Comparison of therapeutic response of keloids and hypertrophic scars to cryotherapy plus intralesional steroid and bleomycin tattoo

Fatemi Naecini Farahnaz; Najafian Jamshid; Ahmadpour Koroush

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Year : 2005 | Volume : 50 | Issue : 3 | Page : 129-132

Comparison of therapeutic response of keloids and hypertrophic scars to cryotherapy plus intralesional steroid and bleomycin tattoo

Fatemi Naecini Farahnaz¹, Najafian Jamshid², Ahmadpour Koroush¹
¹ Department of Dermatology, Internal Medicine, Isfahan University of Medical Science, Isfahan, Iran
² Department of Cardiology, Isfahan University of Medical Science, Isfahan, Iran

Correspondence Address:
Fatemi Naecini Farahnaz
Department of Dermatology, Internal Medicine, Isfahan University of Medical Science, Isfahan
Iran

Source of Support: None, Conflict of Interest: None

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Abstract

Keloids and hypertrophic scars are abnormal responses of body to skin injuries. Overproduction of compacted fibrous tissue is the basic cause of these lesions. In this study the result of treatment of these skin conditions with bleomycin tattoo are compared with cryotherapy and triamcinolone injection. This study involved 45 patients with hypertrophic scar or keloid. Patients were divided into two groups consecutively. Group A (23 patients) was treated with bleomycin tattoo and the group B with cryotherapy and triamcinolone injection. There were four therapeutic sessions one month apart. All patients were followedup for three month after the end of treatment .The therapeutic response was determined as reduction of lesion size or flattening relative to initial size. Therapeutic response was 88.3±14% in group A and 67.4 ±22.5% in group B (p<0.001). In group A 69%, but in group B only 49% of patients were asymptomatic after the end of treatment. In group A there was no relation between therapeutic response and lesion size (p=0.58) but in group B lesions those were smaller (<100mm2) had better therapeutic response than larger ones (p=0.007). It was concluded that bleomycin tattoo is more effective in treatment of hypertrophic scar and keloid than traditional treatment, cryotherapy plus triamcinolone injection especially in larger ones.

Keywords: Cryotherapy, Bleomycin tattoo, Keloids and hypertrophic scar

How to cite this article:
Farahnaz FN, Jamshid N, Koroush A. Comparison of therapeutic response of keloids and hypertrophic scars to cryotherapy plus intralesional steroid and bleomycin tattoo. Indian J Dermatol 2005;50:129-32

How to cite this URL:
Farahnaz FN, Jamshid N, Koroush A. Comparison of therapeutic response of keloids and hypertrophic scars to cryotherapy plus intralesional steroid and bleomycin tattoo. Indian J Dermatol [serial online] 2005 [cited 2023 Dec 2];50:129-32. Available from: https://www.e-ijd.org/text.asp?2005/50/3/129/18924

Introduction

Keloids and hypertrophic scars develop as a result of proliferation of dermal tissue following skin injury. It is generally thought that tension plays a major pathophysiologic role. These proliferative scars are characterized by increased collagen and glycosaminoglycan content, as well as increase collagen turnover.[1] Hypertrophic scars are distributed in all races but keloids are more common in races with pigmented skin.[2] The common causes of these lesions are burn, surgery and vaccination. These lesions are more prevalent in age from 10 to 30 years.[3] In pregnancy and adulthood the keloid may grow to larger size. These lesions contain neuropeptide and nerve ending so they may cause symptoms like pain and itching.[4] Keloid had been reported from 1700 BC but there is no well established treatment for this lesion until now. The therapeutic management of hypertrophic scars and keloids includes occlusive dressings,[5] compression therapy,[6] intralesional corticosteroid injections,[5] cryotherapy[5], intralesional 5FU,[7],[8] excision,[9] radiation therapy[9], laser therapy[10],[11], interferon therapy[12] and other promising lesser-known therapies directed at collagen synthesis[13],[14].

Bleomycin tattooing has only been used in a few studies for the treatment of hypertrophic scars and keloids.[15],[16] In this study, the therapeutic efficacy of bleomycin tattoo in these conditions are compared with cryotherapy plus triamcinolone injection.

Materials and methods

This was a clinical trial. All patients who visited from may 2002 to may 2003 in clinics of Isfahan University of Medical Sciences, with diagnosis of hypertrophic scar or keloid, were enrolled in the study. Because of probability of drug complication pregnant woman and children less than 15 years old were excluded.

Patients were divided into two groups. Group A was treated with bleomycin tattoo and group B with cryotherapy and IL triamcinolone injection.

Using insulin syringe and bleomycin drop with concentration of 1.5 mg/dl tattooing was done with 40 punctures/5mm2. In group B after cryotherapy for 30 seconds triamcinolone acetonide with the concentration of 40mg/ml was injected into the lesion.

In this study the therapeutic response was defined as the reduction in lesion thickness (flattening of the lesion) relative to the initial thickness.

After data collection statistical analysis was done using descriptional statistics, T-test, Spearman correlation test and Chi-square test.

Results

Forty five patients took part in this study; 23 in group A and 22 in group B. The mean age of group A was 28 years and of group B was 26.3 years.

Thirty patients had only one lesion and 15 had multiple lesions.

In [Table - 1] the distribution of frequency of lesions size and in [Table - 2] the therapeutic responses of these groups are depicted along with their complications.

The relative means of resolution score in bleomycin group was 88.3±14% and in the other group treated with cryotherapy and IL triamcinolone was 67.3±22.5% .T test showed that the therapeutic response in bleomycin group was better than the other group (P =0.001).

The difference in therapeutic response was significant for patient less than 30 years old (p<0.001), but not for patients over 30 (P=0.16).

For both groups, the location and the number of lesions were not correlated to the therapeutic response. The therapeutic response was also not correlated with duration of disease.

In the bleomycin group, the size of lesion did not affect on resolution rate (p=0.58), but in the other group, lesions less than 100mm2 responded meaningfully better than the larger ones (P=0.007).

The therapeutic response in lesions less than 100 mm2 was more than 88% in both groups, but about larger lesions the therapeutic response in bleomycin group was meaningfully better than the other group (P=0.03).

The commonest complication of bleomycin tattoo was hyperpigmentation, which was seen in 75% of patients, but it was not observed in group B.

Hypopigmentation (18%) and telangiectasia (20%) were the most common complications in group B, which were not seen in the group A.

Discussion

In our study most of the patients (68%) were female which is in contrast with other reports that showed equal distribution in male and female rates.

Sixtysix percent of our patients were between 15-30 years and 34% are older than 30yrs, which correlate with other reports.[3]

Relative mean of resolution score in bleomycin group was 88.3%±14% (47% complete response, 3% therapeutic response more than 80%, 17% therapeutic response between 60-80%) whereas Agustin Espana, et al, in 2001 reported 53.8% of complete response, and 38.4% of excellent response (more than 90% resolution).[16] Lower response rate in our patients may be due to our patients' skin type, which was mainly type IV and V.

The relative means of resolution score in group B that had been treated with cryotherapy and triamcinolone injection was 67.3±22.5% that correlate well with results of other studies.[17]

Bleomycin tattoo has only been used in a few studies for the treatment of hypertrophic scars and keloids and our study is the only one that compared the therapeutic efficacy of cryotherapy plus IL triamcinolone with bleomycin tattooing.

T test showed that the therapeutic response in bleomycin group was meaningfully better than the other group (P =0.001).

In this study, the response of small lesions to both treatment regimen, was favorable but with increase in size of lesions, therapeutic response to cryotherapy and IL steroid injections decreased, but to bleomycin tattooing didn't changed. This result confirms the recommendation of some authors who suggests that intralesional steroid being only treatment modality for minor keloids with smaller size.

Twentytwo percent of our patients after four session of treatment with bleomycin, had pruritus to the contrast with report of Agustin, that showed that all of his patients became symptom free after treatment.[16]

The most common complication in bleomycin group was hyperpigmentation in 75% of patients, which was seen more than other reports.[16] This may be due to our patients skin type in this region of world. (skin Type III- IV). However, in contrast; the complications like telangiectasia and atrophy in other group(18% and 20% respectively), which are permanent, this complication is temporary.

Conclusion

On the basis of this study and a few other reports about efficacy of bleomycin in keloids and hypertrophic scars[15],[16] and because of low cost, good results especially in larger lesions (even larger than 100 mm2 and negligible absorption into circulation[16] we recommend bleomycin as appropriate treatment for the larger lesions on covered areas.

Overall, this study showed that bleomycin is more effective in treatments of hypertrophic scars and keloids than traditional treatment with cryotherapy plus triamcinolone injection especially in larger lesions.

References

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17.	Lahiri A, Tsiliboti D, Gaze NR. Experience with difficult keloids. Br J Plast Surg2001;54(7):633-5.53 antigen expression in cutaneous