Friday, April 20, 2012

Imiquimod and Keloids

The patient is a 42 yo man who had a cyst I&D's on his mid-back four years ago. Postoperatively,  a keloidal scar developed.  It is very painful and pruritic.  He has had intralesional triamcinalone acetonide 40 mg/cc without much effect.

The lesion measures almost 4 cm in diameter, but, being sessile, the base is only ~ 2 cm wide.

Plan and Question:  We propose to shave this off and use imiquimod post-operatively as has been done with earlobe keloids.  Does anyone have any experience with this for keloids at sites other than earlobes?  Any other suggestions?  The literature on imiquimod use after keloid removal is all over the map.  One wonders whether employing imiquimod followed by judicial use of intralesional triamcinaloine might be appropriate.

5 Weeks p Shave excision: C&E, followed by imiquimod 5 days per week.  At this point we will stop the imiquimod and follow.  Patient does not live near to my office and can be seen only once a month or less frequently.

8 weeks p shave excision:  The patient stopped imiquimod 2 - 3 weeks ago and just applied Vaseline.  The wound is looking better.  There's a slightly raised area in the middle of the erythema.

6 months after surgery.  These is a subtle scar in the mid-portion of the excision.  The area is still quite pruritic.  Will try clobetasol ointment to area, Monday, Wednesday and Friday.  Scars are rich in mast cells and this likely explains the itching;
1 year follow-up shows small hypertrophic scar which is a considerable improvement over baseline.

 References:
1.  Treatment of keloid scars post-shave excision with imiquimod 5% cream: A prospective, double-blind, placebo-controlled pilot study. J Drugs Dermatol. 2009 May;8(5):455-8.  URL

2.  Successful treatment of earlobe keloids with imiquimod after tangential shave excision. Dermatol Surg. 2006 Mar;32(3):380-6.  URL

3.  Failure of imiquimod 5% cream to prevent recurrence of surgically excised trunk keloids.  Dermatol Surg. 2009 Apr;35(4):629-33.  URL
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2 comments:

  1. Henry FoongDecember 25, 2012

    Thanks for the follow up. This is a novel approach of treating keloids. I have treated a similar keloid on the earlobe with shave excision and topical imiquimod and results are very good. Follow up so far is about 6 months now. The technique is not actually new, as one see from the references it dates back to 2006. We can pool our cases and write up the experience.

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  2. Yoon CohenDecember 27, 2012

    Although the reference goes back to 2006, probably there aren't many physicians who would do this approach because of risk of another keloid. You were brave on this and it really yielded a great outcome. Thank you for the follow up and I agree this would make a good case report/ review of literature.

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