National report — Dermatologists can treat patients with keloids more effectively due to new treatment choices, according to an expert who treats patients who have darker skin.

"There are a lot of new therapies that have become available," says Marta I. Rendon, M.D., associate clinical professor at both the University of Miami, Miami, and Florida Atlantic University, Boca Raton, Fla. "So, our options for treating keloids have broadened."

Most dermatologists are familiar with intralesional injections of cortico-steroids. Dr. Rendon adds that surgical excision is also a common approach. In these cases, a silicone gel is added to prevent recurrence of keloids.

Interestingly, some treatments that have been developed for other skin disorders are also effective in resolving keloids. For example, 5 percent imiquimod (Aldara), an immune-response modifier approved for the treatment of human papilloma virus (HPV), actinic keratosis and superficial basal cell carcinoma, also helps resolve keloids.

This is because imiquimod stimulates interferon-alpha and expedites collagen breakdown, Dr. Rendon tells Dermatology Times. She follows surgical excision with topical imiquimod to prevent recurrence.

In addition, tacrolimus (Protopic, Astellas) is often used. Unlike imiquimod, tacrolimus suppresses the immune response, particularly inflammatory factors such as cytokine, tumor necrosis factor (TNF)-alpha and interleukins. This mechanism of tacrolimus suppresses fibroblastic activity and, therefore, reduces collagen formation.

Investigators are exploring other medications that are approved for other conditions, but would be new to the treatment of keloids, Dr. Rendon says.

For example, interferons also reduce collagen formation and may prevent or resolve keloids by increasing the body's production of collagenase. However, investigators are at a very early stage of exploring interferons for keloids, Dr. Rendon says.

Etanercept (Enbrel, Amgen/Wyeth), a TNF-alpha inhibitor that is approved for several autoimmune conditions, is also being investigated for the treatment of keloids.

Cryotherapy, lasers

Cryotherapy is being investigated as an approach to use with other therapies, such as surgical excision. Some dermatologists are using pulsed-dye lasers because of their ability to reduce inflammation. Therefore, they may also prevent keloid formation, Dr. Rendon says.

"I often treat keloids with intralesional injections combined with pulsed-dye laser," she says.

The unifying factor of these diverse approaches is the investigators' intention to identify approaches that counteract inflammation and fibroblastic activity in cell proliferation. Therefore, the hope is that the treatments will reduce hypertrophy and collagen contraction.

In the case of interferon, the hope is that increasing collagenase levels will, in turn, increase the breakdown of collagen formation.

"Some people are focusing on preventing recurrent keloids once we cut them out," Dr. Rendon says. "Others are focusing on how to treat the keloid that is there."

Unanswered questions

Investigators are using multiple approaches, because the etiology of keloids is not straightforward.

"We know little things to prevent keloids, such as avoiding unnecessary wounds in people prone to keloids and avoiding crust formation," Dr. Rendon says. "We don't know definitively why keloids form, though."

As with many conditions, dermatologists need to tailor the treatment of keloids for the individual patient.

The most important action to prevent keloids is to be aware of which patients are at risk of forming them, Dr. Rendon says.

"Do a good history prior to any procedure," she says. "If the patient is keloid-prone, use an aggressive preventive approach early on. If a surgery is necessary, use minimal tension with the surgical closure."

Disclosures: Dr. Rendon reports no relevant financial interests.