10.5826/dpc.1202a72
Introduction: Keloids are benign fibro-proliferative scarring extending outside the initial wound. Different modalities of treatment as intralesional corticosteroid injection, fractional CO₂ laser and others can be used either as mono or combined therapies.
Objectives: To assess the role of fractional CO2 laser versus fractional CO2 laser accompanied with either triamcinolone acetonide or trichloroacetic acid 20% in keloid treatment clinically and radiologically.
Methods: The current study was conducted on 45 Egyptian participants with keloid scar at different sites of the body. They were classified into three groups treated by fractional CO2 laser only (group I), fractional CO2 laser followed by triamcinolone acetonide (group II) or trichloroacetic acid application (group III) respectively. Evaluation of the keloid was done with Vancouver Scar Scale (VSS) and Color Doppler Ultrasound (CDU) before and after treatment. Four sessions, one month apart were applied for the patients. They were followed up for 8 weeks after the last session.
Results: After treatment, there was high statistically significant reduction in Vancouver Scar Scale among the three groups (P value ≤ 0.001), reduction was more in group II then I then III. Also, high statistically significant reduction in keloid scar thickness assessed by Doppler was recorded (P value ≤0.001 in group II and P value ≤0.01 in group I &amp; III).
Conclusions: Combined therapy is favorable in treatment of keloids. Trichloroacetic acid is a promising modality in treating keloid; hence it can be tried in different combinations. Color Doppler Ultrasound is a promising method of keloids pre- and post-treatment assessment.
text/xml
2160-9381
1890
en
Hala Maghraby
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
keloid, fractional carbon dioxide laser, corticosteroids, trichloroacetic acid, Doppler.
Fractional carbon dioxide (CO₂) laser alone versus fractional CO₂ laser combined with triamcinolone acetonide or tricholoroacetic acid in keloid treatment: A comparative clinical & radiological study
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-05-02
2021-07-15
2022-05-02
2022-05-24
e2022072
Dermatol Pract Concept
Introduction: Keloids are benign fibro-proliferative scarring extending outside the initial wound. Different modalities of treatment as intralesional corticosteroid injection, fractional CO₂ laser and others can be used either as mono or combined therapies.
Objectives: To assess the role of fractional CO2 laser versus fractional CO2 laser accompanied with either triamcinolone acetonide or trichloroacetic acid 20% in keloid treatment clinically and radiologically.
Methods: The current study was conducted on 45 Egyptian participants with keloid scar at different sites of the body. They were classified into three groups treated by fractional CO2 laser only (group I), fractional CO2 laser followed by triamcinolone acetonide (group II) or trichloroacetic acid application (group III) respectively. Evaluation of the keloid was done with Vancouver Scar Scale (VSS) and Color Doppler Ultrasound (CDU) before and after treatment. Four sessions, one month apart were applied for the patients. They were followed up for 8 weeks after the last session.
Results: After treatment, there was high statistically significant reduction in Vancouver Scar Scale among the three groups (P value ≤ 0.001), reduction was more in group II then I then III. Also, high statistically significant reduction in keloid scar thickness assessed by Doppler was recorded (P value ≤0.001 in group II and P value ≤0.01 in group I &amp; III).
Conclusions: Combined therapy is favorable in treatment of keloids. Trichloroacetic acid is a promising modality in treating keloid; hence it can be tried in different combinations. Color Doppler Ultrasound is a promising method of keloids pre- and post-treatment assessment.
Hala Maghraby
2022/05/02
10.5826/dpc.1202a72
e2022072
Assisstant professor of Radiodiagnosis, Faculty of medicine for Girls, Al-Azhar University, Cairo, Egypt. 
2160-9381
keloid, fractional carbon dioxide laser, corticosteroids, trichloroacetic acid, Doppler.
en
e2022072
Fractional carbon dioxide (CO₂) laser alone versus fractional CO₂ laser combined with triamcinolone acetonide or tricholoroacetic acid in keloid treatment: A comparative clinical & radiological study
https://dpcj.org/index.php/dpc/article/download/1890/1553
                     Dermatology Practical & Conceptual


 Fractional Carbon Dioxide (CO2) Laser Alone Versus
 Fractional CO2 Laser Combined With Triamcinolone
     Acetonide or Trichloroacetic Acid in Keloid
        Treatment: A Comparative Clinical and
                 Radiological Study
      Engy Abd El-Hamid El-Azhary1, Fatma Mohamed Abd Al-Salam2, Hala Shawky Abd
                           El-Hafiz2, Hala Maghraby Maghraby3


1 Faculty of Medicine Kasr Al-Aini Faculty of Medicine, Cairo University, Cairo, Egypt
2 Dermatology and Venereology Department, Faculty of Medicine for Girls, Al- Azhar University, Cairo, Egypt
3 Radiodiagnosis Department, Faculty of Medicine for Girls, Al- Azhar University, Cairo, Egypt



Key words: keloid, fractional laser, TAC, TCA, doppler.
Citation: El-Azhary EA, Abd Al-Salam FM, Hafiz HSA, Maghraby HM. Fractional carbon dioxide (CO2) laser alone versus fractional CO2
laser combined with triamcinolone acetonide or trichloroacetic acid in keloid treatment: a comparative clinical and radiological study.
Dermatol Pract Concept. 2022;12(2):e2022072. DOI: https://doi.org/10.5826/dpc.1202a72
Accepted: October 11, 2021; Published: April 2022
Copyright: ©2022 El-Azhary et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication
Corresponding author: Engy Abd El-Hamid Abd El-Hamid El-Azhary, MBBCH, General Medicine and Surgery, Kasr Al-Aini Faculty of
Medicine,, Cairo University, Cairo, Egypt. E-mail: gi.elazhary.89@gmail.com




  ABSTRACT             Introduction: Keloids are benign fibro-proliferative scarring extending outside the initial wound. Dif-
                       ferent treatment modalities as intralesional corticosteroid injection, fractional CO2 laser, and others
                       can be used either as mono or combined therapies.
                       Objectives: To assess the efficacy of fractional CO2 laser versus fractional CO2 laser accompanied
                       with either triamcinolone acetonide or trichloroacetic acid 20% in keloid treatment clinically and
                       radiologically.
                       Methods: The current study was conducted on 45 Egyptian participants with keloid scars at different
                       sites of the body. They were classified into 3 groups treated by fractional CO2 laser only (group I), frac-
                       tional CO2 laser followed by triamcinolone acetonide (group II), or trichloroacetic acid application
                       (group III), respectively. Evaluation of the keloid was done with Vancouver Scar Scale (VSS) and Color
                       Doppler Ultrasound (CDU) before and after treatment. Four sessions 4 weeks apart were applied for
                       the patients. They were followed-up for 8 weeks after the last session.




Original Article | Dermatol Pract Concept. 2022;12(2):e2022072                                                                        1
                      Results: After treatment, there was a high statistically significant reduction in VSS among the 3 groups
                      (P ≤ 0.001); the reduction was more in group II than in I and III. Also, a high statistically significant
                      reduction in keloid scar thickness assessed by CDU was recorded (P ≤0.001 in group II and P ≤0.01
                      in group I and III).
                      Conclusions: Combined therapy is favorable in the treatment of keloids. Trichloroacetic acid is a
                      promising modality in treating keloid, hence it can be tried in different combinations. CDU is a prom-
                      ising method of keloids pre-and post-treatment assessment.



Introduction                                                       Inclusion Criteria
                                                                   Either male or female, 18 to 55 years old, duration of keloid
Keloids are formed due to abnormal response of wound heal-         scar of more than 6 months.
ing where scar tissue has grown aggressively outside the initial
wound borders [1]. Treatment of keloid scar is debatable and       Exclusion Criteria
burdensome though combined treatment modalities give bet-
                                                                   Patients who received any previous treatment during the
ter results than single ones [2]. Triamcinolone acetonide (TAC)
                                                                   6 months before enrollment for their keloids, pregnant or
acts through suppression of wound inflammatory factors and
                                                                   lactating women, patients with photosensitivity, patients on
fibroblast growth by decreasing transforming growth fac-
                                                                   retinoids treatment, and facial keloids.
tor-beta (TGF-b) expression while stimulating the breakdown
of collagen and fibroblast apoptosis, thus reducing the density
                                                                   Treatment Protocol
of fibroblasts [3]. Fractional CO2 laser (FCL) creates Micro-
                                                                   All patients underwent complete history taking, general and
thermal Zones (MTZs), which occur due to tissue vaporiza-
                                                                   dermatological examinations, photographs, clinical assess-
tion in the form of rows surrounded by normal skin through
                                                                   ment by Vancouver Scar Scale (VSS), and radiological assess-
which they stimulate wound healing [4]. FCL can be used as
                                                                   ment by Color Doppler Ultrasound (CDU) of keloids.
a delivery system for many drugs as corticosteroids known as
laser-assisted drug delivery (LADD) [5,6]. Trichloroacetic acid
(TCA) induces ultrastructural changes of epidermis and der-        Materials Used
mis. TCA improves the morphologic appearance of collagen           FCL, TAC, and TCA 20%.
and elastin. It acts through the deposition of new collagen and
normalizes elastic tissue that was destroyed due to collagen I     Study design
and III overproduction and hence can be used in keloids [7].       This comparative study included 45 Egyptian partici-
                                                                   pants with keloids, they were of both sexes (21 males and
Objectives                                                         24 females), and their ages were between 20 and 55 years.
                                                                   We classified the 45 cases into 3 groups of 15 cases each, the
To assess the efficacy of FCL versus FCL accompanied with          first group treated by FCL alone (as shown in Figure 1), the
either TAC or TCA 20% in keloid treatment. Keloid treat-           second group treated by FCL followed immediately by TAC
ment progress was assessed clinically and radiologically.          at a dose at a dose of 0.25 ml/cm³ for keloids < 3 cm and 0.5
                                                                   ml/ cm³ for keloids >3 cm (equivalent to 10 mg/cm³ of TAC
                                                                   [40 mg/ vial]) then occluded using transparent film dressings.
Methods
                                                                   Patients were instructed to remove the dressing 3 hours after
This comparative study was conducted from March 2017 to            the session by sterile saline-soaked gauze (as shown in Figure
October 2019 at the Outpatient Clinic of Dermatology and           2) while the third group was treated by FCL followed imme-
Venereology, where 45 Egyptian patients with keloids were          diately by TCA 20% application then occluded for 3 hours as
enrolled randomly.                                                 in group II (as shown in Figure 3). Topical anesthesia in the
    All participants wrote down an informed consent after          form of cream (prilocaine 2.5% and lidocaine 2.5%) was ap-
demonstrating the study steps, expected results, and side ef-      plied before the laser session under occlusion for 60 minutes
fects before taking part in the study. Ethical aspects of human    and wiped off with saline. Laser parameters used were: Power
research were fulfilled in the current study after the official    = 20-25 J, Stack = 1-2, Timing = 300 ms (milliseconds) and
approval of the local research ethics committee of Faculty of      spacing = 350 mm. Evaluation of keloid scars before and after
Medicine for Girls, Al-Azhar University, Cairo, Egypt with         treatment was done by VSS and CDU. The patients received
approval code (202106865).                                         4 sessions 4 weeks apart and followed-up for 8 weeks after
                                                                   the last session.



2                                                                       Original Article | Dermatol Pract Concept. 2022;12(2):e2022072
Evaluation Methods                                                     Statistical Analysis
Photographs by Sony Cyber shot DSC-H10, Japan camera,                  Collected data were revised, coded, and entered into the Sta-
VSS (pliability, pigmentation, vascularity and scar thickness          tistical Package for Social Science version 23. Quantitative
or height) were used, the scores range from 0 to 14 where              data were presented as median, inter-quartile range when data
14 indicates the worst scar while score of 0 indicates normal          were non-parametric. The comparison of quantitative data
skin. Keloid scar thickness measurement by CDU using a su-             and non-parametric distribution between more than 2 groups
perficial probe (10 MHz) and patient satisfaction by patient           was made by using Kruskall Wallis test. The comparison of
satisfaction self-assessment (score from 0 to 4; not satisfied         quantitative data and non-parametric distribution between
0%, mildly satisfied <25%, moderately satisfied 25- 50%,               two paired groups was done by using Willcoxon Rank test.
very good satisfied 50-75% or excellent satisfied >75%)                The confidence interval was set at 95%, and the margin of
were evaluated. Treatment side effects stated by physicians            error accepted was set at 5%. P-value was considered signif-
or patients were documented.                                           icant as the following: P > 0.05: non significant, P < 0.05:
                                                                       significant, and P < 0.01: highly significant.


                                                                       Results
                                                                       Forty-five adult Egyptian cases with keloids were en-
                                                                       rolled. They were 20 -55 years old with a mean 33.69
                                                                       (± 11.02 standard deviation). Among the studied groups, 24
                                                                       cases were females (53.3%), while 21 were males (46.7%).
                                                                       The keloids were at different sites of the body (e.g. ears,
                                                                       chest, and back). Causes of keloid varied from trauma,
                                                                       surgery, spontaneous, and ear piercing. Nine cases (20%)
                                                                       had multiple keloids, 31 cases (80%) had keloid over bony
                                                                       prominences, and 8 cases were treated previously (17.8%).


                                                                       Treatment Outcomes
                                                                       Clinical Assessment
Figure 1. Female patient, 32 years old with abdominal post-surgical    A high statistically significant reduction in VSS after treat-
keloid. (A) before treatment (VSS 10). (B) after 4 sessions of frac-   ment was detected among patients of the 3 groups with
tional CO2 alone (VSS became 6), showing good improvement. VSS         P <0.001. The most significant VSS reduction was in group II
= Vancouver Scar Scale.




Figure 2. Male patient, 23 years old with back post-traumatic keloid. (A) before treatment (VSS 9). (B) after 4 sessions of fractional CO2
followed by TAC (VSS became 2), showing excellent improvement. TAC = Triamcinolone acetonide ; VSS = Vancouver Scar Scale.



Original Article | Dermatol Pract Concept. 2022;12(2):e2022072                                                                          3
                                                                         (-3.73 ± 1.58), then in group I (-3.40 ± 1.18), and the minor
                                                                         reduction was in group III (-1.73 ± 1.33) (Table 1).

                                                                         Radiological Assessment
                                                                         The reduction in the keloid thickness measured by CDU af-
                                                                         ter treatment among the 3 groups was statistically signifi-
                                                                         cant, where the greatest radiological reduction was in group
                                                                         I (-1.55 ± 5.22), then group II (-1.24 ± 2.13), and the minor
                                                                         reduction was in group III (-0.12 ±0.15) (Table 2).
                                                                            The correlation between clinical and radiological re-
                                                                         sponses was not statistically significant.

                                                                         Patient Satisfaction
                                                                         Patient satisfaction score grades 3 and 4 were the highest
                                                                         among group II with 40% (6 patients) and 46.7% (7 pa-
Figure 3. Female patient, 26 years old with thigh post-traumatic         tients) respectively, then in group I with 6.7% (1 patient)
keloid. (A) before treatment (VSS 8). (B) after 4 sessions of frac-      and 33.3% (5 patients), respectively. While grades 1 and 0 of
tional CO2 followed by TCA 20% (VSS became 4), showing good              the score were the highest among patients of group III with
improvement but hypopigmentation occurred as a side effect. TCA=         26.7% (4 patients) and 20% (3 patients) respectively.
Trichloroacetic acid; VSS = Vancouver Scar Scale.




                Table 1. VSS Before and After Treatment for Each Group of the Studied Cases
                                                Group I               Group II         Group III
                                               No. = 15           No. = 15             No. = 15          Test value          P-value
 VSS before          Median (IQR)          8 (6 – 11)          10 (7 – 11)         8 (8 – 11)           1.546            0.462 (NS)
                     Range                 4 – 13              6 – 13              5 – 14
 VSS after           Median (IQR)          4 (3 - 8)           5 (4 – 8)           8 (5 – 9)            5.551            0.062 (NS)
                     Range                 1–9                 2 – 10              3 – 12
 Differences         Mean ±SD              –3.40 ± 1.18        –3.73 ± 1.58        –1.73 ± 1.33         13.789           0.001 (HS)
                     Range                 –5 – –2             –7 – –2             –4 – 1
 Willcoxon Rank test                       –3.436              –3.437              –3.151
 P                                         0.001 (HS)          0.001 (HS)          0.002 (HS)

VSS = Vancouver Scar Scale; No = number; IQR= interquartile range; NS= Non significant; S= Significant; HS= highly significant; SD= stan-
dard deviation.




Table 2. Keloid Thickness by CDU Before and After Treatment For Each Group of the Studied Cases
                                             Group I                   Group II             Group III
                                             No. = 15                 No. = 15              No. = 15            Test value     P-value
 Thickness          Median (IQR)       0.81 (0.27 – 1.35) 1.82 (0.8 – 6.32)            0.36 (0.23 – 0.73)       11.131       0.004 (HS)
 before (cm2)       Range              0.07 – 24.5            0.36 – 23.85             0.09 – 1.4
 Thickness          Median (IQR)       0.48 (0.14 – 2.07) 1.12 (0.36 – 5.11)           0.32 (0.17 – 0.59)       6.162        0.046 (S)
 after (cm²)        Range              0.06 – 8               0.12 – 15.6              0.01 – 1.04
 Difference         Mean ± SD          –1.55 ± 5.22           –1.24 ± 2.13             –0.12 ± 0.15             11.599       0.003 (HS)
                    Range              –19.6 – 1.41           –8.25 – 0                –0.41 – 0.06
 Willcoxon Rank test                   –2.480                 –3.296                   –2.513
 P                                     0.013 (S)              0.001 (HS)               0.012 (S)

CDU= Color Doppler Ultrasound; No = number; IQR= interquartile range; S= Significant; HS= highly significant; SD= standard deviation.



4                                                                            Original Article | Dermatol Pract Concept. 2022;12(2):e2022072
    In the current study, the relationship between clinical re-       Behera et al reported that FCL could be used in keloids
sponse measured by VSS and patient satisfaction self-assess-       excision efficiently, in agreement with the current results
ment score was not statistically significant.                      [12]. Also, Azzam et al reported that keloids could be treated
                                                                   by FCL securely and efficiently upon the results of their study
Side Effects Evaluation Among the Studied Groups                   on 30 patients who received 4 FCL sessions six weeks apart
Among all patients, 20 (44.4 %) had no side effects, while 25      [13]. Nevertheless, they recommended that FCL could give
(55.6%) patients had side effects in the form of pain, itching,    better results when used as a combined therapy. As FCL in-
ulceration, hypopigmentation, and hyperpigmentation. The           hibits TGFb1 release but stimulates basic fibroblast growth
main side effects were increased pain and itching just after the   factor (bFGF) release and hence induces epidermal regrowth
session and subsided within a week maximum in the current          and dermis collagenesis and remodeling [12,14]. The laser
study. As regards types of side effects, the results showed sta-   gives better results when used on early scars of less than
tistically significant difference among the 3 groups (P <0.05)     2 years [15]. In group II, for patients who received combined
whereas patients of groups I and II had suffered from mild         therapy of FCL followed by TAC this combination resulted
side effects as pain and itching while group III patients had      in a significant reduction in VSS parameters after treatment
suffered from severe side effects as ulceration, hypopigmen-       compared to groups I and III with the best satisfaction score
tation (shown in Figure 3), and hyperpigmentation beside           (as shown in Figures 1,2 and 3).
beside pain and itching.. Neither clinical nor radiological re-       Al-Janahi et al treated a 72 years old African American
sponses had a statistically significant association with sex, or   male suffering from aggressive keloid sited at the anterior and
skin phototype of the patients, cause, site, size, multiplicity,   lateral neck, back, and upper chest that lasted for 30 years
or previous treatment of the keloid. However, the clinical im-     resulting in flattening of keloid and improvement of pain after
provement was better at non-bony sites as mean VSS reduc-          1 treatment [16]. Similar to the current study, Alegre-Sánchez
tion was -3.36 (± 1.39) while it was -2.77 (± 1.69) at bony        et al stated that using CO2 laser in combination with TAC sus-
sites. Also, no statistically significant association was found    pension 10% gives excellent results for keloid and hypertro-
between either clinical or radiological responses and patient      phic scars treatment [17]. Also, they declared factors affecting
self-assessment score or side effects.                             the results of FCL followed by TAC suspension combination
                                                                   as the density of FCL, depth of channels created by FCL,

Conclusions                                                        which depend directly on laser fluency, the vehicle used, type
                                                                   of preparation, and formulations. In contrast, Annabathula
Keloid scar occurs as a result of extracellular matrix over-       et al reported that FCL is not recommended to treat keloids
production, mainly collagen. It occurs due to cytokines and        as a single therapy [18], but they recommended a combined
growth factors overexpression [8]. Keloid formation has            therapy for a synergistic effect of treatment. Also, Waibel et
many theories, where the most approved one was the im-             al reported that using FCL followed by TAC suspension ap-
balance between collagen synthesis and degradation together        plication in successive three treatments caused 23 % scar re-
with the imbalance of fibroblasts proliferation, apoptosis,        duction [19]. According to Alexander et al study, they used
and inhibition [3,9]. Keloid pathogenesis is mainly due to         intralesional injection instead of suspension application, giv-
abnormal healing of wounds either due to abnormal re-              ing good results [20]. Alegre-Sánchez et al reported that TAC
sponse to inflammation or prolonged proliferative phase [9].       in the form of suspension has a greater affinity than a cream
Increased collagen synthesis is related to keloid fibroblasts      or ointment, so passes through micro-channels produced by
stimulation through inflammatory mediators, mainly trans-          fractional ablative lasers easier [17]. Also, the improvement
forming growth factors beta-1 (TGF-b1). TGF-b1 isoforms            of texture, thickness, dyschromia, and scar functionality was
are supposed to be responsible for collagen overproduction         reported using topical corticosteroid rather than an intrale-
by fibroblasts in pathological scars [10].                         sional drug.
    Treatment decisions must be based on the patient’s age,           LADD facilitates penetration and provides better results
location, size and depth of the lesion, and past response to       when both medical as drugs and physical as laser treatments
treatment. Hence no specific treatment is best for all keloids     are combined [17]. Another key factor in LADD is the interval
[11]. Regarding the current study, the results showed a sta-       between using laser and drug application. Considering MTZs
tistically significant reduction in VSS score after treatment      closure, it lasts for 6 hours after laser application; however,
compared to before treatment in each group with P <0.01.           the vehicle or drug absorption is most successful during the
However, the main improvement was in pliability. According         first 30 minutes, while after 24 hours, no absorption is ob-
to the current study, the group I received FCL as monother-        served, so no need for further topical applications [17].
apy. Compared to combined therapy in groups II and III,               These studies came in agreement with the current study
group I had good but not the best results.                         as regard laser parameters (Power = 20-25 J), the form of



Original Article | Dermatol Pract Concept. 2022;12(2):e2022072                                                                   5
TAC we used (suspension), and the time of drug application                  In the current study, the improvement of VSS parame-
after FCL application (drug applied immediately after laser             ters after treatment (pliability, vascularity, pigmentation, and
session and removed after 3 hours using sterile saline-soaked           height/thickness of keloid) was statistically significant; how-
gauze). FCL combined with TAC may minimize collagen                     ever, the main improvement was in the pliability component,
production by decreasing fibroblast activity, with a low re-            then thickness/height, then vascularity, and the least com-
currence rate of 15.4%, which is superior to each modality              ponent improved was pigmentation. In agreement with the
and is ideal for large keloids [4].                                     current results, Heppt et al and Azzam et al reported more
    Regarding the current study, group III was treated by               evident improvement in VSS parameters, where scar pliabil-
FCL followed by topical application of TCA 20%. TCA is a                ity was markedly improved while vascularity and dyspig-
peeling agent used for superficial and medium-depth peel ac-            mentation were less pronounced [13,22]. Since biopsies in
cording to its concentration. TCA acts through coagulative              keloids are contraindicated as they can produce an increase
necrosis and protein precipitation of epidermal cells and col-          in size, CDU can support activity assessment and indicate the
lagen necrosis of papillary and reticular dermis. Patients of           response to treatment (as shown in Figures 4,5 and 6).
this group had the slightest improvement of keloids with the                Elrefaie et al and Lobos et al advised using high-reso-
most severe side effects as ulceration, hypopigmentation, and           lution ultrasonography in scar assessment to determine the
hyperpigmentation compared with other groups. The com-                  suitable treatment modality as an available, quick, and af-
bination between FCL and TCA in the treatment of keloids                fordable method [23,24]. As VSS has a high range of the
has not been evaluated before. Hence, we tried to evaluate it           thickness parameter (< 2, 2-5, and > 5mm), the scar thickness
through our third group.                                                may be reduced but with no changes in VSS, while ultra-
    Ghonaim conducted a comparative study of 80% TCA                    sound measures the whole scar thickness not only the su-
multiple puncture techniques versus botulinum toxin type                perficial height as in VSS. Also, CDU can assess the presence
A (BTX-A) in keloid treatment and denoted that TCA                      of calcifications, fistulous tracts, or muscle involvement on
can normalize all types of scars by dermal structure re-                different body sites as ear pinna and trunk.
construction [21]. Keloid fibroblasts have a greater ca-                    Regarding side effects, only 25 patients had adverse
pacity to proliferate and overproduce type I collagen.                  events in the form of increased pain and itching just after
TCA-treated skin expresses cytokines as interleukin-10,                 the session and subsided within a week maximum in group
which is involved in type I collagen synthesis, regulation,             I and II, while group III had suffered from severe side effects
and degradation. On treating cultured dermal fibroblasts                as ulceration, hypopigmentation (as shown in Figure 3), and
with TCA, collagen I was downregulated, and collage-                    hyperpigmentation beside pain and itching.
nase protein was upregulated, where platelet-derived                        In agreement with the current results, Alexander et al
growth factor-B expression was upregulated markedly,                    reported increased size, pain, hyperpigmentation, and de-
then downregulated immediately. This transient increase                 pigmentation [20]. Also, Alegre-Sánchez et al explained that
of platelet-derived growth factor could be beneficent for               adverse effects might appear due to laser high fluencies and
speedy wound repair [21].                                               densities applied [17].




Figure 4. High resolution B mode ultrasonic imaging of a cutaneous keloid with homogenous echopattern. (A) before treatment showing that
keloid thickness was: 0.146 cm while the length was: 1.28 cm. (B) after 4 sessions of fractional CO2 alone showing decrease in the thickness
to become 0.140 cm and in the length to become 1.19 cm, showing good improvement. On CDU application the lesion was completely
avascular before and after treatment. CDU = Color Doppler Ultrasound.



6                                                                            Original Article | Dermatol Pract Concept. 2022;12(2):e2022072
Figure 5. High resolution B mode ultrasonic imaging of a subcutaneous keloid with hypoechoic echopattern deep to the skin by 2 mm. (A)
before treatment showing that keloid thickness was: 0.489 cm while the length was: 5.62 cm. (B) on CDU mode application, few peripherally
located vessels are seen with arterial flow of low resistance. (C) High resolution B mode ultrasonic imaging of a keloid after 4 sessions of frac-
tional CO2 followed by TAC showing decrease in the thickness to become 0.448 cm and in the length to become 2.45 cm, showing excellent
improvement. (D) on CDU mode the keloid was completely avascular. CDU = Color Doppler Ultrasound; TAC = Triamcinolone acetonide.




    In the current study, regarding the site of keloid, 31                     FCL alone is a potent secured treatment modality of ke-
(68.9%) patients had keloids on bony prominences as chest,                 loid, but combined therapy gives better results. However,
forearm, arm, neck, shoulder, back, interscapular, knee, and               combined therapy of FCL and topical TAC is better than
elbow, while 14 (31.1%) patients had keloids on non-bony                   monotherapy or combination with TCA in treating keloids
structures as abdomen, thigh and ear lobe. We found no sta-                as TCA can result in some serious side effects as ulceration,
tistically significant relationship between the site of keloid             hypopigmentation, and hyperpigmentation.
and the clinical or radiological response; however, the clin-                  Further studies of different combinations with FCL are
ical improvement was more at non-bony sites as mean VSS                    recommended in the treatment of keloids. Also, more studies
reduction was -3.36 (± 1.39) while at bony sites, it was -2.77             to assess the efficacy of applying TCA in lower concentra-
(± 1.69). We did not notice any recurrence among studied                   tions after FCL versus TCA as monotherapy in the treatment
cases compared to Behera et al, who reported a high recur-                 of keloids are needed.
rence rate during a one-year follow-up period [12]. This may                   TCA is needed to be tried alone in treating keloid or
be due to the short period of follow-up in our study.                      combined with other therapies other than a fractional laser,
    Current study limitations were a small sample of pa-                   though TCA can be combined with fractional laser but not
tients as we listed the patients who had the full number of                in the same session to lessen the side effects.
sessions and follow-up so, we didn’t mention patients who                      Clinical assessment of keloid scar using score scales as
didn’t complete the whole number of sessions, limited laser                VSS is not always accurate. It may underestimate the activity
sessions, and had a short follow-up period.                                in keloid scar, so adding radiological methods in assessment



Original Article | Dermatol Pract Concept. 2022;12(2):e2022072                                                                                  7
                                                                         8. Mari W, Alsabri SG, Tabal N, Younes S, Sherif A, Simman R.
                                                                            Novel Insights on Understanding of Keloid Scar: Article Review. J
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                                                                        10. Berman B, Maderal A, Raphael B. Keloids and Hypertrophic Scars:
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Figure 6. High resolution B mode ultrasonic imaging of a subcu-         12. Behera B, Kumari R, Thappa DM, Malathi M. Therapeutic
taneous keloid with homogenous to hypoechoic echopattern. (A)               Efficacy of Intralesional Steroid With Carbon Dioxide Laser
before treatment showing that keloid thickness was: 0.175 cm while          Versus With Cryotherapy in Treatment of Keloids: A Random-
the length was: 1.10 cm. (B) after 4 sessions of fractional CO2 fol-        ized Controlled Trial. Dermatol Surg. 2016;42(10):1188-1198.
lowed by TCA 20% showing decrease in the thickness to become                DOI:10.1097/DSS.0000000000000873. PMID: 27661432.
0.144 cm and in the length to become 0.666 cm, with moderate            13. Azzam OA, Bassiouny DA, El-Hawary MS, El Maadawi ZM,
improvement. On CDU application the lesion was completely avas-             Sobhi RM, El-Mesidy MS. Treatment of hypertrophic scars and
cular before and after treatment. CDU = Color Doppler Ultrasound;           keloids by fractional carbon dioxide laser: a clinical, histological,
TCA= Trichloroacetic acid                                                     and immunohistochemical study. Lasers Med Sci. 2016;31(1):
                                                                              9-18. DOI:10.1007/s10103-015-1824-4. PMID: 26498451.
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as CDU is of great importance to help physicians in the
                                                                              CO2 Laser in Dermatology. Laser Ther. 2014;23(1):49-60.
choice of the most appropriate modality of treatment based
                                                                              DOI:10.5978/islsm.14-RE-01. PMID: 24771971; PMCID:
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Original Article | Dermatol Pract Concept. 2022;12(2):e2022072                                                                       9
