LAM FACIAL PLASTICS

Hi Dr. Lam
I just found this discussion after sending email, not sure which would be the best way of discussion.
Have you had positive experiences with treating keloidal scars with bleomycin injections and recurrence rate 1+ year post? There are several studies that show to be the most effective in flattening and preventing recurrence, especially the use of dermojet. It's very difficult to find a doctor willing to try this method for my jawline scar =(

Hi,
First of all, it is very important to distinguish between a true keloid versus a hypertrophic scar. True keloids almost NEVER occur on the face, i.e., the area from in front of the ear, below the hairline, to the jawline. Conversely, they are relatively common in individuals that are predisposed toward them like Africans or darker complected persons in the earlobe (following earpiercing) in the occiput (back of the scalp) or on the neck from ingrown hairs. Almost any race can get them on the body, especially on the chest along the sternum (or central chest). That is why one should almost never remove a mole from the central chest unless one is trying to diagnose a cancer, for example. The diagnosis, clinical course, and treatments are similar but also very different. Let's first explore the differences so that we can make a proper diagnosis and appropriate treatment plan.

A keloid scar extends far beyond the borders of the initial injury and is markedly raised. A hypertrophic scar, on the other hand, is much more limited albeit can still be quite raised, thickened and angry looking. If you took a sample or biopsy of a keloid you would see a very disorganized bundle of collagen fibers whereas for a hypertrophic scar you would observe parallel array of collagen fibers. This histologic distinction is very important in some of the ways you would treat a keloid versus a hypertrophic scar. For example, silicone sheeting or silicone gel is used as an electrostatic device to help realign collagen fibers. This would be really only effective therefore for keloids and not hypertrophic scars.

As far as initial treatments go for both, I have used a combination injection of kenalog (steroid) and 5-flourouracil (5-FU) which can be quite effective in reducing the size and caliber of the scar. Steroids have risks in terms of color change and atrophy (loss of skin texture/tone and creating depressions) so I rarely use it in hypertrophic scars, whereas I use it more liberally in keloids since keloids are difficult to manage and need the kitchen sink thrown at them.

Unfortunately, I have no clinical experience using bleomycin for keloids although I have heard of this treatment through review of journal articles. I have also asked my colleagues at meetings regarding use of bleomycin and they appear not to be very knowledgeable of this treatment. My colleagues are, for the most part, facial plastic surgeons. Accordingly, dermatologists may have more experience with this type of product. I have heard that topical imiquomide (Aldera) can be helpful in hypertrophic scars but with true keloids it may not be effective enough.

For keloids, I usually first remove them while treating them with 5-FU and kenalog injections before, during, and after. I find that with one failure I go straight to radiation therapy that would follow another excision, as the failure rate of simple excision and steroid/5-FU therapy is high for most keloids.

For hypertrophic scars, I also rely on KTP laser treatments to reduce the redness and the thickness of these scars but have no real experience in keloids, as I am afraid that this laser may worsen that condition. I usually use the laser and the injections at 3 to 4 week intervals depending on how aggressive I am. I can do both at the same setting.

There has been recent evidence that topical Vitamin E used in some over-the-counter scar faders can adversely affect the outcome of scars. Accordingly, I have stopped using Vitamin E oil on all postoperative scars and incisions.

Hope that helps. My recommendation officially is to find a dermatologist who can properly diagnose your condition and then possibly manage it with bleomycin if he or she has experience with it. Clearly, if it requires surgery make sure you at least consult a surgeon to make sure that the scar is properly excised, perhaps camouflaged with a z-plasty, oriented along relaxed skin tension lines (see my faqs section for mole removal if you don't understand what that means, e.g., for the jawline all incisions should counterintuitively run perpendicular i.e., up and down across the jawline not along it to have a far better result), and closed without tension with 2 layers.

Best,
SML