Society of Black Academic Surgeons Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy Takintope Akinbiyi a , Geoffrey M. Kozak a, c , Harrison D. Davis a , Louis-Xavier Barrette a , Arturo J. Rios-Diaz a, c , Russell Maxwell b , Estifanos D. Tilahun a , Joshua A. Jones b , Robyn B. Broach a , Paris D. Butler a, * a Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA,19104, USA b Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA,19104, USA c Department of Surgery, Thomas Jefferson University, Philadelphia, PA,19107, USA article info Article history: Received 1 May 2020 Received in revised form 29 June 2020 Accepted 27 July 2020 This study was to be presented at the Soci- ety of Black Academic Surgeons (SBAS) annual meeting in April 2020 in Milwaukee, WI that was unfortunately cancelled sec- ondary to the COVID-19 pandemic. Keywords: Keloid Corticosteroid Surgery Radiation Recurrence Complication abstract Introduction: We evaluate a single center’s, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision þ radiation therapy (SE þ RT). Study design: Patients undergoing keloid treatment were identified (2008e2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE þ RT. Logistic regression was used to determine factors associated with recurrence and complications. Results: 284 keloids (95 MM, 94 SE, 95 S E þ RT) corresponded to patients with a median age of 39.1 (IQR: 26.1e53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6e30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE þ RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recur- rence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE þ RT group. Conclusions: MM resulted in at least some improvement. Recurrence rates after SE and SE þ RT were similar. Female sex is protective, race does not affect outcomes. © 2020 Elsevier Inc. All rights reserved. Introduction Keloids are benign proliferative tumors characterized by an excessive cellular response to skin trauma that extends beyond the borders of the original cutaneous insult. Despite numerous treat- ment options, there is no single universally accepted treatment modality, and multiple approaches are often used concurrently to improve outcomes and minimize recurrence. 1 Common therapies include conservative topical management (e.g. silicone dressings, steroids, imiquimod), intralesional injections (e.g. corticosteroids, 5-FU, interferon), hyperbaric oxygen therapy, autologous fat graft- ing, laser therapy, cryotherapy, surgical excision, and radiotherapy. 2e10 Currently, the most widely used treatments for keloids are surgical excision, steroid injection, or radiotherapy. 11, 12 Clinical recurrence represents a common indicator of treatment failure. Surgical excision as a monotherapy leads to recurrence rates of 45%e100%, making it an imperfect first-line modality. 13, 14 While the use of non-surgical modalities as adjunctive treatments after surgical excision can lead to reduced recurrence, long-term usage requirements can make compliance a challenge. Recently, post- operative radiotherapy, as an adjunct to excision, has demonstrated positive early success rates and durability in numerous case series and meta-analyses. 1, 15, 16 Despite this, current studies may lack adequate sample size, standardized dosing, and long-term follow- up. Additionally, keloid-specific characteristics, surgical technique, Abbreviations: MM, Medical management; SE, Surgical excision; SEþRT, Surgical excision with radiotherapy; IQR, Interquartile range; OR, Odds ratio; BED, Biologi- cally effective dose. * Corresponding author. Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 800 Walnut St, 19th Floor, Philadelphia, PA, 19107, USA. E-mail address: Paris.Butler@pennmedicine.upenn.edu (P.D. Butler). Contents lists available at ScienceDirect The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com https://doi.org/10.1016/j.amjsurg.2020.07.035 0002-9610/© 2020 Elsevier Inc. All rights reserved. The American Journal of Surgery xxx (xxxx) xxx Please cite this article as: Akinbiyi T et al., Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2020.07.035