Keloids arise from an exacerbated response to dermal injury, which results in fibroblast proliferation, too much collagen deposition, and impairment of adjacent healthy skin. The diagnosis is clinical and there are many conservative and surgical methods that are used for treatment
[1]
.
What characterizes keloid is the abnormal growth of normal tissue in the scar, forming the keloid. It is a benign alteration, therefore without risk to health, in which there is a loss of the control mechanisms that regulate the balance of tissue repair and recovery.
Due to the complexity of classifying fibroproliferative scars based solely on their morphological appearance, Muir
[2]
proposed a classification based on the prognosis of these lesions. This classification encompasses three categories: 1) hypertrophic scar (Short-Term Evolution, STE), which clinically corresponds to hypertrophic scar, characterized by being flatter and presenting a more favorable prognosis; 2) keloid scar (Long-Term Evolution, LTE), which corresponds to keloid, being nodular and associated with a more unfavorable prognosis; and 3) mixed scar (Intermediate Group, IG), represented by keloid located in the deltoid and scapular regions, which, despite being flat, is also associated with a more unfavorable prognosis.
How keloid starts: It can be caused by a number of factors, including burns, surgical cuts, ear piercings, tattoos, after vaccinations, and traumatic wounds. Correctly healed wounds hardly become keloids.
The keloid can be improved with cryotherapy, which will reduce the size of the scars. Laser and compression by means of silicone tapes or lead foil have also already been used. The keloid can start from one month after the trauma, but occasionally can appear after 1 year of the scar.
Surgery for keloid removal is performed in the operating room: keloid excision in a certain region. Many professionals also use radiotherapy for the treatment of keloids. The ICD-10 of the disease is L-910.
The difference between keloid and normal healing is the growth, the color of the scar, its height or, popularly, its thickening (pinkish color)
[3]
.
The reason why a scar turns into a keloid involves several factors already mentioned in this manuscript. The scar is hard inside, due to the increase in fibers or extra tissues at the cut site. The deeper the cut, the more the tendency to keloid may be. They can also occur in scars with irregular or very tight spots.
In the case of this manuscript, we used the intralesional infiltrate of triamcinolone diluted 1/10 in 0.9% saline, using insulin needles. The application frequency was once a month for a maximum of three months. As an adjunct to this approach, massage based on triamcinolone ointment was used. The method proved to be valid in comparison to non-infiltrated areas. We can consider the reason for the treatment as focusing on the aesthetic aspect, with the improvement of the appearance of the individual’s skin
[4]
. As there is no reliably effective treatment for keloids, we consider the individual and family history to choose treatment and prevention (
Graph 1
).
Graph 1. Comparative results of treatments for reducing keloid scars.2. Material and MethodTriamcinolone has been employed for the treatment of keloid scars since 1966 (Ferguson, 1992; Griffit). Triamcinolone acetonide is an organic, synthetic corticosteroid compound used in dermatitis, canker sores and keloids. Its formula is C24 H31 F06. It is anti-inflammatory, antipruritic and anti-allergic. The application of triancil, terracortril or other trade name on the keloid requires a suspension that does not exceed 5 mg/ml, varying with each patient. In a new experiment, applications were made every 21 days, no less, once a month, for 3 months, after waiting 5 months only with compress and massages until we see the result. This is a subcutaneous application, preferably intralesional infiltrate, so that results appear only in the desired zones. When we apply it to the subcutaneous tissue, we sometimes observe the destruction of the fat site with small sinks. Improvements are observed in the first few days (<xref ref-type="fig" rid="fig1">
Figure 1
</xref> and <xref ref-type="fig" rid="fig2">
Figure 2
</xref>). The dilution may vary dm 1:4 or 1:10, and dilutions 1:1 and 1:2—are not recommended to avoid unpleasant surprises, respecting the organic response of each patient. The sequence: clean the scar site thoroughly, prepare the diluted substance, use an insulin syringe and needle, and inject it into the keloid until the scar appears clearer. After that, apply corticosteroid-based ointment and cover for the first two days. Triamcinolone should be avoided on healthy skin. After 3 months, review the scar and only perform a new infiltration where there is no favorable response <xref ref-type="bibr" rid="scirp.136103-4">
[4]
</xref>-<xref ref-type="bibr" rid="scirp.136103-6">
[6]
</xref>.Case 1—Patient with abdominal scar, post abdominal dermolipectomy and scar following the line of the previous cesarean section (<xref ref-type="fig" rid="fig1">
Figure 1
</xref>).Case 2—Patient with keloid scar after mastoplasty intralesional infiltrate for comparison (<xref ref-type="fig" rid="fig2">
Figure 2
</xref>).In some cases, patients complained of pain during infiltration, which made us put 1% liquid xylocaine serum together.<xref ref-type="bibr" rid="scirp.136103-"></xref><p class="imgGroupCss_v"><img class=" imgMarkCss lazy" data-original="https://html.scirp.org/file/1050727-rId14.jpeg?20240920031114" /></p>Figure 1. Patient with abdominal scar and triamcinolone infiltration every 1 centimeter.
Figure 2. Patient with keloid scar after mastoplasty and 5 in 5 cm triamcinolone infiltration.
Case 3—The difference between a scar classified only as hypertrophic is the flatter aspect of it, wider and without elevation
[7]
-
[10]
. The keloid is already hardened scar, with itching and without aesthetic presentation (
Figure 3
and
Figure 4
).
Figure 3. Hardened keloid on the chest awaiting infiltration.
Figure 4. Keloid without aesthetic presentation on the right earlobe—without treatment.
3. Discussion
After many years of observation, we chose this method as the one that presented the best visible results when compared to other procedures, such as the use of compression, massages with corticosteroid-based ointments, cryotherapy, laser and others. Infiltration brought better results than lead compress, used in keloids from “Jorge Lobo Disease”
[11]
, considered the most severe. Massages are good, but they require a longer time. Radiation therapy caused some patients to develop dark spots in the most affected parts. Compress with silicone tape could be a choice, but there is no speed in the results. What we could guide to need in the future of the use of injectable triamcinolone would be the treatment, after 21 days after the injury, the placement of Drenison tape 4 mcg/cm2 (trade name), with Fludroxicortide (active ingredient), a species of adhesive tape that already contains the corticosteroid
[12]
-
[14]
.
4. Conclusions
Triamcinolone infiltration was positive with excellent results. This publication aims to assist in solving cases quickly, affordably and with better aesthetics. On the other hand, it is important to highlight that there was the purpose of comparing the treated area with the untreated area, which may lead some professionals to choose this treatment method.
The combination of treatments may be visible in younger patients, in whom the keloid appears harder, itchy and unsightly. In addition, we may observe the lightening of the scar after treatment.
Declaration
Work was carried out in partnership with Alfredo Nasser University (UNIFAN) and Brasil Clinic (Goiânia-GO).
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