Keloid management

Question 1

Keloids are a hyperproliferative response to trauma.

Answer 1

T

Question 2

Keloids appear most commonly in areas of high skin tension.

Answer 2

T Jawline, ant chest, upper back, deltoid

Question 3

Genetic predisposition does not play a role in the development of keloids.

Answer 3

F

Question 4

Darkly pigmented individuals form keloids 2-19 times more frequently than Caucasians.

Answer 4

T

Question 5

New keloid formation is relatively less common in the very young and the elderly.

Answer 5

T

Question 6

Keloids may regress after the menopause.

Answer 6

T

Question 7

Significant keloids can occur after minor trauma.

Answer 7

T

Question 8

Deeper and significant surgical wounds are often more likely to keloid than minor abrasions, burns, insect bites, varicella and zoster, vaccinations and tattoos.

Answer 8

F

Question 9

Chronic oedema in response to the trauma of ear piercing (and subsequent reaction to the presence of a metal foreign body) could result in increased incidence of keloid formation

Answer 9

T

Question 10

Infectious agents themselves are likely to cause keloids, accounting for their development following varicella for example.

Answer 10

F Most likely to trauma, oedema, incr wound tension that occurs from infection.

Question 11

Keloids may grow more readily or appear de novo during pregnancy.

Answer 11

T

Question 12

Keloids are more common before puberty.

Answer 12

F

Question 13

Melanocyte-stimulating hormone does not play a role in keloid formation.

Answer 13

F

Question 14

Collagen synthesis is 20 times greater in keloids than in normal skin.

Answer 14

T

Question 15

The absolute number of fibroblasts within keloids is increased.

Answer 15

F

Question 16

Keloids develop rapidly after surgery, whereas hypertrophic scars may occur months after the inciting trauma.

Answer 16

F Hypertrophic scars develop rapidly, keloids develop slowly over months.

Question 17

Hypertrophic scars may subside with time, whereas keloids generally progress until such time as they become stable.

Answer 17

T

Question 18

Hypertrophic scars stay within the initial wound footprint, whereas keloid exceed the size of the initial trauma

Answer 18

T

Question 19

Keloids are more likely to occur in areas prone to excessive motion, whereas hypertrophic scars are most often found in areas with limited or no motion.

Answer 19

F Hypertrophic in areas of motion (eg joints), keloid in areas with less motion (eg chest and back)

Question 20

Postoperative keloid recurrence is frequently better than the initial lesion.

Answer 20

F Frequently worse.

Question 21

Stable mature keloids tend to be symptomatic with itching, burning and pain.

Answer 21

F This occurs in progressing lesions.

Question 22

Keloids of the jaw, neck and anterior chest can cause dysfunction.

Answer 22

T

Question 23

There are 5 types of earlobe keloids – anterior button, posterior button, dumbbell, wraparound and lobular.

Answer 23

T

Question 24

Button earlobe keloids have a core component within the lobe.

Answer 24

F This is true for dumbbell keloids.

Question 25

Wraparound keloids form a cuff around the lobe from one side to the other.

Answer 25

T

Question 26

Lobular earlobe keloids can be shaved off in their entirety.

Answer 26

F This is true for button keloids.

Question 27

Pedunculated keloids, particularly when they occur on soft, mobile skin, are amenable to simple excisional surgery.

Answer 27

T

Question 28

Intralesional corticosteroids are generally the first line treatment for keloids.

Answer 28

T

Question 29

When used as solo therapy, corticosteroids are most useful in peunculated or raised lesions.

Answer 29

F Most useful in sessile, flat and broad keloids.

Question 30

The most common cause of intralesional steroid injection failure is the use of overly dilute concentrations.

Answer 30

T Most require 40mg/mL.

Question 31

The current standard of care with intralesional TCA injection is not to inject more than 80mg per session.

Answer 31

F 40mg per session, so as not to suppress HPA axis.

Question 32

40mg of triamcinolone is the equivalent of 50mg prednisone

Answer 32

T

Question 33

Intralesional TCA should not be performed more frequently than every 4-6 weeks.

Answer 33

F Every 2-4 weeks (depending on total dose of steroid used and size of keloid).

Question 34

Mixing lignocaine with triamcinolone makes the injections less painful.

Answer 34

F Pain of injection is over before lignocaine takes effect. But good for post-injection pain.

Question 35

Intralesional triamcinolone can be used for prevention of keloids, with injection occurring on the day of surgery.

Answer 35

T One regimen = day of surgery, then at 2, 4 and 6 weeks.

Question 36

Intralesional corticosteroids can be combined with any other treatment modality to improve keloid treatment outcome

Answer 36

T

Question 37

Hypopigmentation is an uncommon side effect of intralesional corticosteroid injection.

Answer 37

F Common.

Question 38

After treatment, the atrophic footprint of the keloid may appear wrinkled or shiny and have telangiectasias. This is unlikely to improve with time.

Answer 38

F Often improves with time.

Question 39

Large bulky keloids respond well to solo treatment with injectables.

Answer 39

F Surgical removal is often necessary.

Question 40

Pedunculated keloids with narrow bases can be excised and closely primarily with little wound tension.

Answer 40

T

Question 41

Surgery is best used as a solo method of treating keloids.

Answer 41

F Must use adjunctive techniques.

Question 42

When using surgery to treat keloids, the incision should be as long as possible in order to reduce tension.

Answer 42

F Small as possible.

Question 43

When excising keloid scars, removal of all keloid material should be attempted.

Answer 43

T

Question 44

When excising keloid scars, monofilament buried sutures should be used.

Answer 44

F Avoid buried sutures – may serve as nidus for keloid reformation.

Question 45

Sutures need to be left in longer than usual after keloid scar excision in order to prevent dehiscence, especially when steroids are injected postoperatively.

Answer 45

T

Question 46

After surgical excision of keloid, the wound should never be left to heal by secondary intention

Answer 46

F Often results in better cosmetic outcome and lower incidence of recurrence.

Question 47

Surgical treatment of earlobe keloids result in high recurrence rates.

Answer 47

F Have lower rate of keloid recurrence.

Question 48

Anterior and posterior button earlobe keloids are most easily removed by simple shave followed by secondary intention healing.

Answer 48

T

Question 49

Dumbbell keloids are anterior and posterior button keloids connected by a smaller core of keloid tissue.

Answer 49

T

Question 50

With dumbbell keloids, the core can be punched out using a punch at least 1mm larger than the core itself, after shave excision of the anterior and posterior buttons.

Answer 50

T Defect then close horizontally on front and vertically on back of lobe (to prevent pointed lobe).

Question 51

Small lobular and wraparound keloids are best excised in a wedge and closed primarily.

Answer 51

T

Question 52

If a large lobular, multilobular, or wraparound keloid earlobe scar has been completely resculpted to leave an earlobed-shaped keloid, there is no need for further treatment.

Answer 52

F Often need XRT + silicone gel + ILCS + IFN injection + pressure to prevent recurrence.

Question 53

Recurrence rate following CO2 laser of keloid scars is low.

Answer 53

F High.

Question 54

PDL may improve hypertrophic scar symptoms, decrease scar height, and improve skin texture.

Answer 54

T

Question 55

XRT alone is often effective in existing keloids.

Answer 55

F Ineffective. Excision of needed prior.

Question 56

XRT treatment of keloids is associated with a long-term risk of malignancy of the skin or underlying structures.

Answer 56

F Numerous large studies report 0% carcinogenesis.

Question 57

Common side effects of XRT treatment of keloid scars are skin atrophy, radiation dermatitis, abnormal skin pigmentation and local alopecia.

Answer 57

T

Question 58

XRT of keloids can be used safely in children.

Answer 58

F Not recommended, or use metaphyseal shields.

Question 59

Compression therapy for keloids involves applying pressure greater than that of capillary pressure (24mmHg).

Answer 59

T Causes reduced soft tissue cellularity. Should be less that a pressure that would diminish peripheral blood circulation

Question 60

Compression is applied for 18-24hours a day for a minimum of 4-6months up to 2 years

Answer 60

T

Question 61

Pressure alone is effective in the treatment of existing keloids.

Answer 61

F

Question 62

Dressings which apply more than 24mmHg, worn 24hrs a day for 4-6months, after often successful in reducing keloid recurrence rates postoperatively.

Answer 62

T

Question 63

With regards to the use of silicone gel sheeting for the treatment of keloid scars, it is possible that wound hydration, not the presence of silicone, is responsible for the clinical effect.

Answer 63

T

Question 64

Interferon- is highly effective in the treatment of keloids.

Answer 64

F Trial results disappointing  not used.

Question 65

Interferon injections improve existing mature and stable keloids.

Answer 65

F Best for young keloids, or for prevention.

Question 66

IFN-2b is best done on the day of surgery, then 1 week postoperatively directly into the wound.

Answer 66

T

Question 67

IFN-2b is used in volumes of 1 million units per linear cm into the wound base and margins

Answer 67

T

Question 68

Side effects of IFN-2b are reduced by limiting total dose to less than 10 million units per treatment,

Answer 68

F 5 million units.

Question 69

Side effects of IFN-2b include a flu-like syndrome, which can be reduced or eliminated by prophylactic use of paracetamol.

Answer 69

T Give 1g 1hr pre-op, then repeat every 4 hrs for first 24hrs.

Question 70

Topical imiquimod is most effective for earlobe keloids.

Answer 70

T

Question 71

Imiquimod application results in a significant improvement in existing keloids or hypertrophic scars.

Answer 71

F

Question 72

Cryotherapy for the treatment of keloid scars is used with 30-second freeze times repeated 2-3 times per cycle.

Answer 72

T This method has lower recurrence rates (ie 2%)

Question 73

Cryotherapy has been show to be effective only in combination therapy

Answer 73

F Alone or in combination

Question 74

Younger keloids respond better to cryotherapy.

Answer 74

T

Question 75

Side effects of cryotherapy in the treatment of keloid scars include pain and a prolonged healing phase of more than one month.

Answer 75

T

Question 76

Combination of cryotherapy and corticosteroids is superior to either modality alone.

Answer 76

T

Question 77

Likelihood of hypopigmentation resulting from melanocyte sensitivity to cold makes cryotherapy less applicable in dark skinned patients

Answer 77

T

Question 78

5-FU can be applied topically to keloid scars.

Answer 78

F Studies are for intralesional injection.

Question 79

Small amounts of 5FU are injected at 1cm intervals along the scar

Answer 79

T Eg 0.05ml of 50mg/ml

Question 80

Total dose of 5-FU per sessions doesn’t exceed 50mg in case series reported

Answer 80

F 2-50mg usually used, 100mg max

Question 81

The side effects of 5-FU for the treatment of keloid scars rarely include ulceration, pain and hyperpigmentation.

Answer 81

F Occur in virtually all patients.

Question 82

Younger, more symptomatic scars show most improvement with 5FU

Answer 82

T

Question 83

Side effects of 5FU include ulceration, pain and hyperpigmentation

Answer 83

T In almost all patients

Question 84

Combination of 5FU and triamcinolone improves efficacy and decreases pain

Answer 84

T No telangiectasia as side effects (vs corticosteroids)

Question 85

Vitamin E topically has been shown to improve or prevent hypertrophic scars.

Answer 85

F No evidence to support this.

Question 86

Bleomycin use in the treatment of keloid scars involves topical application of 1.5IU/ml to the keloid surface that is then punctured repeatedly with a 25-G needle.

Answer 86

T

Question 87

Prevention of keloid recurrence or occurrence can be greatly improved when all available modalities are utilised simultaneously.

Answer 87

T

Question 88

Ears from which keloids have been removed can be re-pierced.

Answer 88

F Should avoid this.

Question 89

Multiple lesions in patients in whom acne lesions tend to form keloids are an indication for oral antibiotics or a course of isotretinoin.

Answer 89

T

Question 90

Keloid patients should be followed-up for at least 1 year after therapy to monitor for recurrence.

Answer 90

T

Question 91

Keloids can rarely become malignant.

Answer 91

F This has never been reported.

Question 92

Bleomycin is used by applying to the surface of the keloid which is then punctured repeatedly with 25G needle

Answer 92

T 1.5IU/ml used. Treatment regimen – 2-5 treatments at 1-4 month interval

Question 93

Adverse effects of bleomycin are rare

Answer 93

F SE include pain, and hyperpigmentation in all patients