Keywords
keloids - ear piercing - electrons - radiation therapy
Introduction
Keloids are essentially a result of excessive pathological scarring, which, along
with the cosmetic distress, may lead to pruritus and pain in certain patients.[1] Ear piercing is very common among females, which makes them susceptible to develop
keloids over the ear as a tract is formed in the subdermal region following the piercing
injury.[2] Due to the extensive prevalence of ear piercings in Indian females along with the
increased susceptibility of keloids formation in pigmented populations,[3] keloids are not an uncommon problem in the country. There exist no standardized
guidelines for use of any treatment modality. Clinicians have tried using compression
therapy, various surgical techniques, radiation therapy (RT), cryotherapy, topical
and intralesional chemotherapy, intralesional steroids, and various types of lasers
to treat keloids.[4] It was in 1898 that RT in form of X-rays was used to successfully treat hypertrophic
scars for the first time.[5] Surgery followed by RT is commonly accepted as one of the standard treatments of
keloids, with the addition of RT in the immediate postoperative period helping in
decreasing the risk of recurrence.[6] We retrospectively analyzed the cases of ear keloids treated with surgery followed
by immediate postoperative electron beam RT in Indian females at our tertiary care
hospital.
Materials and Methods
Sixteen different sites of ear keloids in 10 patients treated at our institute from
January 2013 to October 2015 were analyzed retrospectively. The criteria followed
for considering patients for electron beam RT treatment were patient age between 18
and 75 years, recurrence of keloid following at least one prior local therapy, and
a signed consent following detailed discussion with treating radiation oncologist
regarding efficacy and possible adverse effects of RT. Patients not fitting into the
inclusion criteria were not treated with electron beam radiation and hence were not
included in this study. All these patients had undergone surgical excision of the
keloids followed by external electron beam RT to the postoperative site: 87.5% (14
sites in 8 patients) starting RT within 24 hours and the remaining 2 within 48 hours.
All patients were treated with 10 Gy in two fractions, 5 Gy per fraction delivered
over 2 consecutive days. All patients were reviewed in radiation oncology outpatient
department after 03 months of RT. Telephonic interviews were carried out with all
the patients up to May 2021. Data was collected from patient treatment and follow-up
records and the telephonic interviews.
Prior approval of the institutional ethical committee was taken for analyzing these
patients.
All patients were assessed for cosmetic outcome following RT, complications due to
radiation, and long-term disease control in terms of recurrence of keloids.
Results
All patients in out series were females aged between 19 and 74 years at the time of
treatment with median age of 27 years. Eight out of 10 patients were aged less than
45 years. Other patient characteristics are shown in [Table 1]
Table 1
Patient characteristics
|
Age
|
|
Age range
|
No of patients
|
|
< 20
|
2
|
|
20–40
|
5
|
|
41–60
|
1
|
|
> 60
|
2
|
|
Number of sites treated
|
|
Sites treated
|
No. of patients
|
|
1
|
4
|
|
2
|
6
|
|
Total
|
10
|
|
Laterality
|
|
Right ear
|
9
|
|
Left ear
|
7
|
|
Total
|
16
|
As per the inclusion criteria, all patients had had a prior local therapy for keloid;
and RT was used for the recurrent keloid following surgical excision. A standard fractionation
schedule of 10 Gy in 2 fractions delivered over 2 days was used across all patient
treatments. Direct en face fields conforming to cover the postoperative scar with
adequate circumferential margins were used. About 93.7% sites (15 out of 16) were
treated with 6 MeV electron beam, while 9 MeV beam was used to treat one site as per
the treating physician's discretion.
At the time of final interviews/follow-up, median time since treatment for 10 patients
and 16 sites was 78 months (range: 67–100 months). Of the 16 sites treated, 11 (68.75%)
did not have any recurrence of keloids nor needed any further form of treatment. Five
sites saw recurrence of keloids at the irradiated site, all of them were seen between
12 and 36 months of follow-up, with four (80%) happening within first 24 months of
follow-up. Three of the five recurrences were in patients treated for one site only;
two were in patients treated for both ears, with the contralateral ear in both these
patients not seeing any recurrence. No preponderance of laterality was seen in recurrences;
03 on right and 02 on left ear. Median recurrence free period for entire cohort was
67 months (range: 12–100 months). No relationship between post-RT recurrence and first
treatment modality were observed. Age of patients with recurrent lesion ranged from
19 to 42 years; none of these patients had any comorbidity. In our series, only two
patients were aged more than 42 years, both of whom had no recurrence. However, the
number is too small to attach any significance to the same. None of the 10 patients
reported any adverse effects due to radiation, either short or long term. Cosmesis
achieved following radiation was also acceptable to all patients; no long-term effects
in form of skin darkening or thickening were seen in our series of patients. Patients
getting recurrence at the treated site were bothered by the keloids appearance rather
than any adverse effects of radiation. Four patients were treated with intralesional
steroids for the recurrent lesion, while the fifth patient decided against any treatment,
as the recurrent keloids was stable and did not cause any severe symptoms.
[Fig. 1] shows presurgical 03 weeks post-RT and 76 months post-RT image of youngest patient
in our cohort.
Fig. 1 Keloid in a 19-year-old girl over right ear that developed following piercing injury
(A). Second image (B) shows the right ear at 3 weeks post-surgery and radiation therapy (RT) with electron
beam. Third image (C) shows the present-day condition of right ear at 76 months from RT showing excellent
cosmesis and no long-term sequela like change in pigmentation due to RT.
Discussion
While keloids can develop at site on skin, ear is a common site among females owing
to the injury caused by piercing. A study evaluating relationship between keloids
formation and age of ear piercing showed that as age of ear piercing increases, risk
of developing keloids also increases, more so in females with family history of keloids.[7] Another study of 141 ear keloids found a possible correlation between ear keloids
and metallic backs of earrings, which leads to a local neurogenic inflammation further
leading to more frequency of keloids over posterior surface of the ear lobule.[8]
As with other sites of keloids, multiple treatment modalities have been tried for
treating ear keloids with an aim to achieve acceptable aesthetics and reduce chances
of recurrence. One study evaluated liquid silicone gel application to postoperative
site following excision of keloids tract using loupe magnification technique. Authors
studied results in 26 keloid excisions done in 22 patients. They reported a very good
control rate with recurrence seen in only two patients, managed with intralesional
triamcinolone.[9] In a systematic review and meta-analysis done to evaluate efficacy of intralesional
botulinum toxin, it was seen that that the toxin was significantly more effective
than intralesional steroids or placebo. Authors in the analysis had used visual analogue
scale, Vancouver scar scale, and scar width as comparison points, all of which showed
statistically significant superior efficacy for botulinum toxin type A in treating
hypertrophic scars and keloids.[10] Another systematic review analyzed role of intralesional 5-fluorouracil (5-FU) either
as a single agent or in combination with triamcinolone acetonide (TAC). In 18 eligible
studies for the review, 482 patients' data was evaluated; overall efficacy of 45 to
96% for 5-FU was seen; however, a sizeable proportion of the studies had a follow-up
of less than 1 year in the review. Authors concluded that while 5-FU alone may not
perform better than TAC, TAC:5-FU combination may fare better than TAC alone.[11] Cryotherapy has been used for the treatment of both primary keloids and therapy-resistant
keloids. One randomized controlled trial assessing its efficacy against excision followed
by steroid or brachytherapy, however, had to be terminated prematurely due to inferior
results. Brachytherapy following excision was seen to be superior to intralesional
cryotherapy in terms of cosmesis as well as scar related symptoms of pruritus and
pain. While excision with steroid injection was not statistically better than cryotherapy,
it was seen to improve scar appearance.[12] Another large systematic review, which included 25 studies, looked at efficacy of
triamcinolone and RT as an adjuvant to control recurrences following surgical excision.
While recurrence rates for steroid treatment and for RT were estimated at 15.4 and
14%, respectively, no significant difference was seen between the two modalities.[13]
RT in the form of teletherapy with electrons or superficial X-rays and brachytherapy
as surface mold or interstitial have been used for the treatment of keloids for a
long time, with its application significantly reducing the risk of recurrence post
excision.[14] While multiple studies show efficacy of radiation therapy; only a few of them have
follow-up period as long as ours. The long-term follow-up while establishing the control
rates also provides important information with regard to adverse effects like skin
pigmentation and secondary cancers.
Superiority of brachytherapy versus teletherapy in terms of local control, however,
is a debated topic with evidence available in favor of both modalities.[15]
[16]
[17] A study reported outcomes of superficial high dose rate brachytherapy application
with molds in immediate postoperative period in 80 patients, 90% of which had ear
keloids. Authors reported excellent control rates of 95% after a mean follow-up of
22.18 months. Though all were grade 1, acute toxicity of epithelitis was seen in 15%
patients; and chronic hypopigmentation and fibrosis were seen in 27.5 and 22.5% patients,
respectively.[18] A French study reported outcomes of electron beam and brachytherapy treatment retrospectively.
In vast majority of the 116 scars treated with electron beam, 15 Gy was delivered
in five fractions with control rates of 69% at 2 years and 55% at 5 years. While the
total dose delivered in our institution was lower than this study, control rates were
comparable in both cohorts, 75% at 2 years and 68.75% at 5 years in our cohort.[16]
While surgical excision followed by RT is widely accepted as an effective modality
to treat keloids, optimum fractionation schedule is still elusive. Doses have ranged
from prolonged schedules of 20 Gy in five fractions[19]
[20] to upcoming single-fraction schedules of 10Gy in one fraction.[21] Ogawa et al from Tokyo, Japan, have published their experience with different fractionation
schedules through the years ranging from 20Gy in four fractions to 8 Gy in single
fraction. They advocate use of different fractionation schedules for different sites,
with higher doses being used for sites with preponderance for recurrence, like anterior
chest wall. For ear lobes, the authors have reported their experience with 15Gy in
three fractions, 10 Gy in two fractions, and 8 Gy in one fraction. Over the years,
the authors have been able to maintain acceptable local control rates while decreasing
the total dose used to treat ear lobes in postoperative setting.[22]
[23]
The authors from Japan, while describing various fractionation schedules used for
different sites of keloids, also discuss effects of varying surgical modalities on
keloid recurrence rates. Surgical procedures used by authors are wide excision, core
excision, subcutaneous/fascial tensile reduction sutures, and z-plasties, with the
latter ones being used for sites notorious for multiple recurrences, for example,
anterior chest wall and suprapubic region. The authors attribute their improved control
rates to newer surgical as well as RT techniques/fractionation schedules.[23]
Comparison with other studies using external beam RT (electron and kV beam) is shown
in [Table 2].
Table 2
Comparison of different studies using radiation therapy
|
Sl. no.
|
Study author
|
Patients treated with radiation
|
No of sites treated
|
No. of ear keloids treated with electrons
|
Total dose/fractions
|
Mean/median follow-up period (mo)
|
Control rates
|
|
1
|
Hoang et al[15]
|
108
|
236
|
Not specified (electron beam and kV beam used)
|
9 to 30 Gy in 1 to 10 #
|
42
|
81% at 3.5 years
|
|
2
|
Yossi et al[16]
|
95
|
116
|
88
|
15Gy/ 5#
|
70
|
69% at 2 years 55% at 5 years
|
|
3
|
Rishi et al[19]
|
22
|
40
|
11
|
20Gy/5#
|
35
|
91% at 3 years
|
|
4
|
Song et al[21]
|
12
|
16
|
8
|
10Gy/1#
|
20
|
100% at 1.6 years
|
|
5
|
Chaudhry et al.[24]
|
36
|
36
|
0 (kV beam used)
|
18Gy/3#
|
67
|
97.3% at 5.6 years
|
|
6
|
Our study
|
10
|
16
|
16
|
10Gy/2#
|
78
|
68.75% at 6.5 years
|
A frequent point of concern on using RT for benign diseases is the risk of secondary
carcinogenesis. A 2009 study evaluated the risk specifically in cases of keloids treated
with radiation. Evaluation of studies published over a period of more than 100 years
showed only five cases of carcinogenesis, leading the authors to conclude that the
risk is very low, even more so when the surrounding critical organs like thyroid and
breasts are adequately shielded. RT is an effective and acceptable form of treatment
for keloids.[6]
While retrospective nature and small sample size are shortcomings of our series, the
potentially longest follow-up period as compared to other similar studies is an important
factor in establishing the long-term efficacy and safety of this treatment modality.
Electron beam with its inherent quality of high relative entrance absorbed dose forms
an efficacious and acceptable way of treating such lesions, especially for centers
without dedicated superficial X-ray machines.[25]
Conclusion
Our series of keloid patients provides evidence in favor of electron beam RT in attaining
long-term control when delivered in immediate postoperative period. The lower total
dose with higher dose per fraction used in our patients effectively deals with the
bulk of keloids along with good cosmesis and absent adverse effects.
