Comparison of the efficacy of intralesional bleomycin versus intralesional triamcinolone acetonide in the treatment of keloids

Keloid is characterized by benign overgrowth of dermal collagen in response to skin injury in genetically predisposed individuals. Intralesional triamcinolone and bleomycin have been used with varying success in the treatment of keloids. To compare the efficacy of intralesional triamcinolone versus intralesional bleomycin in the treatment keloids. A total of 164 patients were randomized into two of 82 each. Group A received intralesional bleomycine and Group B received intralesional triamcinolone. Patients were scored at baseline and at the end of treatment for therapeutic response based on reduction on patient and observer scar assessment scale (POSAS). Mean baseline POSAS score was 91 ± 10.98 SD check in Group A and 90 ± 10.85 SD in Group B. POSAS score after 24 weeks 26 SD ± 11.91 in Group and 34 ± 12.28 in Group B. This difference was statistically difference. Intralesional bleomycin is more efficacious than intralesional triamcinolone acetonide in the treatment of keloids.     

Combination treatment of CO2 fractional laser,pulsed dye laser,and triamcinolone acetonide injection for refractory keloid scars on the upper back

Abstract

Keloids and hypertrophic scars are common lesions, which typically present as a cosmetic concern; however, they also can cause significant pruritus and pain. These lesions pose as a particular therapeutic challenge among clinicians due to a lack of complete knowledge of the formation of keloids and hypertrophic scars. Multiple treatments are widely accepted, yet all have shown limited benefit. In this case, we describe the treatment combination of the Affirm CO₂ fractional laser (10 600 nm, Cynosure), Cynergy Pulsed dye laser (585 nm, Cynosure), and triamcinolone acetonide injection for keloids refractory to solitary treatments of triamcinolone acetonide injection and other laser modalities.     

Intralesional triamcinolone alone or in combination with botulinium toxin A is ineffective for the treatment of formed keloid scar: A double blind controlled pilot study

Cutaneous injury can ignite excessive fibroproliferative growth that results in keloid formation. Keloids are associated with significant morbidity related to disfigurement and/or symptoms (e.g., pain and pruritus). First‐line treatment of formed keloids involves topical or intralesional steroids. Recurrent or resistant keloids are managed by surgical excision or cryotherapy, followed by steroidal application or adjuvant irradiation. Although adjuvant irradiation appears to be most efficacious, alternative therapeutic options are needed for patients without access to radiation centers. Botulinum Toxin A (BTA) appears to have similar inhibitory effects to irradiation on the cell cycle via downregulation of pathogenic cytokines. Herein, we conducted a study to compare the efficacy of intralesional triamcinolone used alone, or in combination with BTA, in the treatment of formed keloid scars. Twenty patients with a cumulative of 40 keloids completed the study. There was no significant difference between treatment arms with respect to height vascularization, pliability, and pigmentation scores. The addition of BTA resulted in significant symptomatic improvement of pain and pruritus as compared to intralesional triamcinolone alone (p < 0.001). Irradiation is only effective when administered in the adjuvant setting where inhibitory effects on cell cycle and migration are optimized. Future studies with intralesional triamcinolone and BTA should be performed adjuvantly.     

Retrospective analysis of earlobe keloids treated with the carbon dioxide laser ablation or cold steel debulking surgery

Abstract

Background: Treatment of keloids is a therapeutic challenge. Objectives: To determine the outcome and the risk of recurrence after debulking cold steel surgery or carbon dioxide (CO₂) laser ablation of earlobe keloids. Material and methods: The case records of 16 patients with earlobe keloids managed at Changi General Hospital, Singapore, from 2003 to 2009 were reviewed retrospectively. Results: Fourteen patients were females, and the mean age at presentation was 20 years. Eight patients underwent CO₂ laser ablation, six patients underwent cold steel surgery, one patient underwent both surgery and CO₂ laser ablation, and one patient received only 40 mg/ml of intralesional triamcinolone acetonide. Fourteen patients were followed up for 1–24 months post procedure, and two patients defaulted. Both modalities were equally effective in debulking the earlobe keloids. All 13 patients who had either CO₂ laser ablation or cold steel surgery had recurrence of keloid growth at 2–18 weeks post procedure. The patient who received intralesional triamcinolone acetonide therapy alone had only partial response to the therapy. Conclusions: Both the CO₂ laser ablation and cold steel surgery were equally useful in reducing the size of the earlobe keloids, but were not effective in preventing regrowth of the keloids, even with adjunctive intralesional steroids. Patients should be clearly counselled regarding this.     

Treatment of keloids and hypertrophic scars with dermojet injections of bleomycin: a preliminary study

BACKGROUND: Numerous treatment modalities have been used to treat keloids and hypertrophic scars, but the optimal treatment has not been established. OBJECTIVE: The aim of this study was to determine the efficacy and safety of intralesional jet injection of bleomycin as therapy for keloids and hypertrophic scars that are unresponsive to intralesional steroid injection. METHODS: The study included 14 patients with 15 keloids or hypertrophic scars that had not responded to a minimum of three intralesional injections of triamcinolone acetonide. Multiple jet injections of 0.1 ml of bleomycin (1.5 IU/ml) were administered to each lesion, with injection sites spaced 0.5 mm apart. Injections were repeated each month. Scar height was measured, and scar pliability and erythema were scored at baseline and then monthly during the treatment and follow-up periods. Patients' self-assessments of subjective symptoms (pruritus and pain) were also scored. Clinical improvement was defined primarily on the basis of scar height reduction (percentage reduction from baseline), and was classified using the following scale: complete flattening (100%), highly significant flattening (> 90%), significant flattening (75-90%), moderate flattening (50-75%), and minimal flattening (< 50%). Pre- and post-treatment mean values for scar height, scar pliability, erythema, pruritus and pain were statistically compared. RESULTS: The number of sessions required to successfully treat the lesions ranged from two to six. Eleven lesions (73.3%) showed complete flattening, one (6.7%) showed highly significant flattening, two (13.3%) showed significant flattening, and one scar (6.7%) showed moderate flattening. The mean scar height was significantly lower, and the mean scores for scar pliability and erythema were significantly better at the end of treatment (P < 0.001, P < 0.001 and P < 0.001, respectively). The mean scores for pruritus and pain also improved significantly (P < 0.001 and P = 0.01, respectively). The observed side-effects were hyperpigmentation (four lesions) and skin atrophy (three lesions). No recurrences were noted during follow up (mean duration of 19 months). CONCLUSIONS: Intralesional jet injection of bleomycin is an effective and safe method of treating keloids and hypertrophic scars that are unresponsive to intralesional steroid therapy.     

Topical bioavailability of triamcinolone acetonide: effect of dose and application frequency

The application frequency of topical corticosteroids is a recurrently debated topic. Multiple-daily applications are common, although a superior efficacy compared to once-daily application is not unequivocally proven. Only few pharmacokinetic studies investigating application frequency exist. The aim of the study was to investigate the effect of dose (Experiment 1) and application frequency (Experiment 2) on the penetration of triamcinolone acetonide (TACA) into human stratum corneum (SC) in vivo. The experiments were conducted on the forearms of 15 healthy volunteers. In Experiment 1, single TACA doses (300 μg/cm² and 100 μg/cm²) dissolved in acetone were applied on three sites per arm. In experiment 2, single (1 × 300 μg/cm²) and multiple (3 × 100 μg/cm²) TACA doses were similarly applied. SC samples were harvested by tape stripping after 0.5, 4 and 24 h (Experiment 1) and after 4, 8 and 24 h (Experiment 2). Corneocytes and TACA were quantified by UV/VIS spectroscopy and HPLC, respectively. TACA amounts penetrated into SC were statistically evaluated by a paired-sample t-test. In Experiment 1, TACA amounts within SC after application of 1 × 300 μg/cm² compared to 1 × 100 μg/cm² were only significantly different directly after application and similar at 4 and 24 h. In Experiment 2, multiple applications of 3×100 μg/cm² yielded higher TACA amounts compared to a single application of 1 × 300 μg/cm² at 4 and 8 h. At 24 h, no difference was observed. In conclusion, using this simple vehicle, considerable TACA amounts were retained within SC independently of dose and application frequency. A low TACA dose applied once should be preferred to a high dose, which may promote higher systemic exposure.     

Alopecia Areata in Korea (1982–1994)

I clinically studied 905 patients with alopecia areata (AA) who visited the Department of Dermatology, College of Medicine, Chung Ang University, from January of 1982 to February of 1994. The purpose of the study was to evaluate the clinical manifestations and compare the effects of treatment with intralesional injection of triamcinolone acetonide suspension and immunotherapy with dinitrochlorobenzene (DNCB) or diphenylcyclopropenone (DPCP). The results were as follows: 1) The incidence of AA among all out-patients (59,970) was 1.5% (905 cases), and the ratio of males to females was 1.3:1 (512:393). 2) The age distribution showed high incidences in the third (41.8%) and fourth decades (20.0%). 3) The family history was contributory in 104 cases (11.5%). 4) The relapse rate was 17.5% (158 cases). 5) Almost half of the patients had a solitary lesion (408 cases, 46.7%). 6) The most common site of predilection was the occipital region of the scalp in both male and female patients. 7) Associated diseases were seborrheic dermatitis, atopic dermatitis, hepatitis, hypertension, open heart surgery, thyroid disease, pulmonary disease, and vitiligo in order of frequency. 8) The effect of treatment on the patients who had bald patches less than 50 cm² was not significantly statistically different between intralesional injection of triamcinolone acetonide and immunotherapy with DNCB or DPCP. 9) In cases with bald areas more than 50 cm², including alopecia totalis and universalis, DNCB or DPCP immunotherapy showed better therapeutic effects than did intralesional injection of triamcinolone acetonide.     

Mechanical properties of keloids in vivo during treatment with intralesional triamcinolone acetonide

The mechanical properties of 17 keloids in 9 patients before and during treatment with intralesional triamcinolone acetonide were studied using a recently developed noninvasive suction device for measuring skin elasticity in vivo. Each keloid was treated with intralesional injections of 10 mg/ml triamcinolone acetonide without local anaesthetic at intervals of 3 weeks. A total of four measurements per keloid were performed, before treatment and 3 weeks after the first, second and third treatments. The parameters used were: immediate distension (Ue), delayed distension (Uv), immediate retraction (Ur) and final distension (Uf). Relative parameters independent of skin thickness were calculated:Uv/Ue, the ratio between the viscous and the elastic deformation of the skin, andUr/Uf, representing the ability of the skin to return to its initial position after deformation (biological elasticity). After three injections of triamcinolone acetonide a marked decrease inUv/Ue and a lesspronounced increase inUr/Uf compared with baseline values was observed. These findings indicate that the main effect of intralesional steroids on the connective tissue of keloids is a decrease in viscosity due to a loss of ground substance. This method provides a noninvasive quantitative assessment of the mechanical properties of scars and is well suited to comparative studies on the efficacy of various scar therapies.Dedicated to Prof. Dr. Dr. S. Borelli on the occasion of his 70th birthday     

Intralesional triamcinolone acetonide in notalgia paresthetica: Treatment outcomes in five patients

Numerous treatment modalities have been tried with diverse results for pruritus due to notalgia paresthetica (NP). Corticosteroids suppress ectopic neural discharges from injured nerve fibers and also have short‐lived suppressive effect on transmission in normal C‐fibers. Herein, we evaluated the efficacy of intralesional triamcinolone acetonide in the treatment of NP. The medical reports of five patients who had been diagnosed with NP and treated with intralesional triamcinolone acetonide injections were retrospectively evaluated. Triamcinolone acetonide solution was injected intradermally (10 mg/mL; 0.1 mL/cm²) every 3 weeks for a maximum of four treatments. The severity of itch was scored by the patients on a combined numerical and visual analogue scale. After treatment, reduction in itch severity scores varied between 33% and 100%.     

Role of vascular endothelial growth factor in keloids: a clinicopathologic study

Background  Despite their benign nature, keloids are usually associated with considerable cosmetic effects and may lead to functional problems. Recently, it has been reported that vascular endothelial growth factor (VEGF), a potent angiogenic factor, is overexpressed in keloid tissue and may have a potential role in its evolution.
Methods  Twenty patients with keloids were included in this study and classified into two groups according to the treatment received: intralesional triamcinolone acetonide 20 mg/mL (group 1) and cryotherapy spray technique (group 2). Treatment was continued until clearance or for a maximum of six sessions, and the follow-up period was 1 year. Skin biopsies were taken from patients before and after treatment to evaluate keloid pathology and from patients and 10 healthy controls to detect the immunohistochemical expression of VEGF.
Results  Histopathologic examination revealed a remarkable resolution of the nodular arrangement of collagen after therapy, particularly in group 1. A statistically significant difference in VEGF expression was found between patients before therapy and controls, and between patients before and after therapy in each group. There was no significant difference in the treatment outcome between intralesional steroids and cryotherapy. No significant correlation was observed between the clinical variables of keloids and both VEGF expression and clinical response to therapy.
Conclusion  VEGF seems to play an important role in the pathogenesis of keloids and may be a useful guide in the evaluation of keloid therapeutics. Modulation of its production may provide a valuable treatment for keloids.     

Can we use radiotherapy alone in the treatment of keloids?

Objective The use of radiation for the treatment of keloids has been the topic of debate for years. Methods In this study, 46 symptomatic cases were treated with ⁹⁰Sr-⁹⁰Y β-rays. Patients were given four fractions of 5 Gy per fraction either as weekly or twice weekly schedules. Results Radiation dose of 20 Gy given twice weekly in four fractions showed response in 92% of the cases as compared to 81% in those receiving four fractions of 5 Gy weekly. Conclusion Further studies with numerous dose fractionation schedules would open up new dimensions in the radiotherapy of keloids.     

Latanoprost in the treatment of eyelash alopecia in alopecia areata universalis

Objectives The aim of this study was to test the efficacy of latanoprost in eyelash alopecia areata (AA). Design This study is a 2‐year prospective, non‐blinded, non‐randomized, bilateral eyelash alopecia controlled study. Setting The setting of this study was Trichology Unit, Virgen Macarena University Hospital, Seville, Spain. Patients We conducted a survey of 54 subjects with AA universalis treated with the protocol of the Trichology Unit of our Department. Control group comprised 10 subjects who received injections of 0.5 mg/cm² of triamcinolone acetonide (TAC) in their eyebrows and 1 mg/cm² of TAC injections in affected scalp. The treatment group included 44 subjects who received the same treatment as the control group in scalp and eyebrows but they also applied a drop of latanoprost 0.005% (50 μg/mL) ophthalmic solution in their eyelid margins every night. Subjects were reviewed every 3 months for 2 years. Results Forty subjects finished the study and four subjects were lost to follow‐up. In the treatment arm of this study, the course was well tolerated and uncomplicated. Both investigators and patients evaluated the regrowth. The results we obtained were: complete regrowth in 17.5%, moderate regrowth in 27.5%, slight regrowth in 30% and without response in 25%. Moderate and total regrowth constituted a cosmetically acceptable response. The therapy was continuous and the response remained without any side effects. No patients had cosmetically acceptable eyelash regrowth in the control group. Conclusions Latanoprost may be an effective drug in the treatment of eyelash AA because it induces acceptable responses (total and moderate) in 45% of the patients. A formal, blinded prospective unilateral controlled study will permit further understanding about this promising therapeutic agent for eyelash AA.     

Role of liquid nitrogen alone compared with combination of liquid nitrogen and intralesional triamcinolone acetonide in treatment of small keloids

Keloids are well-defined fibrous tissue overgrowths extending beyond the original defects. The purpose of our study was to compare the efficacy of liquid nitrogen cryosurgery alone with liquid nitrogen cryosurgery and intralesional triamcinolone acetonide combination. Study on 60 clinically diagnosed lesions of keloids from 21 patients was conducted to compare the efficacy of liquid nitrogen cryosurgery alone. The statistical analysis shows synergistic action of cryosurgery and corticosteroids may offer promise in the treatment.     

Combination cryotherapy and intralesional corticosteroid versus steroid monotherapy in the treatment of keloids

Background

Keloids are common and have significant negative effects on quality of life. There is a need for more effective treatment approaches for keloids.

Aims

We investigated treatment outcomes of intralesional triamcinolone acetonide (IL TAC) compared with combination IL TAC and cryotherapy, including changes in pruritus, pain, and keloid size.

Patients/Methods

We performed a prospective study of patients referred to one provider who treated patients with combination therapy and compared them to a historic control cohort treated with IL TAC alone. All patients were seen at Thomas Jefferson University between 2019 and 2021. Patient demographics, location of keloids, and inciting events were recorded. Pruritus and pain scores were self-reported by patients using a 10-point Likert scale administered as standard of care. Changes in keloid size were denoted as “No change,” “up to 50% decrease,” “more than 50% decrease,” and “completely flattened.”

Results

While both treatments produced a significant reduction in mean pruritus and pain scores, there was no difference between the two treatment groups (p = 0.3933 and p = 0.2123, respectively). A greater percentage of keloids in the combination therapy group had a post-treatment size difference greater than 50% compared with those in the IL TAC only treatment group (p = 0.0021). In the subgroup of pubic keloids, all lesions treated with combination IL TAC and cryotherapy responded remarkably well to treatment.

Conclusions

While both IL TAC and IL TAC with cryotherapy were effective at reducing pruritus and pain, combination therapy was more effective in reducing keloid size, specifically for pubic keloids.     

FAILURE OF INTERFERON-ALPHA 2B IN THE TREATMENT OF MATURE KELOIDS

Background. An unchecked proliferation of fibrous tissue after an injury to the skin is the basic mechanism for keloid formation. Recent studies have shown the inhibitory effect of interferons on dermal fibroblast growth and/or collagen production. Various therapeutic modalities have been used for the treatment of keloids, although only with limited success. There are only a few reports on the use of interferons in the treatment of keloids. To our knowledge no controlled clinical trials have examined the efficacy of intralesional interferon-alpha 2b on mature keloid lesions. In this study, recombinant human interferon-alpha 2b was examined for its ability to modify keloids clinically. Methods. Twenty-two patients with at least two mature keloids were studied twice weekly for 3 weeks. Patients were treated by injection of recombinant human interferon-alpha 2b, 0.5 million per cm² of keloid, into one lesional site and diluent alone into another lesional site. Lesions were measured before and on days 8, 15, 22, and 29 after starting treatment. Results. Only 13 of 22 patients could be evaluated at the end of the study; seven patients withdrew from the study because of severe local pain during injection. Three of the 13 patients showed insignificant reduction in the height of keloids after interferon treatment. No serious laboratory abnormalities were detected. Conclusions. Recombinant interferon-alpha 2b is not efficacious in the treatment of mature keloids.     

Pituitary-adrenal function following topical triamcinolone acetonide and occlusion.

This study was undertaken to investigate the possible pituitary-adrenal suppressive effects of triamcinolone acetonide under occlusive dressings in six psoriatic patients. Forty-five grams of a cream containing 0.1% triamcinolone acetonide was applied daily to the psoriatic lesions of four patients and covered with an occlusive dressing. Two patients received daily applications of 45 gm of 0.01% triamcinolone acetonide cream and occlusive dressings. The four patients who received the 0.1% triamcinolone acetonide applications showed a marked decrease in the 24-hour urinary 17-hydroxycorticosteroids and no significant response to intravenous metyrapone testing. The two patients who were treated with 0.01% triamcinolone acetonide also showed a significant decrease in 24-hour urinary 17-hydroxycorticosteroids, but a partial response to metyrapone testing. Percutaneous absorption of as little as 1 to 2 mg of triamcinolone acetonide may affect pituitary-adrenal function.     

Comparative studies of treatments for pityriasis lichenoides

Thirty patients with pityriasis lichenoides were divided into three groups. The first group was treated twice daily with applications of topical 0.02–0.1% triamcinolone cream. The second group was given the same regimen but in combination with oral tetracycline, one to two grams daily in divided doses. The third group was treated with oral psoralen and ultraviolet A (PUVA). The average durations of treatment in the three groups were 6, 7 and 2 months, respectively. The results of the treatment in the first group included two patients with complete remission, two with partial response and four with no response. In the second group, there was one patient with complete remission, eleven with partial response, and two with no response. Significant therapeutic results were observed in the third group; there were five patients with complete remission, two with partial response, and one with no response. Skin lesions of patients in the third group cleared completely or were markedly reduced with an average of 26 treatments at an average UVA dose of 68.80 joules/cm². We therefore concluded that PUVA is more effective than the other modes of treatment for pityriasis lichenoides.     

银屑病皮损鳞屑中两种微生物的检测及外用派瑞松效果

目的探讨银屑病发病与金黄色葡萄球菌(简称金葡菌)、糠秕孢子菌感染的关系及观察外用派瑞松治疗效果。方法对银屑病病人皮损进行细菌培养及真菌真接镜检,并外用派瑞松治疗。结果银屑病患者金葡菌和糠秕孢子菌带菌率均高于正常对照(P<0.01;P<0.05),治疗后带菌率明显下降;治愈率和有效率分别为18.0%,72.0%。结论金葡菌、糠秕孢子菌在银屑病的发病和发展中起一定作用,派瑞松是治疗银屑病较好的药物之一。     

A randomized, double-blind study to assess the efficacy of addition of tetracycline to triamcinolone acetonide in the treatment of moderate to severe atopic dermatitis

Objective To assess the efficacy of tetracycline in triamcinolone acetonide ointment compared with triamcinolone acetonide ointment in patients with moderate to severe atopic dermatitis. Design Randomised, double‐blind parallel group study of 8 weeks’ duration. Setting Outpatient clinic in a university hospital. Participants Forty‐four adult patients with moderate to severe atopic dermatitis (objective SCORAD > 25). Interventions Initial phase (2 weeks): 3% tetracycline 0.1% triamcinolone acetonide vs. 0.1% triamcinolone acetonide twice daily all over the body. Maintenance phase (6 weeks) 0.1% triamcinolone acetonide once daily for 2 weeks, followed by every other day for 2 weeks. In the last 2 weeks, two applications a week were done. An emollient was used additionally once daily. Main outcome measures Primary outcomes were the disease severity scores assessed by objective SCORAD and SASSAD at week 2. Secondary outcomes were the objective SCORAD and SASSAD at weeks 4 and 8, and Staphylococcus aureus colonization at weeks 0 and 2. Results No significant differences in disease severity outcomes were found between the two groups. Both groups showed clinically relevant improvements in disease severity compared with baseline at weeks 2 and 4. At week 8, there was some worsening in disease severity in both groups, but the disease severity was still significantly lower than at the beginning of the study. Improvement of bacterial colonization was seen in 14 (63.6%) out of the 22 patients in the 3% tetracycline 0.1% triamcinolone acetonide group and in 5 (22.7%) out of the 22 patients in the 0.1% triamcinolone acetonide group. Conclusion The addition of tetracycline was effective on skin colonization by S. aureus but did in our patients with atopic dermatitis not result in a significantly different improvement compared with the group treated without tetracycline.     

强力脉痔灵联合曲安奈德益康唑乳膏治疗肛周湿疹疗效观察

目的观察强力脉痔灵联合曲安奈德益康唑乳膏治疗肛周湿疹的临床疗效。方法采用随机法将99例患者分为两组,治疗组50例,予强力脉痔灵2片口服,同时外用曲安奈德益康唑乳膏,均2次/d,连用3周。对照组49例,仅外用曲安奈德益康唑乳膏,连用3周。两组均治疗结束时观察近期疗效,痊愈者随访3个月观察远期疗效。结果治疗组近期疗效有效率80.00%,对照组为71.43%,差异无显著性(P>0.05);痊愈病例随访3个月,治疗组复发率20.0%,对照组57.9%,差异有显著性(P<0.01)。结论强力脉痔灵联合曲安奈德益康唑乳膏治疗肛周湿疹疗效好。