We would like to congratulate Ogawa1 for his timely article on the current algorithms for the treatment and prevention of hypertrophic scars and keloids. The aim of this article was to propose algorithms for evidence-based multimodal therapies and prevention of hypertrophic scars and keloids.
Over the past 20 years, several colleagues, including our group, have extensively studied the treatment modalities of hypertrophic scars and keloids, especially by cryosurgery. Cryosurgery, which has first described in the 1980s as an evidence-based therapeutic method for hypertrophic scars and keloids, has gained acceptance through the years as a major and significant tool with which to treat hypertrophic scars and keloids. However, pain after treatment, hypopigmentation, and a satisfactory response of only small hypertrophic scars and keloids were major drawbacks.1 In contrast, the use of cryosurgery as an effective and successful treatment for hypertrophic scars and keloids, with low recurrence rates, has never been in doubt.2
In recent years, a new cryosurgical technology, the intralesional cryosurgery (CryoShape; Cryogenic Marketing Group Ltd., New York, N.Y.) had been developed for the treatment of hypertrophic scars and keloids.3 This method, which is U.S. Food and Drug Administration and CE approved, has been applied successfully on hundreds of patients with hypertrophic scars and keloids in Israel, Europe, and the United States, with clinical results that are significantly superior to the conventional available treatment modalities. It has been demonstrated repeatedly3–5 that, following a single intralesional cryogenic session, an average volume reduction of 50, 60, and 67 percent of hypertrophic scars and keloids has been achieved at the chest, upper back/shoulders, and auricle, respectively. Furthermore, a significant alleviation of subjective (i.e., itchiness/discomfort, pain/tenderness) and objective (i.e., redness, hardness) clinical symptoms was documented.
Although two of our articles reporting on intralesional cryosurgery have been cited in the article by Ogawa (their references 56 and 59), the results of these studies were not been elaborated on in the text. In these and other publications, it has been demonstrated that large hypertrophic scars and keloids can be treated successfully by intralesional cryosurgery3–6 (Fig. 1). Furthermore, the hypertrophic scars and keloid tissue are rejuvenated (i.e., the hypertrophic scars and keloids collagen following cryosurgery become apparently normal); probably, therefore, the no-response rate is less than 3 percent.3,4 Neither worsening nor infection of the treated hypertrophic scars and keloids has been documented. The pain during cryosurgery has been tackled by composing a published pain control protocol,5 which consists of translesional local anesthesia and pain-relief tablets. This scheme significantly reduced the pain during and after the cryosurgical treatment, with a score of 6 to 8 on the visual analogue scale (which ranges from 1 to 10) without a pain control protocol, to the level of 1 to 3 using this protocol. In addition, by using the intralesional approach, a significantly lower hypopigmentation rate (8.3 percent) had been demonstrated when compared with the contact cryosurgery method (91.7 percent).6 The reason is that the melanocytes are located in the recovery zone when using the intralesional approach, whereas in the contact method, the melanocytes are included in the lethal zone. These findings encourage application of the intralesional cryosurgery method in dark-skinned individuals suffering from hypertrophic scars and keloids.
In the article by Ogawa,1 cryosurgery is only advocated for the treatment of keloids. According to our experience, it is extremely difficult to distinguish clinically hypertrophic scars from keloids, especially a few months after the healing of the initial wound. Therefore, we advocate that cryosurgery should also be applied in hypertrophic scars.
In conclusion, cryosurgery in the past few years has undergone major developments (intralesional approach and a novel cryogenic needle probe) that provide effective and comfortable clinical solutions to overcome the past objective and subjective disadvantages. Therefore, it deserves to be considered as one of the leading technologies in the treatment of hypertrophic scars and keloids.
Yaron Har-Shai, M.D.
Unit of Plastic Surgery
Carmel Medical Center
Wilfred Brown, M.D.
Aesthetic Surgery Associates, P.C.
Norbert Pallua, M.D., Ph.D.
Department of Plastic Surgery, Hand Surgery, Burn Center
University Hospital of the RWTH Aachen University
Christos C. Zouboulis, M.D.
Departments of Dermatology, Venerology, Allergology, and Immunology
Dessau Medical Center
1.Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg
2.Zouboulis CC, Zouridaki E, Rosenberger A, Dalkowski A. Current developments and uses of cryosurgery in the treatment of keloids and hypertrophic scars. Wound Repair Regen
3.Har-Shai Y, Amar M, Sabo E. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. Plast Reconstr Surg
4.Har-Shai Y, Sabo E, Rohde E, Hayms M, Assaf C, Zouboulis CC. Intralesional cryosurgery markedly enhances the involution of recalcitrant auricular keloids: A new clinical approach supported by experimental studies. Wound Repair Regen
5.Har-Shai Y, Brown W, Labbé D, et al. Intralesional cryosurgery for the treatment of hypertrophic scars and keloids following aesthetic surgery. Int J Lower Extrem Wounds
6.Har-Shai Y, Dujovny E, Rohde E, Zouboulis CC. Effect of skin surface temperature on skin pigmentation during contact and intralesional cryosurgery of keloids. J Eur Acad Dermatol Venereol
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