Eur Arch Otorhinolaryngol (2010) 267:575580 DOI 10.

1007/s00405-009-1059-8

H E A D & N E CK

Auricular keloids: treatment and results

Christian Bermueller Gerhard Rettinger Tilman Keck

Received: 20 April 2009 / Accepted: 21 July 2009 / Published online: 9 August 2009 Springer-Verlag 2009

Abstract The aim of this study was to present long-term results in patients with auricular keloids after surgical excision and/or medical therapy by corticoid injection. A retrospective study at an academic tertiary referral centre is presented. Seventeen patients after excision, injection of corticoid, full skin grafting (single therapy or combination of interventions) for auricular keloids were followed up. The validated questionnaires SF-36 and patient outcomes of surgery-head/neck were applied to evaluate the quality of life and the patients satisfaction after therapy. Photographs of the former keloid site were rated by an experienced facial plastic surgeon being unaware of treatment method and the patients own estimation. The best results for retroauricular keloids were reached by excision, skin grafting and triamcinolone injection, and for earlobe keloids by excision, primary wound closure and triamcinolone injection. Both in rating by the patients and in grading by an investigator, the highest scores for aesthetics and satisfaction were found after triamcinolone injection together with or without excision or skin grafting. A size-related resection of keloids with defect reconstruction by full thickness skin grafting for retroauricular keloids and primary wound closure of ear lobe keloids with an additional steroid

injection lead to good cosmetic results and high level of satisfaction among patients. Keywords Keloid Full skin grafting Injection of triamcinolone

Introduction Keloids are scars that extend beyond the borders of the original wound. In contrast to hypertrophic scars, which respect the borders of the initial wound area, keloids show a high recurrence rate despite various treatment modalities [1]. The underlying pathomechanism of both wound healing disorders is a missing control mechanism that regulates wound healing and Wbrous tissue production after skin trauma or surgical skin treatment [1]. It may be diYcult initially to diVerentiate between hypertrophic scars and keloids, but apart from spontaneous softening of hypertrophic scars, which improves their appearance, there are (immuno)-histological, molecular, and biochemical diVerences. Keloids show large, densely packed collagen bundles random to epidermis and horizontal cellular Wbrous bands in the upper reticular dermis [1, 2]. Compared to hypertrophic scars, keloids have relatively fewer cells in their centre [1] and a decreased rate of Wbroblast apoptosis. An abnormal response to platelet-derived growth factor and transforming growth factor of keloid Wbroblasts has also been described [1]. Despite what is known about the histomorphological structure of keloids, no single established treatment regime exists. However, various treatment options, like surgical excision, intralesional injection of corticosteroids [1, 3, 4], 5-FU [5, 6], mitomycin-C [7] or bleomycin [8, 9], compressive therapy [10], diVerent kinds of irradiation [2], skin

C. Bermueller (&) G. Rettinger Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Ulm, Frauensteige 12, 89075 Ulm, Germany e-mail: christian.bermueller@uniklinik-ulm.de T. Keck Department of Otorhinolaryngology, Head, Neck, and Facial Plastic Surgery, Elisabethinen Hospital, Academic Hospital of the Medical University of Graz, Graz, Austria

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grafting [11], CO2-laser, pulse laser therapy [1, 12, 13], cryosurgery, banding [14] and several treatment combinations [1, 15, 16] of the above-mentioned treatment modalities are described. As keloids often recur after various surgical or nonsurgical therapies, treatment of keloids is still a challenging task in surgery. Especially if they occur in the head or neck region, i.e. if they are visible and cannot be disguised, the psychological handicap for patients is acute. Additionally, the skin alteration may result in pain, dysesthesia, pruritus, burning, or restricted range of motion of the head or neck. The aim of this retrospective study on auricular keloids was to evaluate the various treatment options applied in the ENT department of the university clinic of Ulm and to assess the long-term treatment results in respect of quality of life, patient satisfaction, recurrence of keloids, and cosmetic results.

corticoid therapies, treatments IIIIV were corticoid therapies. In each case, the decision for the speciWc treatment modality was done depending of the extent of the keloid. The decision for primary wound closure or full thickness skin grafting for tension-free wound closure was taken according to the extent of the keloid and tension around the wound bed after excision. In all surgical cases, dissoluble subcutaneous sutures and non-absorbable intradermal sutures were used. Evaluation after therapy To evaluate the quality of life and patient satisfaction after therapy, two standardized and validated questionnaires were used: the SF-36 and patient outcomes of surgeryhead/neck (POS-head/neck). The SF-36 is a testing instrument for survey of quality of life related to health, independent of speciWc illness [17]. The SF-36 (the MOS 36-item short form health survey) registers eight dimensions, which can be classiWed in eight health concepts: physical functioning, role limitations due to physical health, bodily pain, general health perception, vitality, social functioning, role limitations due to emotional problems and mental health. The results are adjustable to a correspondent norm group. The raw data are transformed into a 100 score scale. The average result of the norm group is 50. Every value higher than 50 shows an above-average result. The patient outcomes of surgery-head/neck (POS-head/ neck), a validated questionnaire for clinical outcome measurements [18] in head and neck surgery, has good reliability and internal consistency. Satisfaction with the postoperative result (maximum score 11) and psychological functioning and cosmetic appearance (maximum score 30) are scaled. High scores indicate good psychological functioning and satisfaction. Photographs of the former keloid site were taken (C.B.) and rated by an experienced facial plastic surgeon (T.K.). The aesthetic results after keloid therapy were graded by one surgeon on a scale as follows: 1 = excellent, 2 = good, 3 = acceptable, 4 = poor, 5 = bad, 6 = unacceptable. Aesthetic value was graded blind on a scale with no awareness of the detailed treatment modalities and the patients own rating. Results at or below 3 were considered successful, whereas results at or above 4 were considered unsuccessful.

Patients and methods Patient group The charts of 33 patients (17 male and 16 female; mean 21 8 years) consecutively treated between September 1995 and January 2008 because of primary or recurrent keloids at the Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Ulm were reviewed retrospectively. At least 1 year after surgery, the patients were invited to a follow-up examination at our institution for functional and aesthetic evaluation after surgery and for assessment of quality of life and subjective treatment success. Fifteen patients were lost to follow-up and could not be re-examined at our hospital. Out of 33 patients treated because of primary or recurrent keloids, 18 patients could be re-examined. One patient had to be excluded because the keloid was not an auricular keloid, but on the thorax wall (after previous harvesting of rib cartilage for reconstruction of the nasal septum). Finally, 17 patients were eligible for the study and could be enrolled. Surgical and medical therapy The treatment modalities at our institution were as follows: (I) surgical excision along skin tension lines and intradermal wound closure by direct approximation (n = 6 patients), (II) surgical excision and full thickness skin grafting from the inguinal region (n = 6 patients), (III) keloid excision with primary wound closure and single intralesional injection of 10% triamcinolone acetonide (n = 10 patients); (IV) keloid excision, inguinal skin grafting and single intralesional injection of 10% triamcinolone acetonide (n = 11 patients). Treatments I and II were non-

Results Eight male and 9 female patients (mean age at the time of intervention: 23 8 years) were eligible for the study and could be enrolled. The eldest patient at the time of keloid therapy was 31 years old, the youngest patient was 10 years old. The

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longest follow-up interval was 12 years, the shortest 1 year (mean 4 4 years) after surgical and/or medical therapy. Eight patients had a keloid of the earlobe, 6 patients a retroauricular keloid and 3 patients had preauricular keloids. Aetiology of all keloids was ear piercing (lobe, preauricular keloids) or otoplasty (retroauricular keloids). Four patients were treated by excision only (group I), 3 by excision and full skin grafting (group II). Five patients were treated by excision, primary wound closure, and injection of triamcinolone (group III), 5 patients had excision, full skin grafting, and injection of triamcinolone (group IV). A primary keloid was treated in 12 patients, a recurrent keloid in 5 patients. In 2 of the 17 patients treated at our department a recurrent keloid was observed, although reduced in dimensions compared to the pre-operative size of the keloids. Both patients were operated on because of a primary keloid. One patient was treated by resection and skin transplantation (group II), the second patient by resection, skin transplantation, and injection of triamcinolone (group V) (Figs. 1, 2). The mean POS cosmetic appearance score of all 17 patients together was 27 (out of 30 possible), the mean satisfaction score was 8 out of a possible 11. The mean SF-36 score was 58 (bodily functioning), 61 (mental health) and 60 (physical component summary). The mean cosmetic appearance, graded by one investigator, was 1.8. The results of each group are shown in detail in Table 1. Generally, the aesthetic result and well-being were rated highly positive after each treatment modality. However, diVerences between the treatment groups were found, especially when comparing non-corticoid groups (I and II) with corticoid groups (IIIIV). Both in patient self-assessment and in grading by a single investigator (T.K.) the highest scores for aesthetics and satisfaction were found after an injection of triamcinolone, in conjunction with excision or full skin grafting (corticoid groups IIIIV). Most ear lobe keloids were treated by excision, primary wound closure and injection of triamcinolone, whereas retroauricular keloids mostly were treated by excision, full skin grafting and injection of triamcinolone with a high rating by the investigator and a high POS score. Larger keloids were treated by resection and transplantation (with or without accompanying steroid injection), smaller keloids were resected and primary wound closure with or without steroid injection or steroid injection only was performed (details see Table 2).

Fig. 1 Photographs of an auricular keloid before and 16 months after successful excision, primary wound closure, and single injection of triamcinolone

Discussion The aim of our retrospective study was to evaluate various treatment options of auricular keloids, applied at our hospital,

and to assess the treatment success with regard to quality of life and satisfaction of patients, local recurrence of keloids, and cosmetic results. One major problem of retrospective studies is the loss of follow-up of patients due to moving, job-related or family commitments. In this study, almost half of the patients treated for auricular keloids could not be enrolled because of these reasons. Thus, only a small number of patients after previous keloid therapy at our hospital could be re-examined. However, more dissatisWed patients may be expected to be seen under conditions such as these, thus

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Fig. 2 Photographs of a retroauricular keloid after previous otoplasty before and 20 months after successful keloid excision, inguinal skin grafting, and single intralesional injection of 10% triamcinolone

representing a more negative sample. To our knowledge, this is the Wrst study to evaluate patient satisfaction with the results of keloid treatment. To assess the patients satisfaction with the postoperative result, the patient outcomes of surgery-head/neck (POS-head/neck) was applied [18]. This user-friendly questionnaire contains six questions to assess psychological functioning, cosmetic appearance and satisfaction and is site speciWc to head and neck skin lesions. It took less than 5 min to be Wlled out for each patient. Unfortunately, because of the retrospective character of this study, only results after keloid therapy and no results before intervention can be presented. However, the POS-head/ neck is also acceptable in the evaluation of outcomes only

after therapy of head/neck skin lesions and satisWes rigorous scientiWc criteria [18]. Patient satisfaction in all treatment groups was generally high (8 out of a possible 11 points). The mean psychological functioning and cosmetic appearance was 27 out of possible 30 points. These results indicate that the patients were basically satisWed with the cosmetic results, even the two patients with minor recurrent keloids that needed no additional therapy yet. Currently, only scant data on evaluation of cosmetic results after treatment of keloids exist. De Lorenzi et al. [2] reported on treatment of keloids, mostly located (50%) on the breast by brachytherapy. Cosmetic outcome after therapy was graded by the patients and investigators on a sixpoint scale, similar to the classiWcation used in our study. Fifty percent of the patients rated the cosmetic result as good, 23% as quite satisfactory, and almost 20% as not so good, bad, or very bad. Grading of the cosmetic results by the medical investigators was good in 38%, quite satisfactory in 27%, and not so good, bad, or very bad in 14% of the patients. However, the quality of life was not evaluated in the study presented by De Lorenzi et al. Quality of life is diYcult to measure. In the presented study, the SF-36 questionnaire to assess quality of life of patients after therapy of keloids was used. This questionnaire is well established for evaluation of health-related quality of life independent of underlying diseases [17]. Eight dimensions of somatic and mental health are detected. In our study, the patients had a higher-thanaverage quality of life with regard to bodily functioning, mental health and physical component summary. Actually, it is doubtful if the high quality of life in the patients after keloid treatment is associated with the treatment of the keloid. However, since treatment of a keloid was only performed in patients who had signiWcant psychological problems with their visible keloids in the head and neck area, the high satisfaction of the patients with their treatment result and the positive evaluation of the aesthetic outcome by the patients indicate a strong relation of quality of life and the treatment success of the previously visible and disturbing skin pathology. In our follow-up examination, two recurrent keloids (in 17 patients; recurrence rate: 12%) were seen. Compared with other retrospective studies evaluating the recurrence rate after treatment of head and neck keloids, the recurrence rate in our study is small. Rosen et al. [19] described a recurrence rate of 23% after treatment of keloids with excision and intraoperative and postoperative injection of steroids. Keloid excision and radiation has been associated with a recurrence rate of lower than 10% [2022]. Laser therapy was reported to lead to a recurrence rate of more than 90% [23, 24]. In studies with 5-FU injection [6],

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Table 1 Grading of aesthetics and well-being by the patients and one facial plastic surgeon after surgical and/or medical therapy of auricular keloids Group Therapy No. of patients POS cosmetic appearance 26.8 26.3 25 29.8 27 POS score satisfaction SF 36 bodily functioning 52 57.3 63 63 58 SF 36 mental health 56.3 55 66.2 60.4 61 SF 36 physical component summary 56 59.5 61.4 64 60 Surgeons aesthetic rating 2 3 1.4 1.4 1.9

I II III IV IIV

Excision Excision and full skin grafting Excision, primary wound closure, and injection of triamcinolone Excision, full skin grafting, and injection of triamcinolone All

4 3 5 5 17

6.5 8.7 9 8 8

The mean values of each grading parameter is shown. Bold value highest value of each parameter tested in 4 treatment groups

Table 2 Localization and mean size of keloids according to treatment groups

Group Therapy

No. of Mean Earlobe Retroauricular Preauricular patients size (mm2) 4 3 5 5 17 10 10 20 20 20 20 30 20 1 1 5 1 8 1 1 0 4 6 2 1 0 0 3

I II III IV IIV

Excision Excision and full skin grafting Excision, primary wound closure, and injection of triamcinolone Excision, full skin grafting, and injection of triamcinolone All

bleomycin injection [9], and excision and imiquimod application [6], no recurrent keloids were observed. These treatment regimes may be eYcient in avoiding recurrence of keloids, but they may have potential side eVects. Radiation is known to cause hyperpigmentation and teleangiectasia. This may be acceptable for skin areas that can be disguised, but in the head and neck area they can cause cosmetic problems. Irradiation of auricular keloids may cause cancer of the salivary glands, such as the parotid glands, which are located close to the ear. Although there are insuYcient studies that substantiate an increased risk of local malignancies, it is, in our opinion, not acceptable to treat benign lesions of the skin with a potential cancercausing regime. The same is true for local 5-FU injection or bleomycin injection, which may have a potential risk of local induction of malignancies. Another problem in evaluating the rate of recurrence is the interval of follow-up. Most studies have follow-up times of 2 or less years. Only few provide data of long-term results, i.e. more than 5 years [1, 19]. To summarise, as mentioned above, the main limitation of our study is the small sample size of various treatment arms and the retrospective sampling method. To further obtain valid data on wound healing, complications after diVerent treatment regimes in head and neck keloids, and local recurrence after diVerent therapies, a large prospective

randomized trial (stratiWed random sampling) and multicentre study would be necessary to demonstrate possible diVerences.

Conclusion The size-related treatment strategy of auricular keloids, applied in the ENT Department of the University Clinic of Ulm, leads to a small rate of recurrence and a high level of life quality and patient satisfaction. Larger keloids, especially retroauricular keloids should be resected and the defect, to ensure a tension-free wound closure, covered by full thickness skin grafting. Smaller keloids, especially ear lobe keloids, should be resected and a primary wound closure is preferable. Because of the trend of increased patient satisfaction, an additional steroid injection is useful.

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