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High-Dose-Rate Brachytherapy for the Treatment of Recalcitrant Keloids: A Unique, Effective Treatment Protocol

van Leeuwen, Michiel C. E. M.D.; Stokmans, Suzanne C. B.Sc.; Bulstra, Anne-Eva J. B.Sc.; Meijer, Otto W. M. M.D.; van Leeuwen, Paul A. M. M.D., Ph.D.; Niessen, Frank B. M.D., Ph.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 527–534
doi: 10.1097/PRS.0000000000000415
Reconstructive: Head and Neck: Original Articles

Background: Keloids cause aesthetic disfigurement and physical complaints, mainly pain and pruritus. Treatment of these scars is difficult, with high recurrence rates forming the main issue. Surgical excision with adjuvant radiotherapy is considered the most efficacious treatment. At their institution, the authors have been treating keloids with a high-dose-rate brachytherapy procedure for over 10 years, using a protocol with the lowest total radiation dosage known in the literature.

Methods: This prospective study included 43 patients of all Fitzpatrick skin types, with 67 keloids in total. After extralesional excision, a radiation scheme of 2 × 6 Gy was administered in two fractions: the first within 4 hours after surgery and the second within 24 hours. Scars were measured and recurrence was judged. Scar appearance was evaluated using the Patient and Observer Scar Assessment Scale.

Results: The recurrence rate was 3.1 percent at a mean follow-up of 33.6 months. A significant average scar surface decrease of 56.7 percent was measured (p = 0.01). Complaints of pain and pruritus decreased by 82.9 and 87.2 percent, respectively. Patients were satisfied with the treatment in 88.6 percent of the cases and with the cosmetic result in 77.1 percent. Pigmentation problems were seen in 21.4 percent of the patients, mostly in Fitzpatrick type V and VI/African American individuals.

Conclusions: The results of this prospective study show a good cosmetic outcome with a low recurrence rate. The unique radiation schedule proves the efficacy and safety of high-dose-rate brachytherapy and suggests the importance of immediate postoperative irradiation. In addition, only one outpatient treatment is required after surgery, enhancing patient convenience.


Amsterdam, The Netherlands

From the Departments of Plastic and Reconstructive Surgery, Radiation Oncology, and Surgery, VU University Medical Center.

Received for publication December 10, 2013; accepted March 17, 2014.

This trial is registered under the name “High Dose Rate Brachytherapy for Treatment of Keloids,” identification number NCT02005055 (

Disclosure: The authors have no financial interest to declare in relation to the content of this article. No external funds were received.

Michiel C. E. van Leeuwen, M.D., Department of Plastic, Reconstructive and Hand Surgery, VU University Medical Center, Postbus 7057, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands,

©2014American Society of Plastic Surgeons