INTRODUCTION
In 1909, Porter reported case of a 19-year-old male patient with massive facial keloids that were triggered by an antecedent burn injury. This publication documented utilization of adjuvant radiation therapy in post-operative management of keloid disorder in summer of 1905 at Massachusetts General Hospital. In his report, Porter concluded, “although X-rays were conscientiously tried over several periods, there was no benefit.”
A retrospective study of S-ART in 568 Chinese patients reported nearly 12% keloid recurrence rate with median follow up period of 40 months. A recent comprehensive review of adjuvant radiation therapy for treatment of keloid lesions by van Leeuwen et. al identified 207 publications. The authors excluded most these publications for lack of follow up data, and limited their study to 33 articles, of which only 10 provided data on the incidence of recurrence. The mean time-to-recurrence in this meta-analysis was 14.8 ± 6.7 months. The authors concluded, “the costs of excision with irradiation exceed the costs of other treatments significantly. Therefore, excision with adjuvant radiation therapy should be regarded as a “last resort” for (recalcitrant) large keloid scars, when other nonsurgical treatments have failed.”
CASE PRESENTATION
A 40-year-old African American female, born in 1976, presented to the author in September 2016 with a massive left ear keloid (Figure 1). She had her ears pierced twice, first at age of ten and then again when she was thirteen. A small keloid formed on the posterior aspect of her left earlobe soon after her second piercing. At that time, this keloid was treated with intra-lesional steroid injections, but it failed to respond to this intervention. In 1991, she underwent an excision of this keloid lesion but soon after surgery, the keloid regrew and failed to respond to post-operative steroid injections or pressure earring. Second surgery was performed in 1992. Rapid recurrence was noted during her pregnancy in 1994. S-ART was performed in 1995, which resulted in a long-term disease control until 2008 when recurrent keloid was once again noted at the same site. Repeat surgeries were performed in 2008, 2010 and S-ART in 2014.
Unfortunately, the keloid regrew soon after each surgery. As part of her last keloid surgery, skin was harvested from her lower abdomen to reconstruct the defect caused to her ear. Soon after this surgery, there was a recurrence of the keloid at the site of the ear surgery and reconstruction. In addition, she developed a totally new keloid on her lower abdomen, at the site of skin harvest (figure 2). After so many failed surgeries, patient gave up hope and decided to live with her keloid. Her ear keloid continued to grow. She presented to the author in September 2016, at which point she was started on a course of treatment with cryotherapy. Figures 3 and 4 depict her progress and tremendous reduction in the mass of her keloid with contact cryotherapy alone. As of May of 2017, she remains under treatment to further improve the appearance of her ear.
Figure 1. September 2016, massive left ear keloid with extension to the posterior auricular and upper posterior cervical skin at presentation.
Figure 2. September 2016. Keloid formation at the site of skin graft harvest from the left lower abdomen for reconstruction of the ear defect.
FIGURE 3. December 2016, after two treatments with cryotherapy.
FIGURE 4. May 2017, after three treatments with cryotherapy.