Keloids are benign fibroproliferative tumors that arise as a reaction to any kind of injury to the skin of inclined individuals. Keloid tissue extends beyond the margins of the wound. Keloids tend to grow symptomless, but still can often cause pain or itching. They have a functional, aesthetic, or psychosocial impact on patients, as highlighted by quality-of-life studies.

Keloids are elevated fibrous scars that extend beyond the borders of the original wound, do not regress, and usually recur after excision. 

Keloid scars result from a complex aberrant response during the tissue remodeling phase, which can result in disfiguration, restriction of movement, pain, pruritus, ulceration, and infection.

Keloid scars can lead to significant patient morbidity and disfigurement, especially when located on the head and neck. Massive keloid scars are particularly difficult to manage due to ulceration, infection, pain, and high recurrence rates following excision.

Here we present a case of refractory keloids treated with laser-assisted drug delivery using fractional ablative laser followed by a combined treatment of topical application.

A 35-year-old male came with complaint of necrotic keloid scar overlying his left posterolateral scalp, neck, and retroauricular area with associated dermatopathic regional lymphadenopathy. He had fallen off 15 years earlier, suffering a laceration which healed as a large keloid scar. This recurred despite three previous attempts atexcision and grafting in addition to numerous intralesional corticosteroid injections. He suffered from significant decreased quality of life due to social stigma, pain, ulceration from minor trauma, infection, and restriction in lateral neck rotation and flexion.

The patient′s keloids were painful, cosmetically bothersome, and limiting his range of motion, most notably of the neck.

The keloids on the neck and back were the most symptomatic, laser-assisted drug delivery using fractionated carbon dioxide (CO₂) laser with Deep Fx setting was performed.

After the procedure, 2% mupirocin ointment was applied. The patient tolerated the procedure well with only mild discomfort and, in follow-up, he denied any postprocedural swelling, bruising, pain, or purulent discharge.

Remarkably, the patient noticed flattening of keloids and improvement in pain and range of motion after 1 treatment. The Vancouver scar scale of the lesion on the upper back was decreased from 7 at baseline to 2 after treatments. After 2 treatments on the neck, the patient reported improvement of range of motion on the neck and reduction of pus discharge and pain.

The patient suffered from no further ulceration of the skin during this fractional laser-assisted drug delivery. The patient remains pleased with the functional and cosmetic appearance of his scar 22 months from his last such treatment and has not had recurrence of the keloid 47 months from his excision.

The patient showed more rapid response to the treatment. This may represent a promising new approach in the treatment of extensive or refractory keloids that do not respond to traditional methods, and its therapeutic application warrants further exploration.

Suggested Reading

1. Juckett G., Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician. 2009;80(3):253–260.
2. Naeini F.F., Najafian J., Ahmadpour K. Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars. Dermatol Surg. 2006;32(8):1023–1029. discussion 9-30. 
3. Sabry H.H., Abdel Rahman S.H., Hussein M.S., Sanad R.R., Abd El Azez T.A. The efficacy of combining fractional carbon dioxide laser with verapamil hydrochloride or 5-fluorouracil in the treatment of hypertrophic scars and keloids: a clinical and immunohistochemical study. Dermatol Surg. 2019;45(4):536–546. 
4. Waibel J.S., Wulkan A.J., Rudnick A., Daoud A. Treatment of hypertrophic scars using laser-assisted corticosteroid versus laser-assisted 5-fluorouracil delivery. Dermatol Surg. 2019;45(3):423–430.
5. Kraeva E., Ho D., Jagdeo J. Successful Treatment of keloid with fractionated carbon dioxide (co2) laser and laser-assisted drug delivery of triamcinolone acetonide ointment in an African-American man. J Drugs Dermatol. 2017;16(9):925–927.