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ABSTRACT

ND-YAG laser and combined cryotherapy with intralesional corticosteroid injection proved to be a rational therapeutic modality for keloids and hypertrophic scars. The study was performed on 43 outpatient attendants of El-Menia University Hospital. The patients were classified into two groups according to the treatment modality. Patients treated with ND-YAG laser showed excellent results in 28%, good results in 44%, and poor results in 28%. On the other hand, cryotherapy followed by intralesional corticosteroid injection showed excellent results in 32%, good results in 40%, and poor results in 28% of patients. It is concluded that both ND-YAG laser and cryotherapy followed by intralesional corticosteroid injection showed satisfactory results in treatment of keloids and hypertrophic scars.

Introduction

A keloid is an overgrowth of dense fibrous tissue which develops in the skin as a result of trauma, although in some cases it may be trivial(1). Several modalities of treatment for keloids and hypertrophic scars have been suggested including surgery, pressure therapy, radiation, intralesional corticosteroids, cryotherapy, laser and systemic medical treatment in the form of corticosteroids, methotrexate, penicillamine and colchicine (2).

ND-YAG laser, has been used successfully in treatment of keloids. This may be due to the relatively deep power of penetration of this laser light or to the selective bioinhibition of the keloidal fibroblast activity by the near infrared radiation of ND-YAG laser(3).

Cryotherapy has been used in treatment of keloids, either alone or in combination with corticosteroids. The freeze causes local oedema that allows for easier infiltration of corticosteroids into the hard, fibrotic keloid mass. The remarkable lack of scarring after cryotherapy makes it an ideal modality for treatment of keloids (4).

The study aims to evaluate the efficacy of ND-YAG laser versus combined cryosurgery with liquid nitrogen & intralesional corticosteroid injection in the treatment of keloids and hypertrophic scars and to predict the possible complications of both modalities.

Patients and Methods

The study was performed on 43 outpatient attendants of the Dermatology clinic of El-Menia University Hospital. The patients were divided into two groups according to the treatment modality. A group of patients treated by ND-YAG laser and another group by combined cryotherapy with liquid nitrogen and intralesional corticosteroid injection by dermojet.

Full history taking, general and local dermatological examination, photographing, as well as explanation of the procedure with its possible results and complications were done for each patient.

Group I (laser group) : The total number of treated patients was 18. The " Opmilas YAG M" laser manufactured by Zeiss, with a wavelength of 1064 nm was used. Infiltration anaesthesia with xylocaine 2 % was required. The entire area to be lasered was chilled with ice bags before, during, and after the laser operation. After calibration of the device, the desired power, pulse mode, pulse duration, pulse interval, and spot size were determined. In the present study, these parameters was standarized as follows :

- Average power from 5-10 watt.

- Power density 50-70 joules/cm2.

- Pulse duration 10-20 msec.

- Pulse interval 10-20 msec.

- Pulse mode = repeated pulse mode.

- Spot size 1-5 mm in diameter.

The laser procedure consisted of treating the target lesion in segmental manner using a test segment in the first session to predict the possible cosmetic results and complications. In the following sessions, after 6 weeks, the laser was applied to the lesion until whitening of the treated area of the skin occured but no vaporization was allowed except in 3 cases where the vaporizational excision technique was used.

Group II (combined cryotherapy and intralesional corticosteroids) : The total number of treated patients was 25. The "WSL Nitrospray II" manufactured by Tower manufacture -San Antonio-Texas was used (liquid nitrogen -196oc). No anaesthesia was required. Surface cryosurgery technique was used in all the cases using either spray, cryoprobe or cryocone technique.

When using the cryoprobe technique, the probe was cooled before applying to the surface of the lesion to avoid adherence of the probe to the site of cryoapplication. Then, the probe tip was applied firmly to the target site. Pressure in varying degrees can influence the depth of freeze. Freezing was continued until the lesion assumed a white frosted appearance. When the frozen area has reached the desired extent, defrosting occurred by releasing the occlusion of the atmospheric vent by the index finger. Then, the probe was allowed to thaw sufficiently before removing it from the treatment site. The freezing was continued until a rim of 2 mm of the surrounding normal tissue became involved in the freezing process.

When using the spray technique, different spray patterns "Spiral, Paint brush, midway zone pattern" was used in a noncontact manner. After complete thawing of the lesion, and waiting for few minutes until oedema occured to facilitate the intralesional injection of corticosteroids by the dermojet. The concentration and dose of steroid injected was decided according to the size of the lesion. The concentration used was 20 mg/ml. The used preparation in the study was triamcinolone acetonide diluted in a percentage of 1:1with the addition of sterile water or xylocaine 2%. In most of the cases, the interval between the cryosurgical sessions was 4 - 6 weeks.

Evaluation of response to both modalities was graded as follows; Excellent when removal or flattening and softening of the lesion with good cosmetic results and minimum complications. Good when flattening and softening of the lesion or decreasing the size of the lesion without recurrence during the follow up with satisfactory cosmetic results. Poor when persistence of most of the lesion or recurrence during treatment without improvement or poor cosmetic results.

Results The age of the patients ranged between 2-65 years. The sex distribution of the patients has shown that males constituted 42 % (18 patients) while females constituted 58 % (25 patients) in the whole study. The response of patients to treatment in both groups was as follows (Fig 1):

- In the laser group, five patients (28%) showed excellent result (Fig 2,3,4,5). Eight patients (44 %) showed good result with satisfactory cosmetic result. Five patients (28 %) showed poor response with poor cosmetic result and many complications.

- In the combined cryosurgery and intralesional corticosteroids injection group, eight patients (32 %) showed excellent results (Fig 6,7,8,9). Ten patients (40 %) showed good result and seven patients (28%) showed poor response with poor cosmetic result. Many factors modified the response of the keloidal lesion to both modalities.

The aetiology of the lesion whether idiopathic or secondary lesions, represented an important measure for the success or failure of treatment. In the laser group, idiopathic lesions responded poorly as they showed no excellent results, 33.3% good results, and 66.7% poor results. Secondary lesions showed, 41.4% excellent results, 50.4% good results, and 8.2 % poor results. On the other hand in cryosurgery group, idiopathic lesions showed no excellent results, 33.3 % good results, and 66.7 % poor results. Secondary lesions showed 42.3 % excellent results, 42.3 % good results, and 15.4% poor results.

The duration of the lesion represented an important parameter in the response of the lesion to both treatment modalities. In laser group, younger lesions (< 1 year) responded well to laser giving a 50 % excellent results, 50 % good results and no poor results. Older lesions (1-5 years) showed 25% excellent results, 75% good results and no poor results. Old lesions (> 5 years) responded poorly, as they showed no excellent results, 16.7 % good results and 83.3 % poor results. On the other hand, in cryosurgery group, younger lesions (< 1 year) responded well to cryosurgery followed by intralesional corticosteroid injection, as 66.7 % of them showed excellent results, 33.3% showed good response, with no poor results. Older lesions (1-5 years) showed no excellent results, 50% showed good results and 50% showed poor response. Old lesions (>5 years) showed 16.6 % excellent results, 41.7 % good results and 41.7 % poor response.

The consistency of the lesions also represented an important parameter in the results of the study. In the laser group, hard lesions responded very poorly to treatment, as they showed no excellent results, 16.4% showed good results, and 83.6 % poor results. On the other hand, in firm lesions, excellent results were observed in 41.7%, good results in 58.3%, and no poor results. In cryosurgery group, hard lesions showed excellent results in 14.3 ý%, no good results, and poor results in 85.7 %. On the other hand, firm lesions showed excellent results in 38.8 %, good results in 55.6 %, and poor results in 5.6 %.

According to the technique of treatment, the results varied in both groups. In the laser group on using the vaporizational excision technique, no excellent results were observed, 33.3% of patients showed good results, and 66.7 % poor results. While on using the blanching defocused technique, 34 % of patients showed excellent results, 46.2 % good results, and 19.8 % showed poor results. On the other hand, in the cryosurgery group on using the cryoprobe technique, 36.3% of patients showed excellent results, 45.4 % good results, and 18.3% poor results. The cryocone technique showed 33.4% excellent results, 66.6% good results and no poor results. Finally, the cryospary technique showed excellent results in 27.3 %, good results in 27.3 %, and poor results in 45.4 %.

As regards incidence of complications in the study; it was developed in 72 % in laser group and 44 % in the cryosurgery group. In the laser group, the complications encountered were; infection 44%, hypopigmentation 12 %, hypertrophic scars 8%, vasovagal attack 4%, and hyperpigmentation 4%. In the cryosurgery group, the complications were; hypopigmentation 18 %, infection 17 %, oedema 4 %, hypopigmentation surrounded by hyperpigmentation 4 %, and hypertrophic scars 2 %.

Discussion

The management of keloids and hypertrophic scars is one of the most difficult problems for the dermatologist. Keloids represent an uncontrolled, random growth of the fibrous tissue(5). LASER is an acronym of Light Amplification by Stimulated Emission of Radiation. If a laser beam is directed at a tissue, it may be reflected back toward the source or absorbed giving many laser tissue interactions that could occur at the time of laser impaction; such as : heat, photochemistry, flourescence, photoablation , ionization, plasma formation and optical force generation(6).

The intense laser light is able to alter a variety of cutaneous tissues by thermal injury in either a nonspecific but highly controllable manner or with high degree of specificity(5). Cryotherapy, originating from the Greek word " Kryon ", meaning " Icy cold", has firmly established itself as a modality for the destruction of superficial benign and malignant lesions(7). Many cryogens are known, but there are four in common use; fluorocarbons , carbon dioxide, nitrous oxide and liquid nitrogen. The boiling temperatures for these cryogens are : -30 to -60, -79, -89 and -196°C, respectively(8).

As regards the response of Keloids to ND-YAG laser, excellent results were obtained in 28 %, good in 44 %, and poor in 28 %. The results indicated that, on using the defocused blanching mode of laser, better results were observed. These results may be attributed to the low power and consequently low extraheat absorbed by the target lesion and its surrounding normal tissues. Chilling the lesion with ice, reduced the extra -heat and improved the cosmetic result.

Kantor et al.(1965)(9) reported that 50 % of his patients, showed complete resolution of their keloids by the use of CO2 laser in its excisional focused mode. Abergel et al.(1984)(10) noticed that keloids respond well to ND-YAG laser in the defocused-blanching mode.

Henderson (1992)(11) treated 1000 hypertrophic scar since 1976 by Argon and CO2 laser, and rarely have seen a recurrence and the overal results of rendering the scars softer, flatter, and less symptomatic has steadily risen from 60 % to a current 90 % while in keloidal lesions, he observed that the laser will cause softening of the keloids in about 60 % of cases but recurrence is inevitable. In the present study, all patients even those showing poor results showed marked reduction and softening in the keloidal mass immediately after laser session.

The results of the present study agree with those of Abergel et al. (1984) (10)and also with the results of Kantor et al. (1965) (9), however they noticed good results with the excisional - focused mode while in the present study we failed to have excellent results using this technique. On the contrary to Henderson (1992) (11), recurrence of keloids in our study was observed in only 28% of patients, during the follow up period of 18 months. The difference may be due to different laser modes, power densities, wavelength, and techniques used in each study.

In the present study, 72 % of laser group patients developed complications. Infection was the commonest complication as it occurred in 44 % and using systemic and local antibiotics is advised during and after laser sessions. Hypopigmentation was observed in 12 % of patients and it was temporary. On the contrary to Arndt and Noe (1982)(12), hypertrophic scarring developed in only 8 %. Hyperpigmentation was observed in 4 % of patients. Vasovagal attack was encountered in 4 %.

Ceilly and Babin (1979) (13) reported satisfactory results in treating keloids with cryotherapy followed by the intralesional injection of triamcinolone acetonide. As regards the results of treatment of keloids with combined cryosurgery using liquid nitrogen and intralesional corticosteroids in the present study, 32% showed excellent results, 40% good results, and 28% poor results. Cryoprobe and cryocone techniques gave better results than cryospray method and This may be attibuted to the fact that the more the depth of freeze, the greater the compromise of the microcirculation and this effect is well achieved by the cryoprobe and cryocone techniques in whom more pressure could be applied to the lesion.

Meltzer (1983) (14) reported satisfactory results on 32 patients using a cryoprobe and a double freeze cycles as the only treatment. Shephard and Dawber (1982) (15) treated 17 keloids by cryosurgery with liquid nitrogen and they reported poor response to cryosurgery, however they treated old lesions using an open spray technique.

Mostafa et al.(1990) (16) treated 8 keloids; 4 by cryotherapy and 4 by combined cryotherapy and intralesional corticosteroids injection. The cryogen was Nitrous oxide. Results showed improvement in all keloids, especially traumatic and postburn variety. In the present study, 44 % of patients showed complications when treated with combined cryosurgery and intralesional corticosteroids. Hypopigmentation in 18 % is considered an inevitable copmlication of cryosurgery as melanocytes are completely destroyed at -4 oc. Infection in 17 %. Two patients 4 % having lesions in their forearms developed oedema of the limb. Hypopigmentation surrounded by hyperpigmentation in 4% and hypertrophic scarring in 2 %. Many parameters must be considered when evaluating the efficacy of treatment in keloids. These parameters include; duration, consistency, and aetiology of the lesion. Old lesions showed poor response while younger ones showed excellent results and this agree with the results of the study of Zacarian (1973) (17) and Shephard and Dawber (1982) (15). These results may be due to the fact that younger lesions are more vascular especially at the periphery of the lesion, as keloids in their early stage tend to form fibroblast and vascular proliferations. On the other hand, in older lesions fibrous tissue is laid down and collagen becomes thick and hyalinized. The desired therapeutic effects on dealing with keloids depends greatly on the degree of microcirculatory failure produced by therapy. Meanwhile, hard lesions showed poor results while firm lesions showed good and excellent results and this could be attributed to the less vascularity of the old lesion and the difficulty of penetrating the lesion during intralesional injection. Again, idiopathic lesions showed poor results while secondary lesions showed good and excellent results and this agree with the results of Mostafa et al.(1990)(16).

Finally, it is concluded that ND-YAG laser and cryosurgery followed by intralesional corticosteroids showed very similar cure rates in treatment of keloids but cryosurgery showed more tolerability by the patient and less complications. Both methods could be considered as an optimum therapeutic modality for treatment of keloids and hypertrophic scars. However, good selection of the patient for achieving the best results should be fulfilled on the basis of, younger, secondary, firm, more vascular lesions will give excellent results whether treated by ND-YAG laser or cryosurgery followed by intralesional corticosteroid injection.

References

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