Successful cosmetic outcome of earlobe keloid after surgical excision and topical imiquimod 5%

Dear Editor, Keloids represent an exacerbate response to wound healing with excessive collagen deposit in dermal tissue. Susceptible patients after cutaneous trauma such as surgery, ear piercing, wound injury, burns, and some cutaneous are more likely to be affected. The upper trunk and back, shoulders, head, and neck region, especially earlobes and the helix of the auricle, are the most common areas for keloid formation. It is a challenge for physicians to manage this esthetic condition due to unsatisfactory response to most of the therapeutic option. Imiquimod is an immunomodulator that induces the production of IFN-α, IFN-γ, TNF-α, and IL-12 that stimulate both acquired and innate immune responses that have been successfully used in condyloma acuminata, Bowen disease, actinic keratoses, basal cell carcinomas, molluscum contagiosum, Kaposi sarcoma, and infantile hemangiomas. A 45-year-old man was referred to our Dermatology Outpatient Clinic presenting an indurated, erythematous, and nodule on the left earlobe of 2 year duration (Figure 1). It progressively developed after ear piercing. Patient complained of pain and psychological problems due to unfavorable cosmetic disfigurement. Radical excision and electrocoagulation with no suture were performed, leaving the wound by second-intention healing followed by topical imiquimod 5% cream daily for 6 weeks. After 4 weeks and 12 months of followup, no infection signs and satisfactory esthetic result was evidenced (Figure 2). According to some authors, the difference between hypertrophic and keloid scars is that in the latter ones the raised scar tissue extends beyond the original margins with rare spontaneous regression. The pathogenesis remains unclear, but there is an amplified and prolonged inflammatory response, overexpression of growth factor signals, and increased activation of fibroblasts. This condition leads to collagen synthesis in the fibroblasts and decreased collagen decomposition after tissue injury up resulting in a 20-fold increase of collagen production compared with normal skin. A large amount of therapeutic options, such as combining surgical interventions with radiation, intralesional triamcinolone injections, pressure therapy, radiotherapy, cryotherapy, silicone-gel sheeting, lasers (fractional CO2, dye laser, and diode), and antitumor or immunosuppressive agents have been used with variable success results depending on localization. The reported success rate varies markedly with recurrences ranging from 50% to 100% in case of excision alone to lower recurrence rates when different therapeutic methods are implemented together. Although wedge excision or radical keloidectomy has been recommended in sessile, single nodular pattern, type II, we did not use any suture method, leaving by secondary intention healing. Imiquimod 5% cream is a topical immune response modifier that enhances migration of Langerhans cells to regional lymph nodes and tolllike receptor 7 signaling by cytokines including IFN-α, IFN-γ, IL-1α, IL-6, IL-8, IL-12, and TNF-α. Imiquimod's effectiveness in the prevention of keloid recurrences after surgical excision could be explained by IFN-γ stimulation that would downregulate the expression of TGF-β and the T helper 2 immune response-associated cytokines such as interleukin-4, known to promote fibrotic processes. Its ability to induce the expression F IGURE 1 Erythematous, infiltrated, nodule on the left earlobe F IGURE 2 Keloid earlobe after surgical excision and topical imiquimod 5% Received: 10 May 2020 Revised: 1 June 2020 Accepted: 9 June 2020