Non Invasive Adjuvant Therapy for Ear Keloid

Abstract

Keloids are benign fibroproliferative scars that extend or originate outside the confines of the original lesion. They usually evolve at the anterior chest, shoulders, upper arms, cheeks, and ears and show the highest incidence in dark-skinned individuals aged between 20 and 30 years.1 The efficacy of most pressure devices developed for the treatment of ear keloid is limited by the insufficient control of the applied pressure causing pain and increased bleeding with a subsequent increased risk of infection and cosmetic problem.2 This clinical report describes a conservative, non invasive pressure therapy for ear keloid.

INTRODUCTION

Ear keloids commonly develop in young females, especially after ear piercing. They have also been reported to develop after otoplasty and other injuries of the ear. Ear keloids are cosmetically displeasing and difficult to treat because of their location.3 Several treatment modalities, directed toward prevention of recurrences after surgical excision, have been described including radiotherapy, corticosteroid injections, carbon dioxide laser therapy, pressure therapy, and various combinations of these.

The combination of surgical excision and adjuvant pressure therapy is considered highly efficacious in reducing keloid recurrences with minimal adverse effects. Numerous compression mechanisms have been described as adjuvant therapy of ear keloids, generally limited to treatment of the earlobe only and relying on active pressure over the excised area. The custom-made methyl methacrylate stent described in the present case report provides the ear with uniform pressure by confinement of the keloid growth to the internal dimensions of the stent, giving no space for recurrent growth of the keloid.4

CASE REPORT

A 20-year-old female patient was referred from the Department of Plastic Surgery for the fabrication of pressure clip for the left auricular keloid. Her chief complaint was swelling on the helix of the left ear since 3 years which was excised surgically 1 year after its appearance. The swelling recurred after 4 months of the surgery and increased progressively, growing larger than the previous one. The surgery was planned after 1 year again and the patient was referred for the fabrication of an appliance which would prevent the recurrence of the lesion.

On examination, a firm, nontender, nonpedunculated, swelling with a smooth surface and regular margins, measuring 21 mm superoinferiorly and 12 mm anteroposteriorly [Figure 1] was present on the helix of the left ear. There were no accompanying symptoms except impaired esthetics. A clinical diagnosis of keloid was given. A custom fabricated methyl methacrylate pressure appliance was planned to reduce the size of the keloid.

Patient’s skin over the ear and keloid was lubricated with petroleum jelly, and external auditory meatus was blocked with gauze pack tied with a thread [Figure 2].

Figure 1: Swelling on the left ear.	Figure 2. External auditory meatus blocked with gauze pack tied with thread.

Impression compound was moulded to form the beading for the confinement of the impression material. Skin and hair were protected using covering with thin cellophane sheet around the ear. Then, light body vinyl polysiloxane impression material (Affinis Light body; Coltene, UK) with backing of putty addition silicone impression material was used to make the impression [Figures 3,4].

Figure 3. Vinyl polysiloxane impression material confined by impression compound.	Figure 4. Vinyl polysiloxane putty backing.

Completed impression was retrieved after the impression materials were set. The impression was poured in dental stone (Kalstone, Kalabhai Karson Pvt. Ltd., Mumbai, India) with adequate land area to make the diagnostic model. A modified configuration of the spring was planned using 21gauge stainless steel wire that was used to make a helix at its apex and adapted over the swelling on the cast. A custom made pressure appliance was fabricated incorporating this loop in clear methyl methacrylate [Figure 5].

Figure 5. Ear pressure clip.

Care was taken to ensure adequate space for acrylic resin to avoid direct contact of stainless steel wire with the skin and a wax spacer was used to provide this adequate space. The appliance was finished, polished and adjusted to remove any sore spots. The patient was instructed to wear the pressure appliance for 24 h a day continuously. The gap between the two halves permitted the adjustment of pressure by closing the helix. This design negated the fabrication of a new appliance for pressure modifications.

DISCUSSION

Keloidal scarring is a common clinical problem in wound healing. Dermal injury is a common reason for exhibit exuberant, indefinite growth of collagen, leading to keloid formation. These are more common in dark skinned individuals and do not occur in the extremes of age. Keloid formation has been ascribed to altered growth factor regulation, genetics, altered mechanics, immune dysfunction, sebum reaction, and aberrant collagen turnover. Numerous hypotheses have been explained for keloid formation. Various treatments for keloid include surgical excision, laser, steroid injection, radiation therapy and pressure therapy.5 In the first systematic review of keloids, in 1961, Cosman et al documented the presentation, characteristics, and treatment of keloids. Mancini and Quaife, and later Peacock et al., differentiated between keloids and hypertrophic scars. They are separate entities- both clinically and histochemically.6

Pressure therapy is an effective therapy for keloids and has found its widest use as a postoperative adjunct for earlobe keloids.7 In a controlled trial in 1942, Nason found that adjuvant postoperative pressure reduced recurrence rates of keloids excised from various parts of the body from 67 percent to 18 percent. The mechanism of pressure therapy has not been determined. As tension affects collagen production and organization, some of the therapeutic benefit of pressure might be a result of altered wound tension. An additional mechanism may be through pressure-induced ischemia that enhances collagen degradation, thereby modulates fibroblast activity. The compression earrings should be worn 24 hours per day, hence patient compliance can be an issue, so patient compliance becomes an important criteria in treating such patients.8

CONCLUSION

Clinicians always find it difficult to treat hypertrophic scars and keloids. Various treatment modalities are available. Treatment has to be individualized depending upon the distribution, size, thickness, and consistency of the lesions and association of inflammation. A combination approach to therapy seems to be the best option. Prolonged pressure on the hypertrophic collagen has been reported to be effective in preventing recurrence of keloid after surgical treatment. Garments made up of elasticized material are available for different anatomical areas of the body. Such garments are advised immediately after wound healing.9 The pressure therapy delivered through custom made appliance successfully managed the ear keloid.

REFERENCES