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DERMATOLOGIC THERAPY
ISSN 1396-0296
THERAPEUTIC HOTLINE
Intralesional cryosurgery and
intralesional steroid injection:
a good combination therapy
for treatment of keloids
and hypertrophic scars
Ahmed Hany Weshahy & Rania Abdel Hay
Dermatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
ABSTRACT: Hypertrophic scars and keloids exhibit high recurrence rates following surgical excision.
Intralesional cryosurgery (ILC) can achieve a higher degree of effectiveness than the surface cryotherapy. The aim of this study is to assess the clinical efficacy of ILC using Weshahy cryoneedles followed
by IL steroid in a trial of getting rid of the fibrous mass by destruction, not by surgery to avoid being
under tension of the new scar. This study included 22 patients. Evaluation of the volume reduction of
the lesions was done after a single ILC session followed by IL steroid injections. There was a significant
decrease in the volume of the lesions after 4 months (P < 0.01), with a volume reduction of 93.5%. By
using ILC at the base of keloids or hypertrophic scars, we can change the old fibrous tissue into a recent
scar or granulation tissue which will respond more successfully to IL steroid injection.
KEYWORDS: hypertrophic scars, intralesional steroid, keloids
Introduction
Hypertrophic scars and keloids are benign, fibrous
proliferations that exhibit high recurrence rate
following surgical excision (1). Various treatment
modalities are available, and treatment has to be
individualized depending upon the distribution,
size, thickness, consistency of the lesion and association of inflammation (2).
A combination approach to therapy seems to be
the best option (2). When used alone, corticosterAddress correspondence and reprint requests to: Rania Abdel
Hay, MD, Consultant Dermatologist, Dermatology
Department, Faculty of Medicine, Cairo University, 13th Abrag
Othman, Kournish el Maadi, Cairo 11431, Egypt, or email:
omleila2@yahoo.com.
273
274
Results
There was a significant decrease in the volume of
the lesions in all patients 4 months after a single
session of ILC compared to baseline (P < 0.01), with
a volume reduction of 93.5% (Table 1, Fig. 1).
A significant softening of lesions versus baseline
was observed (P < 0.01), with a significant decrease
in height of lesions and in redness score in the 7th
month compared to baseline (P < 0.001) in all
patients. All patients mentioned a significant
reduction of their subjective complaints after the
treatment that persisted during the follow-up
period (Table 1).
The IL treatment was generally well tolerated.
Minor bleeding from the penetration points was
detected and disappeared after 515 minutes of
compression. Infection was not reported. 712
days following ILC, the lesion began to become
necrotic. Within 34 weeks, the necrotic tissue was
separated leaving an erythematous area of new
healed tissue which would be subjected to IL
steroid. No adverse textural changes were observed
at the cryosurgical site; however, 21 lesions (84%)
showed temporary hypopigmentation for 36
months. Fourteen cases of them (66.7%) showed
repigmentation, while seven cases of them (33.3%)
showed hyperpigmentation at the periphery which
improved almost by time with IL steroid. A small
scar recurrence (0.51 cm3) was noted at the
periphery of three lesions (12%) during the
Intralesional cyosurgery
Before treatment
4 months after treatment
% volume reduction
3 years after treatment
Before
7 months after treatment
Before treatment
7 months after treatment
Before treatment
7 months after treatment
Before treatment
4 months after treatment
Before treatment
7 months after treatment
Before treatment
7 months after treatment
Range
Mean SD
1.48
01
75100
01
23
01
23
01
23
02
03
0
03
0
03
01
3.39
0.18
93.54
0.1
2.84
0.24
2.88
0.24
2.8
0.52
1.28
0
0.84
0
0.88
0.12
1.791
0.252
8.067
0.289
0.374
0.436
0.332
0.436
0.408
0.714
0.843
0.8
0.781
0.332
P value
<0.001
<0.001*
<0.001
<0.001
<0.001
<0.001
<0.001
0.001
FIG. 1. A female patient (a) with a keloidal lesion at her left ear with 6 cm3 volume (b) during the intralesional cryosurgery (ILC)
session with the frost denoted at the base of the lesion (c) 4 months after the session with complete keloidal disappearance.
Discussion
Cryosurgery has been successfully used to treat
keloids and hypertrophic scars (48,10,1214). In
this study, all indices were significantly improved
for all cases (Table 1).
The results of our study are comparable with
those reported previously (10,13,14,16,17). Our
better results may be explained by the more
timewe gave until the ice cylinder formed
extended 2 mm outside the clinical borders of the
lesions, and by the deep insertion of our cryoneedles at or immediately under the base of the
lesions, targeting the blood supply of the lesion,
others might do the procedure more superficially.
275
Conclusion
Our message is that by using ILC, we can change
the old fibrous tissue into a recent scar or granulation tissue which will respond more successfully to
the IL steroid injection with better spreading of the
steroid injected and decreasing of the resistance
faced with the IL injection. However, this is a small
pilot study, and further larger, randomized, controlled trials need to be done to evaluate ILC.
276
References
1. Russell R, Horlock N, Gault D. Zimmer splintage: a simple
effective treatment for keloids following ear piercing. Br J
Plast Surg 2001: 54: 509510.
2. Mutalik S. Treatment of keloids and hypertrophic scars.
Indian J Dermatol Venereol Leprol 2005: 71: 38.
3. Donkor P. Head and neck keloid: treatment by core excision
and delayed intralesional injection of steroid. J Oral Maxillofac Surg 2007: 65: 12921296.
4. Zouboulis CC, Orfanos CE. Cryosurgical treatment of hypertrophic scars and keloids. Hautarzt 1990: 41: 683638.
5. Zouboulis CC, Blume U, Bttner P, Orfanos CE. Outcomes
of cryosurgery in keloids and hypertrophic scars. A prospective consecutive trial of case series. Arch Dermatol 1993:
129: 11461151.
6. Ernst K, Hundeiker M. Results of cryosurgery in 394 patients
with hypertrophic scars and keloids. Hautarzt 1995: 46: 462
466.
7. Zouridaki E, Trautmann C, Alvertis H, Katsambas A, Orfanos
CE, Zouboulis CC. Cryosurgery alone and cryosurgery combined with intralesional steroids are equally effective on
keloids but induce different histological changes: results
of a prospective randomized study. J Eur Acad Dermatol
Venereol 1996: 7: S87 (abstract).
8. Dalkowski A, Fimmel S, Beutler C, Zouboulis CC. Cryotherapy modifies synthetic activity and differentiation of
keloidal fibroblasts in vitro. Exp Dermatol 2003: 12: 673
681.
9. Zouboulis CC, Zouridaki E, Rosenberger A, Dalkowski A.
Current developments and uses of cryosurgery in the treatment of keloids and hypertrophic scars. Wound Repair
Regen 2002: 10: 98102.
10. Har-Shai Y, Amar M, Sabo E. Intralesional cryotherapy for
enhancing the involution of hypertrophic scars and keloids.
Plast Reconstr Surg 2003: 111: 18411852.
11. Weshahy AH. Intralesional cryosurgery. A new technique
using cryoneedles. J Dermatol Surg Oncol 1993: 19: 123
126.
12. Zouboulis CC. Principles of cutaneous cryosurgery: an
update. Dermatology 1999: 198: 111117.
13. Zouboulis CC, Rosenberger AD, Forster T, Beller G, Kratzsch
M, Felsenberg D. Modification of a device and its application for intralesional cryosurgery of old recalcitrant keloids.
Arch Dermatol 2004: 140: 12931294.
14. Gupta S, Kumar B. Intralesional crysurgery using lumbar
puncture and/or hypodermic needles for large, bulky, recalcitrant keloids. Int J Dermatol 2001: 40: 349353.
15. Lee JH, Kim SE, Lee AY. Effects of interferon-alpha2b on
keloid treatment with triamcinolone acetonide intralesional injection. Int J Dermatol 2008: 47: 183186.
16. Zouboulis CC, Orfanos CE. Cryosurgical treatment. In:
Harahap M, ed. Surgical techniques for cutaneous scar revision. New York, NY: Marcel Dekker, 2000: 185234.
17. Har-Shai Y, Sabo E, Rohde E, Hyams M, Assaf C, Zouboulis
CC. Intralesional cryosurgery enhances the involution of
recalcitrant auricular keloids: a new clinical approach supported by experimental studies. Wound Repair Regen 2006:
14: 1827.
18. English RS, Shenefelt PD. Keloids and hypertrophic scars.
Dermatol Surg 1999: 25: 631638.
19. Zacarian SA. Cryogenics: the cryolesion and the pathogenesis of cryonecrosis. In: Zacarian SA, ed. Cryosurgery for
skin cancer and cutaneous disorders. St. Louis, MO: CV
Mosby, 1985: 130.
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