50 yrs male OBESE patient presented with these types of hypertrophic scars/keloidal lesion on front of chest, both shoulders since last 35 yrs.At times severe itching around the borders.k/c/o HTN n DM. Patient took intralesional steroid injections on several times with temporary relief from itching. Surprisingly patient gets these lesion on upper body part only.He had injuries on lower part of body but those injuries got healed without leaving keloid formations.Her younger sister is also prone to develop keloids. What is the pathophysiology of this case n what is further line of treatment apart from intralesional steroid injections? Is it hereditary in nature?

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The keloid over dhoulder can be excised including a normal rim of the skin and suture the cut edges with mylon. If rrsponse is satisfsctory try the other keloids in two or more sittings. No skin grafting adviced as keloid may develop over the donor site.

1) I/L Inj Kenacort 40 mg repeated after 21 day 2) massage with Hexilak Ultra gel TDS to QID 3) Silicone gel sheet application 4) pressure garment 4) although direct heredity is not seen but it runs in siblings or Cary forward in generations 5) more common in African and Indian population...

Sir...Do you think on these large,widespread, scattered areas this treatment will work or advocated?
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Excision and skin grafting,lateron silicon sheet application

How does the silicon sheeting works on keloid? What is the pathophysiology of keloid n is it inherited?
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It is hereditary.surgical removal by cold lesser..

It requires multimodality treatment as dr Ravi has pointed out. Any single treatment is definitely going to recur so pressure garment Silicon sheet applications But intralesional injections of steroids to such large area is not feasible as any particular point of time maximum dose of total steroid should not. E more than 400-600mg that to spaces in four to six months otherwise systematic effects of steroid Amy appear. So my suggestion is to go for intralesional excision and skin grafting followed by as mentioned

I am not in favour of excision and skin grafting as area involved id large and recurrence will definitely be there anf in fact more disfiguring keloids.......Silicone occlusive sheeting with pressure worn 24 hrs /day for 6-12 months may be effective. Other options are 1 Cryosurgery. 2 . radiation therapy .3 . laser therapy. 4 . photodynamic therapy. 5 . UVA -1 or narrow band UVB therapy. 6.Imiquimod 5% cream. 7 . Intralesional Interferon therapy. 8 . Intralesional 5-FU, doxorubicin snd bleomycin. 9.Intense pulsed light

Keloid is due to irregular and disorganized distribution of collagen fibres in the dermal matrix along with excess fluid retention in the matrix. It has racial predisposition ( more common in African population and people with darker complexion) Keloid usually appears in upper trunk (presternal region and chest), upper arms, back. Lower trunk and lower limbs are usually spared. Keloid can appear De novo without any history of trauma/scar or may appear over previous scars as well, grows beyond the boundaries of scar and do not regress on its own (unlike hypertrophic scar which usually regress within 6 months) Moreover keloids have preponderance to recur. In this patient, as he has already undergone intralesional Kenacort therapy, so it will be prudent to go for intralesional excision, followed by STSG cover, along with silicone gel sheet therapy. Donor site must also undergo pressure garment application The exact mechanism of action of silicone gel sheet is still controversial. But as per accepted hypothesis, it reduces edema, abolishes excess fluid accumulation, exerts pressure effect which finally helps in realignment of collagen fibres.

Thanks mam for your exhaustive answer. .
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Give inj. Kenacort intraperitoneal .3-4 sittings needed at 4 weeks interval. Results r awsome

???? Intraperitoneal
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Usually there is recurrence after excisions. Intralesional Triamcenolone and Silicon gel sheet with pressure garments will help.

@Dr. Girish Dahake - non ablative laser follwed by intraleisional steroid. Surgical excision is another option but area is large ;let plastic surgeon should give their opinion

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