With Dr Helen Douglas.

Today I’d like to welcome to the PodMD studio Dr Helen Douglas

Dr Helen Douglas is a Specialist Plastic Surgeon at The Scar Clinic Perth, specialising in burns, scarring and laser treatments.
Dr Douglas graduated in medicine in 2004, before starting her specialist plastic surgery training in the UK in 2011 which she completed in Perth, WA. Helen is a Fellow of the Royal Australasian College of Surgeons and the Royal College of Surgeons of England and was awarded the prestigious Ian McGregor Gold Medal for outstanding performance in her specialist examinations in 2015.

Helen is currently a Senior Lecturer at The University of Western Australia and a Clinical Tutor at Cardiff University where she undertook her Master’s degree in Laser and Wound Healing and has done 2 laser fellowships.

Today, we’ll be discussing the topic of Keloid Scars

*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

The topic of today’s discussion is keloid scars. Helen, can you describe for our listeners what a keloid scar is?

Helen: Well interestingly, humans are the only species that keloid scars are present in, and they’re pretty similar in men and women, but women tend to present more often for treatment, so the literature shows that there’s slightly more females being treated. They usually start between the age of about 10 to 30, so they’re not really seen in the very young or the very old. And usually it’s in the more pigmented skin types. So certainly black skin and Southeast Asian skin and southern Asian skin, more than Caucasian. But they can occur in any skin types. There are certainly some genes identified. They run in families, so the typical patient might have some in their relatives and they’re often on particular sites of the body – ears, the jaw and the deltoid region of the arm and chest. They’re thick, they’re sore, itchy and red and worryingly, they can get bigger if you operate on them or injure them in any way.

Could you provide an overview of the various treatment options available for keloid scars?

Helen: So there’s lots of non-invasive therapies that people use and those include things like moisturizers and silicone therapy to make sure that the scar stays hydrated. Steroid tapes to try and apply some steroid to the scar and of course pressure. Pressure therapy on a keloid scar reduces the blood flow into the scar and will prevent it from growing, but it’s hard to apply pressure to all areas of the body. Some areas, like the ear lobes, you can get pressure buttons for but if it’s the centre of your chest, quite difficult to apply pressure to that all the time.

Then we’ve got the non-operative options and those are the ones I’ll be focusing on today mainly. And that’s the CO2 laser and steroid injections. But in addition to that, there are other things like injections of anti-metabolites or chemotherapy agents such as 5 fluorouracil, bleomycin and the like; all aim to turn off this excessive growth of what is essentially a benign tumour.

Then you go on to the operative side of things, but if you remember, I’ve already said that any injury to keloids can make them worse. So surgery is often reserved for the types of scars that are so big that they are causing serious functional problems, and then they are removed with the knowledge that almost 100% of the scars will grow back if they’re not treated with other things and I’ll come back to that. Some of them are so big they need skin grafting and then that skin graft starts to keloid as well and continues to grow. So an operative intervention has previously been something that was a last resort and with the knowledge that it will make it worse.

Then there’s the post-operative treatments and again the classic of this is pressure. So once you’ve removed a keloid, let’s say from the ear lobe, you can apply a pressure button and that will put pressure on the wound to stop it from growing back. And that’s pretty effective about 80 to 85% of people will have less growth of their keloid back with good pressure on the ear lobe. But also things like radiotherapy have been used, particularly in areas that you can isolate so that you don’t give too great a dose because obviously there’s carcinogenic risks with that as well.

It’s best as a multimodal therapy. So a complete combination of what I’ve described and what we have found in the last few years in the literature and also in our own studies, is that laser combined with steroid and perforates holes in the scar and then the steroid is able to distribute through the scar more equally.

Are there any conditions which can masquerade as keloid scars?

Helen: Most keloid scars you can tell from the history. There’s an injury that could be quite insignificant, then there is a resulting scar which grows and is excessive, continues to grow. And that’s the classic history where you can be fairly sure it’s a keloid. However, there’s a few that are a bit more unusual in their presentation and some of them can masquerade as keloids when actually they’re are slightly different condition such as cutaneous sarcomas, which is a particular type of cancer which grows in the skin.

The classic one is called DFSP, which stands for dermatofibroma sarcoma protuberans, which is a bit of a mouthful, but that looks like a keloid. It spreads slowly like a keloid and grows slowly like a keloid, but it’s actually a skin cancer, so I’d say the ones that just don’t have the classic history, the ones that aren’t responding to steroid treatment are the ones that people, including myself need to think ‘does this need a biopsy?’ which is something you don’t undertake lightly because any injury as we’ve said could make it worse. But there are some conditions that can masquerade as keloids yes.

Why are Keloid scars so difficult to treat?

Helen: Well, as we’ve said, anything that we do to them, any injury, can make them worse, you know, and lots of people say they’ve got spontaneous keloids when it was probably an insect bite or a scratch, something so minor. So if you think of that, then people are very reluctant to treat them, quite reasonably, because they’re worried about making these quite awful scars worse for their patients. As we’ve said, surgery has got a near 100% risk of recurrence unless it’s followed by pressure or radiotherapy and in some areas like the chest, we have said you just can’t do either of those.

So you’re a bit stuck. However, I think that CO2 laser and steroid combined has been a game changer for this, because it treats the scar without injuring it as the fractionated delivery means that they heal within two days and I have previously talked about fractionated delivery. But I’ll just summarize it quickly. It’s where the energy of the laser instead of just burning the top of the scar, is delivered in micro columns so that it can target the depth of the scar and stimulate healing without creating too much of an injury. I have done this for many years and I can count on one hand the number of keloids that I’ve seen that have gotten worse with CO2 laser, which is really important.

What is the likelihood of success of laser treatment? What are the risks?

Helen: It’s a good question because keloids are traditionally, very resistant to a lot of treatments and most people that come to see me have had several steroid injections for their keloids and steroids can be a really good treatment for some keloids. Some respond very easily and I think the difficulty in predicting success is that that all keloids are different. However, I think that in terms of steroid and laser treatment combined, like I said before, you can drill channels into the scar. And then the steroid dissipates through the holes easier, so it disperses easier. I think you can apply that steroid throughout more and the effect of the laser potentiates it and I think about 95% of patients I treat with keloids have significant reduction in the itch and the pain they feel within a couple of weeks, which is important as these are itchy painful scars.

I think about 60 to 70% of the keloids I treat with scar therapy, laser and steroid get about 60 to 70% flattening of their keloids. So 60-70% of people I think are happy that their keloids are softer and flatter, but most of them need between 3 and 6 treatments. And of those, I reckon about 50% need a couple a year to maintain the effects and to prevent regrowth because as we’ve said, all keloids are different and some of them continue to grow.

I think it’s all about patient expectations. If you say to people 3 out of 10 of you will be slightly disappointed because it won’t go completely flat the I think people can be happy that it will get rid of the pain and the itch and soften and flatten in 70% of cases.

When should a GP refer?

Helen: Well, I think the GP will know the patient and if they’ve got a keloid that is bothering their patient and if a steroid injection hasn’t worked, which is usually the 1st port of call, then that’s a good time to refer it.

f they’re concerned that the keloid hasn’t responded to steroid or that it’s slightly unusual then that could be a good time to refer it, or just if there’s multiple keloids, or they’re quite sore because like I say, the laser combined with the steroid dissipates it easier and I think it’s less painful to inject in that manner.

What role does the GP play in the treatment of the condition?

Helen: I think the recognition and acknowledgement by their own General practitioner that these are really difficult scars. A lot of people sometimes think you know, oh, it’s just a cosmetic thing, but it’s not. These scars are really itchy; they’re full of blood and they increase the discomfort when they exercise because the blood flow goes to them. It affects quality of life. So I think that your own family doctor can empathize with you in a way that a specialist probably can’t because we don’t see them as much, so that acknowledgement that these are really difficult and it’s not just a cosmetic issue. And just the knowledge that there are treatment options available, particularly if the steroid hasn’t worked so well.

Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Keloid scars?

Helen: Sure. So I think the 1st is that

1. CO2 laser has been a game changer for keloid scars. It’s low risk and potentially high yield.
2. Keloid scars can be really improved as long as you use a multimodal approach of laser, steroid and scar therapy and you manage your patient expectations.
3. There’s very little risk worsening a keloid with this approach and that is so important for these patients who have already got a bad scar.

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