CASE SERIES Year : 2022  |  Volume : 28  |  Issue : 4  |  Page : 314-316

Pre- and postoperative treatment of keloid pinna with triamcinolone injection: Our experience

D Anand Karthikeyan, Poornima Kumar
Department of Otorhinolaryngology, Tagore Medical College and Hospital, Rattinamangalam, Tamil Nadu, India

Date of Submission05-Jun-2022Date of Acceptance11-Aug-2022Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. D Anand Karthikeyan
Department of Otorhinolaryngology, Tagore Medical College and Hospital, Rattinamangalam, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/indianjotol.indianjotol_90_22

Introduction: Keloid is a pathological cutaneous dermal lesion resulting from aberrant wound-healing process. It mainly arises in the chest, upper back, earlobes, and shoulder region. Keloid pinna is common diagnosis in the ear, nose, and throat, for which various treatment options are available. We describe our experience with pre- and postoperative injections with triamcinolone. Materials and Methods: This is a retrospective observational study from December 2020 to April 2022. A total of 16 cases (14 females and two males) were included in the study. Triamcinolone acetonide (TAC) (40 mg/mL) was injected both preoperatively and postoperatively following surgical excision. Results: The triamcinolone injections resulted in drastic size reduction of the keloids and made the keloids softer in consistency. The main benefit of the triamcinolone injection was the soft-tissue margin reclamation making surgical excision easy. Discussion: The main advantage of preoperative intralesional TAC is size reduction, reduced vascularity and scar pliability, and better soft-tissue margin reclamation which helps in getting better operative margins for surgical excision leading to better cosmetic results. Conclusion: TAC injection perilesional in keloid pinna preoperatively improves the surgical outcomes and postoperative injection reduces the recurrence rates considerably.

Keywords: Keloid, operative margins, pinna, preoperative, recurrence, size, triamcinolone

How to cite this article:
Karthikeyan D A, Kumar P. Pre- and postoperative treatment of keloid pinna with triamcinolone injection: Our experience. Indian J Otol 2022;28:314-6
  Introduction 

The term keloid is derived from the Greek word “chele” which means crab claw.[3] It is a pathological cutaneous dermal lesion resulting from uncontrolled deposition of collagen and glycosaminoglycan around the wound[4] and affects 10%–15% of all wounds.[1] Keloids can affect any part of the body, common sites being the chest, shoulder, earlobes, and upper back.[4] The younger age group and dark skin color are the main risk factors for the development of keloid. Any kind of trauma reaching the reticular dermis is considered the main inciting factor for keloid formation.[1] Various theories have been postulated describing the origin and formation of keloid. The pathogenesis of keloid scar is complex and various genetic and environmental factors play a vital role. The larger lesions may lead to cosmetic disfigurement, and functional impairment and affects the quality of life.

Aberrant wound-healing process can lead to the formation of hypertrophic scar and keloid with main differentiating features being extended beyond the original margins, recurrence, and no spontaneous resolution which are seen in keloids.

Various theories have been postulated describing the origin of keloid but the pathophysiology is still not fully understood. The most important factor is imbalance between the extracellular matrix deposition and degradation seen during wound healing in the remodeling phase.[2] Alteration in fibroblast phenotype plays a pivotal role in the formation of keloid, with keloid fibroblasts showing increased numbers of growth factor receptors and responding more briskly to growth factors such as transforming growth factor-beta. Cytokines such as interleukin (IL)-6, IL-13, and tumor necrosis factor, vascular endothelial growth factor are found to be elevated in keloids.[3] Other postulated theories are genetic immune dysfunction, mechanical tension, increased hyaluronic acid production, sebum reaction, tissue hypoxia, and abnormal epithelial–mesenchymal interaction.[2]

A wide variety of treatment modalities is being used in treating keloids with intradermal corticosteroid injections being the most common. Other modalities are surgical removal of keloid, use of verapamil, 5-FU, silicone gel, cryotherapy, etc.

At present, there is no consensus on the effectiveness of different treatment modalities. Through this article, we will like to emphasize on effectiveness of steroid therapy when used in the perioperative period in combination with surgical excision.

  Materials and Methods 

Pinna serves not only the function of hearing but also for ornamental purposes. In many cultures and ethnicity, ear piercing is done at multiple sites. We come across many cases of keloid scar tissue formation in ear piercings, that too piercings through the cartilage along the helix. These patients did not have a history of keloid or excessive scar formation anywhere else in the body. As the literature says, we see a lot of dark-skinned people with keloid in the pinna. At occasions, we have observed even males with keloid pinna; one such case after suturing the pinna laceration following trauma. In this study, we present our experience in management of keloid pinna.

We did retrospective observations on all the keloid pinna cases that came to our ear, nose, and throat outpatient department from December 2020 to April 2022. We saw a total of 16 cases out of which 14 were females and two were males. As per our departmental protocol, the keloid tissue would be injected with triamcinolone acetonide (TAC) at 40 mg/mL both preoperatively and postoperatively following surgical excision. The infiltration was done perilesionally very close to the keloid. Injections were repeated once per week for a minimum of 3 weeks to a maximum of 6 weeks (duration depended on keloid size and operating margin) and they underwent surgery afterward. We used a tuberculin syringe and undiluted triamcinolone (40 mg/mL). Around 0.2–0.7 mL was used. The exact volume of the drug infiltrated depended on the keloid size. After suture removal, the injections were continued weekly once for three more weeks to prevent recurrence. Twelve patients were followed till 4 weeks postoperative and three patients came for follow-up till the 3rd month postoperative.

  Results 

Only one patient who did not follow-up for postsurgery injections had a recurrence after 3 months. Others did not review with recurrence. One patient needed urgent intervention after a 3rd-week injection as the skin became gangrenous but fared the postoperative period well. The triamcinolone injections resulted in drastic size reduction of the keloids and made the keloids softer in consistency. However, the main benefit from the triamcinolone injection was the soft-tissue margin reclamation. Many keloids were broadly adherent to the helix and its cartilage so excision of keloid meant excising a part of helix cartilage leaving a defect with the inability to primarily repair the wound margins. Triamcinolone injections helped us to reclaim a margin of soft tissue near its attachment which enabled us to easily close the wound margins without tension.

  Discussion 

Keloids are pathological scars which result from cutaneous injury in which tissue grows above and beyond the inciting insult. These are cosmetically as well as symptomatically distressing for the patients impairing their quality of life. A wide array of treatment modalities is available for the treatment of keloid ranging from the use of steroids, chemotherapeutic agents such as bleomycin, verapamil, hyaluronic acid, botulinum toxin, laser, and cryotherapy. There is no consensus for the treatment of choice and it depends on various factors such as doctor's preference, geographically as the steroid-impregnated tape is the first-line treatment for keloids in Japan, whereas steroid injections are the treatment of choice in the USA.[5] Surgical manipulation as initial treatment is not the best option due to high recurrence rates.[4]

According to the review of the literature performed by Khansa et al., treatment modalities such as silicone gel, pulsed-dye laser, TAC, and 5FU showed higher efficacy as compared to onion extract and fat grafting.[7] Wong et al. conducted a systematic review and meta-analysis to further compare the effectiveness of TAC with different treatment regimens. According to their review, TAC treatment resulted in marked reduction in size of keloid as compared to untreated controls and TAC was more effective than silicone gel, verapamil, and cryotherapy in improving the scar while 5FU showed significant improvement in scar in comparison to TAC. However, 5FU has limitations in keloid treatment as injection site pain, ulceration, cautious use in pregnancy, lactation, intercurrent infection, and bone marrow depression. Verapamil is a calcium channel blocker which induces procollagenase production leading to reduction in collagen in scar fibroblasts. It is usually used in burn scars. According to Lawrence who first used verapamil as treatment modality for ear keloids, 52% success rate was thereafter injection at 7–14 days postremoval. When compared with TAC, TAC was found superior in the reduction of scar pliability and scar vascularity with no statistical difference in pigmentation and height.

According to our study, the combination of preoperative steroids with surgical excision followed by postoperative steroid injections at suture line provide superior results cosmetically and less recurrence rates in the postoperative period. The main advantage of preoperative intralesional TAC being size reduction, reduced vascularity and scar pliability, and better soft-tissue margin reclamation which helps in getting better operative margins for surgical excision leading to better cosmetic results.

A study done by Jung et al. reported similar findings as observed by us with a recurrence rate of 16.6% on a combination of perioperative steroids with surgical excision.[6]

  Conclusion 

TAC injection perilesionally in keloid pinna preoperatively improves the surgical outcomes and postoperative injection reduces the recurrence considerably matching the previous international literature. However, this being a retrospective observational study with small samples, we need further prospective controlled trials to support this evidence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Chua SC, Gidaszewski B, Khajehei M. Efficacy of surgical excision and sub-dermal injection of triamcinolone acetonide for treatment of keloid scars after caesarean section: A single blind randomised controlled trial protocol. Trials 2019;20:363.  
    2.Morelli Coppola M, Salzillo R, Segreto F, Persichetti P. Triamcinolone acetonide intralesional injection for the treatment of keloid scars: Patient selection and perspectives. Clin Cosmet Investig Dermatol 2018;11:387-96.  
    3.Hunasgi S, Koneru A, Vanishree M, Shamala R. Keloid: A case report and review of pathophysiology and differences between keloid and hypertrophic scars. J Oral Maxillofac Pathol 2013;17:116-20.  
[PUBMED]  [Full text]  4.Wong TS, Li JZ, Chen S, Chan JY, Gao W. The efficacy of triamcinolone acetonide in keloid treatment: A systematic review and meta-analysis. Front Med (Lausanne) 2016;3:71.  
    5.Limmer EE, Glass DA 2nd. A review of current keloid management: Mainstay monotherapies and emerging approaches. Dermatol Ther (Heidelb) 2020;10:931-48.  
    6.Jung JY, Roh MR, Kwon YS, Chung KY. Surgery and perioperative intralesional corticosteroid injection for treating earlobe keloids: A korean experience. Ann Dermatol 2009;21:221-5.  
    7.Khansa I, Harrison B, Janis JE. Evidence-based scar management: How to improve results with technique and technology. Plast Reconstr Surg 2016;138:165S-178S.