Journal of Integrated Health Sciences

ORIGINAL ARTICLE
Year
: 2014  |  Volume : 2  |  Issue : 2  |  Page : 3--6

Efficacy of intralesional 5 Fluorouracil, triamcinolone acetonide and CO2 laser for treatment of keloids and hypertrophic scars- A comparative study


MM Shah1, AC Shah1, KR Ninama2, RS Mahajan2, FE Bilimoria3,  
1 Resident, Department of Dermatology, Sumandeep Vidhyapeeth, Piparia, Vadodara, India
2 Assistant Professor, Department of Dermatology, Sumandeep Vidhyapeeth, Piparia, Vadodara, India
3 Professor & HOD; Department of Dermatology, Sumandeep Vidhyapeeth, Piparia, Vadodara, India

Correspondence Address:
M M Shah
Resident, Department of Dermatology, Sumandeep Vidhyapeeth, Piparia, Vadodara
India

Abstract

Background: Effective keloid management is still a distant dream in spite of many recent modalities being tried for the same. Objective: To compare the efficacy of intralesional 5-Fluorouracil, intralesional triamcinolone acetonide and CO2 laser in the treatment of keloids. Materials and Methods: This randomized controlled trial was conducted on 45 patients with keloids, randomly divided into three groups, treated with intralesional 5-fluorouracil (Group A), CO2 laser (Group B) and triamcinolone acetonide (Group C). The groups were compared for reduction in the size of keloid, symptoms (pain and itching) and the incidence of adverse effects. Results: The reduction in the size of the keloid was found to be significantly better in Group A (86.33%) than in Group B (80%) and in Group C (66.66%). Conclusion: Reduction in the size of the keloid was significantly better in those treated with 5-fluorouracil than those treated with triamcinolone acetonide and CO2 laser. The incidence of adverse effects like immediate burning sensation, ulceration are more with intralesional 5-fluorouracil. The incidence of recurrence was higher with CO laser than the other modalities.



How to cite this article:
Shah M M, Shah A C, Ninama K R, Mahajan R S, Bilimoria F E. Efficacy of intralesional 5 Fluorouracil, triamcinolone acetonide and CO2 laser for treatment of keloids and hypertrophic scars- A comparative study.J Integr Health Sci 2014;2:3-6


How to cite this URL:
Shah M M, Shah A C, Ninama K R, Mahajan R S, Bilimoria F E. Efficacy of intralesional 5 Fluorouracil, triamcinolone acetonide and CO2 laser for treatment of keloids and hypertrophic scars- A comparative study. J Integr Health Sci [serial online] 2014 [cited 2022 Sep 30 ];2:3-6
Available from: https://www.jihs.in/text.asp?2014/2/2/3/239545


Full Text



 Introduction



Keloid is an exuberant form of scar,[1] occur in response to an abnormal wound healing process.It is a benign dermal hyperproliferative fibrous growth with excessive formation of connective tissue predominantly collagen and glycosaminoglyacans and refractory to treatment. It was first coined by Alibert in 1806 as ‘Crab Claw’ [2], which iillustrate the way the lesion expands from the original scar into the normal tissue. Because keloids are cosmetically disfiguring and associated with itching, pain, treatment is necessary. Various treatment modalities are intralesional corticosteroids: triamcinolone acetonide (most commonly used), 5-Fluorouracil (5-FU), Bleomycin, Interferon α-2b, Verapamil; Imiquimod 5% cream, pressure therapy, silicone products(cream, gel sheet, silastic sheet, orthosis and garments), radiotherapy, cryosurgery, lasers (Carbon dioxide laser, Pulsed Dye Laser (PDL)) and surgical excision.[3]

In early stages, keloids and hypertrophic scars have similar pathologic feathers: an increase in fibroblasts, bundles of thick, glassy, acidophilic, haphazardly arranged collagen fibres and increased vascularity. The collagen is different from normal skin and non-hypertrophic scars. Mast cells are increased in number. Hypertrophic scars have less glassy collagen and less mucin as compared to keloids. In addition, the contraction of myofibroblasts present in hypertrophic scars is responsible for the flattening of the lesion after an initial growth phase. Hyalinization is seen in the later stages of both these tumors. [Figure 1]{Figure 1}

Normally wound healing proceeds through an early inflammatory stage to a “fibroblastic” stage, in which one finds granulation tissue composed of numerous capillaries, fibroblasts and collagen fibres. The collagen fibres in the reticular dermis show a parallel, wavy orientation.[4] Usually, after 5 weeks, the number of capillaries and fibroblasts is decreased, and the collagen lies as thick, hyaline bundles in parallel arrangement.[5] While in hypertrophic scars and keloids, the formation of new collagen following the inflammatory stage extends over a much longer period of time than in normally healing wounds. Even in the early period of fibroblastic stage, the collagen fibres in the granulation tissue are arranged in a whorl like or nodular pattern. The nodules gradually increase in size and ultimately show thick, highly compacted hyalinised bands of collagen lying in a concentric arrangement.[6]

Method

It was a prospective and comparative study in which 45 patients were enrolled between 18-60 years of age having history of keloid of >1 year duration. Keloids with secondary infection, patient with past history of treatment within last 3 months and pregnant females were excluded from the study. This study was conducted at Dhiraj hospital, Sumandeep Vidyapeeth from September 2012 to December 2013. Approval for this study was obtained from the Institutional Ethical Committee.

Three different treatment modalities used were

Intralesional 5-Fluorouracil (Dose-250 mg/5 ml)CO laser (CONTINEOUS MODE 3 WATT POWER, TON 0.1;TOF 0.11)Intralesional Triamcinolone acetonide (TA). (Dose20mg/ml)

And patients were randomly divided into these 3 groups,

Treatment was given for duration of 4 months and follow up for 6 months after discontinuation of treatment to observe for recurrence of lesions. Injections (5 FU, TA) were given at the duration of 15-20 days of interval in specified doses.

Proper counseling and informed written consent, pre and post treatment photographs were taken of each patient.

Visual Analog Scale with scar ranking was used to study response to various treatment modalities. (7) it is a photograph-based scale derived from evaluating standardized digital photographs in 4 dimensions (pigmentation, vascularity, acceptability, and observer comfort) plus contour. It sums the individual scores to get a single overall score ranging from “excellent” to “no improvement.” (6)

Evaluation criteria

Criteria for Subjective improvement

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Criteria for Objective Improvement

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Analysis

{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

 Results



{Table 1}{Table 2}{Table 3}

 Discussion



Out of 45 patients 11 patients (24.44%) showed excellent response this was more common with patients treated with Co laser (6/10=60%).Good response that is reduction in size by 50% was more with intralesional 5FU seen in 10 out of 15 patients (66.66%) of that group and 24 out of total 45 patients (53.33%).Out of 45, 11 patients had satisfactory response (24.44%) while 2 patients did not show improvement (4.44%).13 of 45 patients (28.88%) showed recurrence of the lesion during 6 months of follow up period, this was also common with CO2 laser excision, seen in more than half of the treated patients (8 out of 15 patients=53.33%).One or more complications were noted in 20 patients (20%) during treatment period but they were reversible. Recurrence and secondary infection ware noted with CO laser excision, blistering with 5FU and telangiectasia, atrophy with triamcinolone acetonide.

 Conclusion



No single treatment is uniformly effective in all patients and multiple treatments may be needed in a single patient. 5-FLUROURACIL causes faster reduction in size compared to triamcinolone acetonide but higher incidence of side effects like burning, blistering and ulceration, if given very superficially. It is contraindicated in pregnancy.

CO2 LASER is a de-bulking tool thus causes immediate reduction in size of lesion so immediate patient satisfaction is high but chances of recurrence is also high and if not properly done, recurred lesion may be of more size.

Although TRIAMCINOLONE ACETONIDE is conventional method of treatment and chances of recurrences are less compared to other two modalities but adverse cutaneous effects like hypo/de pigmentation, telangiectasia and atrophy can occur and longer duration of treatment and follow up is required so patient's compliance is less.

So consider the treatment modality appropriate for an individual patient on the basis of efficacy, adverse effects, therapeutic and cosmetic outcome, feasibility, patient's preference and cost.

References

1Satishsavant. Hypertrophic scars and keloid. Textbook of dermatosurgery cosmetology. 2nd ed. Delhi, India: Association Of Scientific Cosmetologists And Dermatosurgeons; 2008. p315
2Prabhu A.,Sreekar H.,PowarR.,Uppin VM. A randomized controlled trial comparing the efficacy of intralesional 5-fluorouracil versus triamcinolone acetonide in the treatment of keloidS. 2012;(39/1):19-25.
3Somesh G, VK Sharma, Standard guidelines of care: Keloids and hypertrophic scars; Dermatosurgery specials. 2011; 77(1): 94-100.
4Linars and Larson. Early differential diagnosis between hypertrophic and nonhypertrophic healing, Journal of Investigative Dermatology. 1974; 62:514.
5Linares, HA, Kischer, CW, Dobrkovsky, M, Larson, DL. ‘The histiotypic organisation of the hypertrophic scar in humans’. Journal of Investigative Dermatology. 1972;59:323-331.
6Fearmonti R., Bond J., Erdmann D. , Levinson H.,Review of Scar Scales and Scar Measuring Devices;Eplasty. 2010 ; 10:e43