Management of Ear Keloids

Sir: We would like to make comments on an article by Rosen and colleagues entitled “A Primary Protocol for the Management of Ear Keloids: Results of Excision Combined with Intraoperative and Postoperative Steroid Injections” (Plast. Reconstr. Surg. 120: 1395, 2007). This article has some problems that could potentially be misleading to workers in this field. First, throughout their article, they failed to make any distinction between the upper part of the auricle (cartilaginous part of the auricle) and the earlobe. In our experience, the recurrence rates of keloids after surgery in these regions are clearly different. We have treated ear keloids with a combination of surgery and postoperative electron-beam irradiation (15 Gy in three fractions over 3 days). The recurrence rate of keloids under these conditions in the earlobe was 5.7 percent, whereas the occurrence rate in the auricle, excluding the earlobe, was 38.5 percent.1 This led us to propose that postoperative irradiation of keloids on earlobes could be reduced from 15 Gy in three fractions over 3 days to 10 Gy in two fractions over 2 days, with maintenance of good results.1 Thus, we believe that keloid treatment requires site-specific protocols and that it is very important to distinguish between the auricle, excluding the earlobe, and the earlobe when performing this type of treatment. Second, they mentioned that radiation therapy should not be the primary postexcisional adjunct because of its potential adverse side effects. They listed radiation dermatitis, hyperpigmentation, hypopigmentation, telangiectasia, localized pruritus, paresthesias, and pain as potential side effects. However, in our experience, these side effects are temporary and mild if the appropriate radiation doses are used.1,2 Moreover, we have never encountered telangiectasia, localized pruritus, paresthesias, pain, dysraphia, wound infection, or malignant tumors after radiation treatment of Asian patients. Thus, we believe that postoperative radiation therapy should be the primary adjunct therapy of keloids. Third, it is unquestionable that patients are much more likely to complete treatment with irradiation than with corticosteroid injections. In a randomized, prospective study, 12.5 percent of keloids recurred after surgery and radiation therapy, whereas 33 percent recurred after surgery and steroid injections.4 Every effort should be made to treat keloids in one operation, as a second operation will be hampered by the small volume of earlobe available. Moreover, in our hospital, we not only implement effective measures to prevent the recurrence of keloids but also engage in earlobe repiercing on the patient’s request.3 We propose repiercing when postoperative irradiation has been performed and the patient is capable of self-management. Lastly, steroid injection sometimes causes irregular menstruation and thinning of the skin and subcutaneous tissue.5 We suspect that the deformation of the earlobe visible in the figures in the article of Rosen et al. may be a side effect of steroid injection. In addition, we suspect that secondary operations were difficult because of the steroid injections. Thus, we do not recommend steroid injections either intraoperatively or preoperatively. Satoshi Akaishi, M.D. Rei Ogawa, M.D., Ph.D. Hiko Hyakusoku, M.D., Ph.D. Department of Plastic, Reconstructive and Aesthetic Surgery Nippon Medical School Hospital Tokyo, Japan