.

Our prayers and support are with her and her family during this difficult time.
Dr Shane Alexis
PRESIDENT

Symptoms and signs

•  The majority of individuals bitten by a mosquito infected with chikungunya virus (CHIKV) will present with symptomatic disease after an incubation period of 3 to 7 days (range 1 to12 days).
• Patients usually present with abrupt onset of fever typically greater than 102°F (39°C) and severe polyarthralgia.
• Other signs and symptoms may include headache, diffuse back pain, myalgias, polyarthritis, rash, conjunctivitis, nausea and vomiting.

Physical examination

•  Fever can be continuous or intermittent, and occasionally may be associated with relative bradycardia.
• Joint symptoms are usually symmetric and most commonly occur in hands and feet but they can affect more proximal joints. Swelling can also be seen and is often associated with tenosynovitis. Patients are often severely incapacitated due to pain, tenderness, swelling and stiffness.
•  Rash usually occurs 2 to 5 days after onset of fever in approximately half of all patients. It is typically maculopapular, involving the trunk and extremities, but can also include palms, soles, and face. The rash can also present as a diffuse erythema that blanches with pressure. In infants, vesiculobullous lesions are often the most common skin manifestation.

Clinical course

• CHIKV can cause acute, subacute and chronic disease.
• Acute symptoms typically resolve within 7–10 days.
• Some patients might have relapse of rheumatologic symptoms 2 to 3 months after acute illness, including distal polyarthritis, exacerbation of pain in previously injured joints and bones and subacute hypertrophic tenosynovitis in wrists and ankles.
• Chronic diseases is defined by symptoms that persist for more than 3 months.
• Maternal-fetal transmission is possible among pregnant women with the highest risk for severe infection in the neonates during the intrapartum period.
• Persons at risk for severe disease include neonates exposed during the intrapartum period, older adults (e.g., > 65 years) and persons with underlying medical conditions (e.g., hypertension, diabetes, or cardiovascular disease)
•  Recovery from chikungunya infection usually results in lifelong immunity
• Chikungunya is rarely fatal

DIFFERENTIAL DIAGNOSIS

 

•  In the Caribbean, Chikungunya (CHIK) must be differentiated from dengue fever, which has the potential for much worse outcomes including death:
  •  Especially useful in establishing the differential diagnosis are that with CHIK the onset is more acute, the duration of fever much shorter, the maculopapular rash more frequent, and the pain much more pronounced and localized to joints and tendons, in comparison to dengue fever.
  •  Shock or severe hemorrhage are very rarely observed in CHIK, whereas dengue virus infection is more likely to cause neutropenia, thrombocytopenia, hemorrhage, shock and death.
  •  Co-infection with dengue virus and CHIKV has been documented.
•  Other diseases that may be confused with CHIK include leptospirosis, malaria, rubella, and infections with group A streptococcus, enteroviruses and adenoviruses.

DIAGNOSTIC TESTS

•  Chikungunya virus can be identified using RT-PCR or viral isolation during the first week of illness.  Serological diagnosis can be performed by detection of specific IgM antibodies in serum specimen from day 4–5 after the onset of illness, or a four-fold rise of specific CHIKV IgG antibody titre on a pair of sera (acute and convalescent specimens). Specific IgM can persist for many months, in particular in patients with long-lasting arthralgia.

TREATMENT AND PREVENTION

•  There is no specific antiviral drug treatment for CHIK.
• Symptomatic treatment during acute disease comprises rest and oral fluids, acetaminophen or paracetamol, and ibuprofen, naproxen, or another non-steroidal anti-inflammatory agent (NSAID).
• In some chronic cases, recovery from CHIK can be prolonged (sometimes up to a year or even more) with persistent joint pain requiring pain management, including long-term anti- inflammatory therapy.
• To prevent the infection of others, acutely infected patients need to be protected from further mosquito exposure during the first week of illness.
  • Use of air conditioning or window/door screens
  •  Use of mosquito repellents on exposed skin
  • Wearing long-sleeved shirts and long pants
  •  Covering empty standing water from outdoor containers
•  Physicians and health care workers who visit CHIK- infected patients should take care to avoid being bitten by mosquitoes by using insect repellent and wearing long sleeves and pants.