Journal of Clinical and Aesthetic Dermatology

AUG 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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6cm and has the advantage of treating superficially without causing significant damage t o deeper structures. 7 ,8 p ostsurgical excision followed by eBRt has a low rate of recurrence depending on several factors, such as the treatment protocol that was used and keloid site. 9 –13 various treatment protocols have been described for the treatment of keloids with eBRt. the dose of radiotherapy used is dependent on the location of the keloid: keloids located in high- stretch tension areas including the chest, scapular region, and suprapubic region may need higher doses in contrast to low-tension areas such as the neck or earlobes. 9 For example, ogawa et al suggested that the earlobes can be treated effectively with eBRt using a dose of 10Gy fractioned over two days, while the chest, scapular region, and suprapubic region should be treated with 20Gy fractioned over four days. 10 other authors have suggested a higher dose of 15Gy for earlobe keloids and keloids on the cartilaginous part of the auricle with low recurrence rates. 1 2,14 a large study examining 834 keloids treated with excision followed by a total dose of 18Gy in two fractions had a relapse rate of 9.59 percent. this study showed that there were increased relapse rates in men, persons under 28 years in age, persons in whom radiation occurred more than 24 hours after surgery, keloids located in high-stretch tension sites, keloid size longer than 5cm, and if grafting was performed. moreover, no radiation- induced malignancies were observed after a median follow-up of 40 months, and there was a low adverse effect profile of 9.38 percent, primarily composed of pigmentary changes. 15 these findings suggest that postsurgical radiation is more effective within 24 hours of excision. SUPERFICIAL AND ORTHOVOLTAGE RADIATION THERAPY superscial and orthovoltage radiotherapy have a depth of penetration of 5mm and 2cm, respectively. superscial radiation therapy (sRt) has been used for treatment of keloids, as it entirely targets the skin, avoiding deeper tissues (d max =0). one study used 60kv (for chest keloids) or 100kv (for earlobe keloids) irradiation and a dose of 10Gy in a single f raction after excision of keloids; this study noted that the majority of keloids could be controlled by resection with immediate radiotherapy with a probability of relapse of nine percent at one year and 16 percent at sve years. 16 another study including 194 keloids treated with excision followed by postoperative superscial radiation therapy (55kv or 100kv depending on site and total of 16Gy or 40Gy dose) showed 91-percent reduction in itching and 96-percent reduction in pain. with total radiation doses greater than 21Gy, there was a greater risk of pigmentary changes. 17 moreover, sRt (dose of 12Gy divided into 3 fractions) was shown to be superior in a randomized trial when compared to multiple sessions of cryotherapy followed by intralesional triamcinolone. in fact, the cryotherapy/intralesional triamcinolone group experienced more side effects including ulceration, necrosis, and telangiectasia as well as a more prolonged course of treatment, higher recurrence rate, and less satisfaction. 18 in a large study by speranza et al, 234 keloids were treated 24-hours postexcision with orthovoltage radiation therapy using a dose of 15Gy divided into three daily fractions. with this regimen, 60 percent of patients reported a satisfaction level of 8 or higher on a 10-point scale. twenty-seven percent of patients developed telangiectasias as a late adverse event; this was the greatest predictor of dissatisfaction. 19 BRACHY THERAPY Brachytherapy has also been very effective for management of keloids postexcision. it involves placing a radioactive source (commonly iridium-192 or cobalt) into or onto the target tissue. 20 high-dose-rate (hdR) brachytherapy can be performed in an outpatient setting and delivers more than 12Gy per hour. 21 hdR interstitial brachytherapy, during which a catheter is inserted into the surgical site with delivery of radiation through the catheter, was shown to have excellent results with a 3.4- percent recurrence rate at seven years using a dose of 12Gy divided into four fractions and delivered within 48 hours. 22 another study of 67 keloids treated with postexcision hdR interstitial brachytherapy using iridium-192 and a dose of 12Gy in two fractions showed a 3.1-percent recurrence rate. 23 although hdR interstitial brachytherapy has an advantage over external radiotherapy (including superscial/ orthovoltage radiation therapy and electron beam) of involving less normal tissue, the administration 13 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY august 2017 • volume 10 • number 8 R e v i e w FIGURE 1. outlined keloid on the scalp before radiation therapy FIGURE 2. Resolved keloid on the scalp 6 months after excision and radiation therapy (1300cGy, 1 fraction, postsurgery)

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