Effect of combination therapy in the treatment of auricular keloid

Keloids are dermal fibroproliferative benign disorders that develop at the site of cutaneous injury, due to an imbalance of the mechanisms that control tissular repair and regeneration. The pathogenesis is not well understood, however it is postulated that an imbalance between anabolic and catabolic factors occurs in the healing process, resulting in overproduction of collagen. There are several treatment modalities, nevertheless recurrence rates are high. The objective of the present paper is to describe five cases of keloid in the ear lobe that showed a good response to a combination therapy: excisional surgery, corticosteroid injection, and pressure device.


INTRODUCTION
Keloid is an abnormal proliferation of cicatricial tissue formed during the healing process, usually in the location of cutaneous injuries.It does not regress spontaneously, grows beyond the original edges of the scar and should not to be mistaken with hypertrophic scars, which are elevated, do not grow beyond the original margins and can regress over time. 1,2 t occurs in a percentage that varies from 5% to 15% of scars, only in humans, at a mean onset age of between 10 and 30 years.
In general, it arises within one year after the event of a cutaneous injury and is 15 times more common in individuals with more intensely pigmented skin than in those with less pigmented skin. 3Prolonged inflammation is one of the major risk factors for the development of keloid. 4Some regions of body are more susceptible to the formation of keloids, such as the anterior thorax, anterior surface of the neck, shoulders, arms, ears and in wounds perpendicular to the skin's tension lines. 4][5] Growth factors and cytokines are intimately involved in this process.There is an increase in transforming growth factor β (TGF-β), that regulates the proliferation of fibroblasts and collagen synthesis, promoting the differentiation of fibroblasts into myofibroblasts.Myofibroblasts present an important role in the contraction and remodeling of granulation tissue due to its ability to contract actin filaments and to increase the synthesis of collagen.
Other factors involved include the increase in mast cells, elastin, glycosaminoglycans, tumor necrosis factor β (TNF-β), interferon β (IFN-β), platelets derived growth factor (PDGF), insulin-like growth factor 1 (IGF-1) and interleukin 6 (IL-6), in addition to the decrease of the apoptosis in fibroblasts and of factors that reduce the synthesis of collagen type I, III, and possibly IV (TNF-β, IFN-β and g, and metalloproteinase 9). 4,5 here is also alteration of the immune response, with a predominance of Th2 lymphocytes that promote fibrogenesis at the expense of Th1 lymphocytes, which attenuate the fibrosis of tissues. 4,5 ere are no guidelines for the treatment of keloids, and among the diverse treatment modalities, there is an effort aimed at achieving the best treatment -one that offers the lowest recurrence rate, due to the aesthetic and functional alterations as well as the impact on the patient's quality of life that these lesions cause. 5,6 e objective of the present paper is to report five cases of keloid in the ear lobe that did not recur after being treated with a combination therapy: excisional surgery, corticosteroid injection and the use of a pressure device.

CASE REPORTS
CASE 1: VJS, 14 years old, phototype III, describes the appearance of a keloid in the lobe of the left ear (Figure 1), two years before, after having the ear pierced.The partial removal of the keloid was performed 10 months before the present paper was approved for publication, with subsequent local monthly injection of 40mg/ml triamcinolone acetonide and the use of a pressure device (Delasco ® ,Council Bluffs, Iowa, USA) for 8 to 12 hours daily (Figure 2).Outcome nine months after the beginning of the treatment (Figure 3).CASE 2: LPR, 46 years old, phototype III, developed keloids in the earlobes following the piercing of the ears (Figure 4).Underwent four previous surgeries and serial injections of corticosteroids without success.Three months before the present paper was approved for publication, the partial removal of the keloid was carried out in the right ear, associated with monthly injections of triamcinolone acetonide and use of pressure devices (Figure 5).CASE 3: AGP, 21 years old, phototype V, alleges having keloids in both earlobes for six years.Has undergone two previous surgeries, with recurrence.The partial removal of the keloid was performed three months before the present paper was approved for publication.The patient is in use of pressure device and monthly triamcinolone acetonide injections (Figure 6).4: ACSS, 40 years old, phototype V, describes the emergence of a keloid in the right ear lobe two years before the present paper was approved for publication.The patient had previously undergone six injections of corticosteroids without success.One year before the present paper was approved for publication the partial removal of the keloid was performed, associated with local injection of 40mg/ml triamcinolone acetonide and the use of a pressure device for 8 to 12 hours daily (Figure 7).CASE 5: DC, 25 years old, phototype III, reports the onset of bilateral auricular keloids five years before.Surgery to partially remove the keloid was performed three years before.Injections of corticosteroids have been applied since then, combined with the continuous use of a pressure device, without recurrence (Figure 8).
All cases underwent intralesional excision of the keloid with an almost complete removal, leaving in place a thin portion of the affected tissue, where primary suture was performed with   It is believed that the pressure devices promote hypoxia, collagen degradation and increased collagenase activity due to the reduction of the α-macroglobulins activity. 1 In addition to reducing the time of scar formation, they re-direct the collagen fibers and increase the levels of hyaluronic acid. 6As a result, pressure earrings (ear pressure devices) were developed with the following characteristics: non-flammability, easiness of placement and removal by the patient, capability of promoting the adequate pressure, easiness of cleaning and being aesthetically acceptable. 9There are different shapes for these devices, some of them with adaptations for the ear helix region.
Treatment recommendations with pressure earrings are not well defined, however it is postulated that the exerted pressure should be between 25-40mmHg and should be applied for 12-24 hours a day for periods ranging from months to years. 1,6 Ban et al. report that the combination of surgery and postoperative pressure treatment leads to good response in 90-100% of cases, especially in the treatment of auricular keloids. 6In line with the literature, 1-10 the cases reported in the present study showed good response to the combined therapy, with absence of reports of recurrence to date.However, long term monitoring is necessary for the detection of possible recurrences and early re-operation, in order to that the desired therapeutic success be achieved.

Conclusion
Keloids arise as a frequent complaint in dermatology practices, especially due to the impact on the quality in life caused by aesthetic changes.The authors believe that the combined treatment, with the use of aesthetically acceptable devices, is more effective, with lower recurrence rates when compared to the monotherapy, being a good therapeutic choice for the keloids in the earlobes.l

Figure 4 :
Figure 4: Patient with keloid in the right earlobe

Figure 6 :Figure 7 :
Figure 6: A-Keloid in the left earlobe.B -Three months after surgery.C -Pressure device used by the patient

Figure 8 :Figure 5 :
Figure 8: Outcome 3 years after the beginning of combined therapy