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: firstname.lastname@example.org 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.