KELOID MANAGEMENT AND THERAPIES
Keloids are a common problem, and occur disproportionately among patients with darker skin types.
Dermatologic surgeons have several options available for keloid management, ranging from intralesional injections to excision and flap repair.
Therapy must be tailored to the individual patient, as tolerance for invasive or costly therapies varies considerably.
Intralesional steroid injections are the generally accepted first-line treatment for keloids.
It is better to start with a lower volume and lower concentration (10 mg/cc) and move up if needed to minimize the risk of steroid-associated complications.
Laser and radiation approaches are generally best used as an adjuvant to excisional surgery.
Combining meticulous surgical excision and another adjuvant therapy, such as radiation or intralesional injection, may yield the lowest recurrence rates.
Cryotherapy may be associated with significant residual hypopigmentation.
Bleomycin injections are often very painful, and local anesthesia is generally required prior to injection.
Pitfalls and Cautions
Many of these treatments are not approved by the FDA for keloid treatment.
Radiation in particular can be very costly, and patients should be aware of the potential costs and complications associated with the various approaches.
Patient Education Points
Keloids are notoriously difficult to treat, and recurrence is possible even when combining multiple approaches and using meticulous technique.
Overly aggressive steroid injections should be weighed against the potential for atrophy and telangiectasia development; patients should understand that these are common and expected side effects prior to initiating therapy.
Excision and repair of keloids may be billed using standard excision (11400 series) and repair (12000 and 13000) series codes.
If a flap is used, it should be coded independently without an excision code.
Be sure to document the medical necessity for flap closure.
Insurance companies are variably willing to cover the cost of radiation treatment of keloids; careful documentation of past treatments that have failed may help increase the likelihood that these approaches could be reimbursed.
Keloids represent an aberrant response to wound healing, and are defined as thickened scars that spread beyond the boundaries of the original wound. Keloids may grow over time, and can be associated with symptoms such as pruritus, burning, and pain, and—particularly when located over joints—may lead to functional limitations. They may also lead to other physical limitations, such as dysuria or pain with ambulation when located in areas such as the genitals or feet, respectively. The greatest morbidity from keloids, however, is the psychological distress that stems from their sometimes cosmetically disfiguring appearance.
Several therapies have been developed to treat keloids, though no true cure exists, and no single treatment is consistently successful. Often, combinations of different therapies must be employed to achieve satisfactory outcomes. These include various topical and intralesional (IL) therapies, surgery, ...