Keloid Treatment Evaluation

: TREATMENT KELOIDS

EVALUATION Thesis Submitted in partial fulfillment of Master Degree In Dermatology and Venereology

q3(1"

Sawsan Omran Hashim Am' M.Bcli) Faculty of Medicine University (

Zagzi

cOnder

Supervision of Professor Mona Anwar El-Harras

Professor Salem

Abdul-faer

Ahmed

Venrolgy

Professor of Dermatology and Faculty of Medicine

Professor of Dermatology and Venrolgy

Faculty of Medicine Zagazig University

Zagazig University

Amr

Dr. Nazir Saadawi

Assistant Professor of Dermatology and Venrolgy Faculty of Medicine Zagazig University

Faculty of Medicine Zagazig University

2004

ACKNOWLEDGEMENT Above all and first of all praise and thanks must be to ALLAH. I

would

like to express

my deepest gratitude to

Professor Ahmed Abdul Kader Salem, Professor of -

Dermatology and Venereology, Faculty of Medicine, Zagazig University, for his deep interest, sincere supervision, generous assistance and continuous support during the progress of this work. I am really grateful to Professor Mona Anwar El-Harras, Professor of Dermatology and Venereology, Faculty of Medicine, Zagazig University, for her kind advice, support, supervision and sincere cooperation, in the accomplishment of this work. I

am honoured to express my deep thanks to

Dr. Amr Nazir Saadawi, Assistant Professor of Dermatology and

Venereology, Faculty of Medicine, Zagazig University, who helped me and gave me much of his valuable experience and sincere directions to complete this work.

LIST OF ABBREVIATION a - SMA

a - smooth muscle actin

BFGF

Basic fibroblast growth factor

CO 2 Carbon dioxide laser

CW ECU EGF

Continues wave

Er : YAG

Erbium : YAG

FGF

Fibroblast growth factor

FPDL

Flash lamp — pumped pulsed dye laser

HSC

Hypertrophic scars

IFN - a

Interferon - a

IFN - 13

Interferon - [3

IFN - y

Interferon - y

IGF — 1 KFs

Insulin-like growth factor-1

Nd : YAG

Neodymium — yttrium — Aluminum — Garnet

PDGF

Platelets derived growth factor

TGF- beta I

Transforming growth factor beta — I

Extracellular matrix Epidermal growth factor

Keloid — producing fibroblast

Transforming growth factor TGF-[3

TRT

Thermal relaxation time

CONTENTS Page

Introduction and Aim of the Work - - - - - - - - - - - - - 1 Review of Literature - - - - - - - - - - - - - - - - - - - - - - 4 Chapter 1: Keloids - - - - - - - - - - - - - - - - - - - - - - - - - - - - 4 - Historical background - - - - - - - - - - - - - - - - - - - - - - - - 4 - Epidemiological factors - - - - - - - - - - - - - - - - - - - - - - - 4 - Clinical features - - - - - - - - - - - - - - - - - - - - - - - - - - - 5 - Histopatholology of keloids - - - - - - - - - - - - - - - - - - - - 7 - Physiology of wound healing - - - - - - - - - - - - - - - - - - 8 - Events in the process of wound healing - - - - - - - - - - - - 9 - Pathogenesis of keloids - - - - - - - - - - - - - - - - - - - - - - - 10 - The role of cytokines - - - - - - - - - - - - - - - - - - - - 15 - The role of mast cells - - - - - - - - - - - - - - - - - - - - 18 Chapter 2 : Treatment of keloids 19 1- Surgical therapy - - - - - - - - - - - - - - - - - - - - - - - - - - - 20 2- Physical therapy - - - - - - - - - - - - - - - - - - - - - - - - - - - 23 a- Laser in keloids - - - - - - - - - - - - - - - - - - - - - - - - 23 b- Radiation therapy - - - - - - - - - - - - - - - - - - - - - 41 c- Cryotherapy - - - - - - - - - - - - - - - - - - - - - - - - - - 42 d- Pressure therapy - - - - - - - - - - - - - - - - - - - - - - - 44 3- Pharmacological therapy - - - - - - - - - - - - - - - - - - - - - 46 a- Intralesional corticosteroids - - - - - - - - - - - - - - - 46 b- Silicon gel - - - - - - - - - - - - - - - - - - - - - - - - - - - 49 c- Antihistamine - - - - - - - - - - - - - - - - - - - - - - - - - 50 d- 5-Flurouracil - - - - - - - - - - - - - - - - - - - - - - - - - 51 e- Calcium channel blockers - - - - - - - - - - - - - - - 53 4- Immunotherapy - - - - - - - - - - - - - - - - - - - - - - - - - - - 54 Patients and Methods - - - - - - - - - - - - - - - - - - - - - 56 Results - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 66 Discussion - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 82 Summary and Conclusion - - - - - - - - - - - - - - - - - - 89 References - - - - - - - - - - - - - - - - - - - - - - - - - - - - 92

•

Arabic Summary - - - - - - - - - - - - - - - - - - - - - - - -

INTRODUCTION AND AIM OF THE WORK Keloids are human dermal fibroproliferative disorders occurring following trauma, inflammation, surgery and burns and possibly spontaneously (Horn, 2001). A Family history of keloids is frequently elicited. In familial cases, the exact mode of inheritance is unclear. Both autosml recessive and autosmal dominant patterns of inheritance are being reported. A predisposition for keloids formation has been noted in 1 6, and

197).

blood group A (Tredget,

B 14,

BW

individuals with human leucocyte antigens (HLA)

Clinically, keloids are defined as over growth of dense, fibrous tissue following healing of the skin injury that extends beyond the border of the original cutaneous insult (when identifiable), does not regress spontaneously and tends to recur after excisions (English and Shenefelt, 1999). Histologically, keloids are characterized by haphazard deposition of collagen fibers within the dermis, surrounded by a mucinous extracellular matrix with few macrophages and abundance of eosinophils, mast cells, plasma cells and lymphocytes. The collagen appears as thick hyalinized bands of eosinophilic nodules. These nodules consist of a dense mass of fibroblasts within the collagen, encircled by numerous small vessels (Horn, 2001).

1

The variety of treatment suggests that non is very satisfactory, as the lesions are recurrent. The goal in managing keloids is four folds. It includes restoration of the functional utility of the affected anatomic part, relief of symptoms, enhanced cosmetics, and prevention of recurrence. If keloids can be recognized early and treated, resolution may be possible. The broad lines of treatment include surgery, physical treatment, pharmacological therapy and immunotherapy (Niessen et al., 1999). Surgical excision of keloids has a high recurrence rate vary from 50 to 100%. However, beneficial effects of surgical excision of keloids has occurred with narrow-based (

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