Eur Arch Otorhinolaryngol (2010) 267:575–580

DOI 10.1007/s00405-009-1059-8

HEAD & NECK

Auricular keloids: treatment and results

Christian Bermueller · Gerhard Rettinger · Tilman Keck

Received: 20 April 2009 / Accepted: 21 July 2009 / Published online: 9 August 2009© Springer-Verlag 2009

Abstract The aim of this study was to present long-termresults in patients with auricular keloids after surgical exci-sion and/or medical therapy by corticoid injection. A retro-spective study at an academic tertiary referral centre ispresented. Seventeen patients after excision, injection ofcorticoid, full skin grafting (single therapy or combinationof interventions) for auricular keloids were followed up.The validated questionnaires SF-36 and patient outcomesof surgery-head/neck were applied to evaluate the qualityof life and the patients’ satisfaction after therapy. Photo-graphs of the former keloid site were rated by an experi-enced facial plastic surgeon being unaware of treatmentmethod and the patient’s own estimation. The best resultsfor retroauricular keloids were reached by excision, skingrafting and triamcinolone injection, and for earlobekeloids by excision, primary wound closure and triamcino-lone injection. Both in rating by the patients and in gradingby an investigator, the highest scores for aesthetics and sat-isfaction were found after triamcinolone injection togetherwith or without excision or skin grafting. A size-relatedresection of keloids with defect reconstruction by full thick-ness skin grafting for retroauricular keloids and primarywound closure of ear lobe keloids with an additional steroid

injection lead to good cosmetic results and high level of sat-isfaction among patients.

Keywords Keloid · Full skin grafting · Injection of triamcinolone

Introduction

Keloids are scars that extend beyond the borders of theoriginal wound. In contrast to hypertrophic scars, whichrespect the borders of the initial wound area, keloids show ahigh recurrence rate despite various treatment modalities[1]. The underlying pathomechanism of both wound heal-ing disorders is a missing control mechanism that regulateswound healing and Wbrous tissue production after skintrauma or surgical skin treatment [1].

It may be diYcult initially to diVerentiate betweenhypertrophic scars and keloids, but apart from spontaneoussoftening of hypertrophic scars, which improves theirappearance, there are (immuno)-histological, molecular,and biochemical diVerences. Keloids show large, denselypacked collagen bundles random to epidermis and horizon-tal cellular Wbrous bands in the upper reticular dermis [1,2]. Compared to hypertrophic scars, keloids have relativelyfewer cells in their centre [1] and a decreased rate of Wbro-blast apoptosis. An abnormal response to platelet-derivedgrowth factor and transforming growth factor of keloidWbroblasts has also been described [1].

Despite what is known about the histomorphologicalstructure of keloids, no single established treatment regimeexists. However, various treatment options, like surgicalexcision, intralesional injection of corticosteroids [1, 3, 4],5-FU [5, 6], mitomycin-C [7] or bleomycin [8, 9], compres-sive therapy [10], diVerent kinds of irradiation [2], skin

C. Bermueller (&) · G. RettingerDepartment of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Ulm, Frauensteige 12, 89075 Ulm, Germanye-mail: christian.bermueller@uniklinik-ulm.de

T. KeckDepartment of Otorhinolaryngology, Head, Neck, and Facial Plastic Surgery, Elisabethinen Hospital, Academic Hospital of the Medical University of Graz, Graz, Austria

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grafting [11], CO2-laser, pulse laser therapy [1, 12, 13],cryosurgery, banding [14] and several treatment combina-tions [1, 15, 16] of the above-mentioned treatment modali-ties are described.

As keloids often recur after various surgical or non-surgical therapies, treatment of keloids is still a challengingtask in surgery. Especially if they occur in the head or neckregion, i.e. if they are visible and cannot be disguised, thepsychological handicap for patients is acute. Additionally,the skin alteration may result in pain, dysesthesia, pruritus,burning, or restricted range of motion of the head or neck.

The aim of this retrospective study on auricular keloidswas to evaluate the various treatment options applied in theENT department of the university clinic of Ulm and toassess the long-term treatment results in respect of qualityof life, patient satisfaction, recurrence of keloids, and cos-metic results.

Patients and methods

Patient group

The charts of 33 patients (17 male and 16 female; mean21 § 8 years) consecutively treated between September 1995and January 2008 because of primary or recurrent keloids atthe Department of Otorhinolaryngology, Head and Neck Sur-gery, University Hospital of Ulm were reviewed retrospec-tively. At least 1 year after surgery, the patients were invitedto a follow-up examination at our institution for functionaland aesthetic evaluation after surgery and for assessment ofquality of life and subjective treatment success.

Fifteen patients were lost to follow-up and could not bere-examined at our hospital. Out of 33 patients treatedbecause of primary or recurrent keloids, 18 patients couldbe re-examined. One patient had to be excluded because thekeloid was not an auricular keloid, but on the thorax wall(after previous harvesting of rib cartilage for reconstructionof the nasal septum). Finally, 17 patients were eligible forthe study and could be enrolled.

Surgical and medical therapy

The treatment modalities at our institution were as follows:(I) surgical excision along skin tension lines and intrader-mal wound closure by direct approximation (n = 6patients), (II) surgical excision and full thickness skin graft-ing from the inguinal region (n = 6 patients), (III) keloidexcision with primary wound closure and single intrale-sional injection of 10% triamcinolone acetonide (n = 10patients); (IV) keloid excision, inguinal skin grafting andsingle intralesional injection of 10% triamcinolone aceto-nide (n = 11 patients). Treatments I and II were non-

corticoid therapies, treatments III–IV were corticoid thera-pies. In each case, the decision for the speciWc treatmentmodality was done depending of the extent of the keloid.

The decision for primary wound closure or full thicknessskin grafting for tension-free wound closure was takenaccording to the extent of the keloid and tension around thewound bed after excision. In all surgical cases, dissolublesubcutaneous sutures and non-absorbable intradermalsutures were used.

Evaluation after therapy

To evaluate the quality of life and patient satisfaction aftertherapy, two standardized and validated questionnaireswere used: the SF-36 and patient outcomes of surgery-head/neck (POS-head/neck). The SF-36 is a testinginstrument for survey of quality of life related to health,independent of speciWc illness [17]. The SF-36 (the MOS36-item short form health survey) registers eight dimen-sions, which can be classiWed in eight health concepts: physicalfunctioning, role limitations due to physical health, bodilypain, general health perception, vitality, social functioning,role limitations due to emotional problems and mentalhealth. The results are adjustable to a correspondent normgroup. The raw data are transformed into a 100 score scale.The average result of the norm group is 50. Every valuehigher than 50 shows an above-average result.

The patient outcomes of surgery-head/neck (POS-head/neck), a validated questionnaire for clinical outcome mea-surements [18] in head and neck surgery, has good reliabilityand internal consistency. Satisfaction with the postoperativeresult (maximum score 11) and psychological functioning andcosmetic appearance (maximum score 30) are scaled. Highscores indicate good psychological functioning and satis-faction.

Photographs of the former keloid site were taken (C.B.)and rated by an experienced facial plastic surgeon (T.K.).The aesthetic results after keloid therapy were graded byone surgeon on a scale as follows: 1 = excellent, 2 = good,3 = acceptable, 4 = poor, 5 = bad, 6 = unacceptable. Aes-thetic value was graded blind on a scale with no awarenessof the detailed treatment modalities and the patient’s ownrating. Results at or below 3 were considered successful,whereas results at or above 4 were considered unsuccessful.

Results

Eight male and 9 female patients (mean age at the time ofintervention: 23 § 8 years) were eligible for the study andcould be enrolled.

The eldest patient at the time of keloid therapy was31 years old, the youngest patient was 10 years old. The

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longest follow-up interval was 12 years, the shortest 1 year(mean 4 § 4 years) after surgical and/or medical therapy.Eight patients had a keloid of the earlobe, 6 patients a retro-auricular keloid and 3 patients had preauricular keloids.Aetiology of all keloids was ear piercing (lobe, preauricularkeloids) or otoplasty (retroauricular keloids).

Four patients were treated by excision only (group I), 3by excision and full skin grafting (group II). Five patientswere treated by excision, primary wound closure, and injec-tion of triamcinolone (group III), 5 patients had excision,full skin grafting, and injection of triamcinolone (groupIV).

A primary keloid was treated in 12 patients, a recurrentkeloid in 5 patients.

In 2 of the 17 patients treated at our department a recur-rent keloid was observed, although reduced in dimensionscompared to the pre-operative size of the keloids. Bothpatients were operated on because of a primary keloid. Onepatient was treated by resection and skin transplantation(group II), the second patient by resection, skin transplanta-tion, and injection of triamcinolone (group V) (Figs. 1, 2).

The mean POS cosmetic appearance score of all 17patients together was 27 (out of 30 possible), the mean sat-isfaction score was 8 out of a possible 11. The mean SF-36score was 58 (bodily functioning), 61 (mental health) and60 (physical component summary). The mean cosmeticappearance, graded by one investigator, was 1.8.

The results of each group are shown in detail in Table 1.Generally, the aesthetic result and well-being were rated

highly positive after each treatment modality. However,diVerences between the treatment groups were found, espe-cially when comparing non-corticoid groups (I and II) withcorticoid groups (III–IV). Both in patient self-assessmentand in grading by a single investigator (T.K.) the highestscores for aesthetics and satisfaction were found after aninjection of triamcinolone, in conjunction with excision orfull skin grafting (corticoid groups III–IV).

Most ear lobe keloids were treated by excision, primarywound closure and injection of triamcinolone, whereas ret-roauricular keloids mostly were treated by excision, fullskin grafting and injection of triamcinolone with a high rat-ing by the investigator and a high POS score.

Larger keloids were treated by resection and transplanta-tion (with or without accompanying steroid injection),smaller keloids were resected and primary wound closurewith or without steroid injection or steroid injection onlywas performed (details see Table 2).

Discussion

The aim of our retrospective study was to evaluate varioustreatment options of auricular keloids, applied at our hospital,

and to assess the treatment success with regard to quality oflife and satisfaction of patients, local recurrence of keloids,and cosmetic results.

One major problem of retrospective studies is the loss offollow-up of patients due to moving, job-related or familycommitments. In this study, almost half of the patientstreated for auricular keloids could not be enrolled becauseof these reasons. Thus, only a small number of patientsafter previous keloid therapy at our hospital could bere-examined. However, more dissatisWed patients may beexpected to be seen under conditions such as these, thus

Fig. 1 Photographs of an auricular keloid before and 16 months aftersuccessful excision, primary wound closure, and single injection oftriamcinolone

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representing a more negative sample. To our knowledge,this is the Wrst study to evaluate patient satisfaction with theresults of keloid treatment. To assess the patients’ satisfac-tion with the postoperative result, the patient outcomes ofsurgery-head/neck (POS-head/neck) was applied [18]. Thisuser-friendly questionnaire contains six questions to assesspsychological functioning, cosmetic appearance and satis-faction and is site speciWc to head and neck skin lesions. Ittook less than 5 min to be Wlled out for each patient. Unfor-tunately, because of the retrospective character of thisstudy, only results after keloid therapy and no results beforeintervention can be presented. However, the POS-head/neck is also acceptable in the evaluation of outcomes only

after therapy of head/neck skin lesions and satisWes rigor-ous scientiWc criteria [18].

Patient satisfaction in all treatment groups was generallyhigh (8 out of a possible 11 points). The mean psychologi-cal functioning and cosmetic appearance was 27 out of pos-sible 30 points. These results indicate that the patients werebasically satisWed with the cosmetic results, even the twopatients with minor recurrent keloids that needed no addi-tional therapy yet.

Currently, only scant data on evaluation of cosmeticresults after treatment of keloids exist. De Lorenzi et al. [2]reported on treatment of keloids, mostly located (50%) onthe breast by brachytherapy. Cosmetic outcome after ther-apy was graded by the patients and investigators on a six-point scale, similar to the classiWcation used in our study.Fifty percent of the patients rated the cosmetic result as“good”, 23% as “quite satisfactory”, and almost 20% as“not so good”, “bad”, or “very bad”. Grading of the cos-metic results by the medical investigators was “good” in38%, “quite satisfactory” in 27%, and “not so good”, “bad”,or “very bad” in 14% of the patients. However, the qualityof life was not evaluated in the study presented by DeLorenzi et al.

Quality of life is diYcult to measure. In the presentedstudy, the SF-36 questionnaire to assess quality of life ofpatients after therapy of keloids was used. This question-naire is well established for evaluation of health-relatedquality of life independent of underlying diseases [17].Eight dimensions of somatic and mental health aredetected. In our study, the patients had a higher-than-average quality of life with regard to bodily functioning,mental health and physical component summary.

Actually, it is doubtful if the high quality of life in thepatients after keloid treatment is associated with the treat-ment of the keloid. However, since treatment of a keloidwas only performed in patients who had signiWcant psycho-logical problems with their visible keloids in the head andneck area, the high satisfaction of the patients with theirtreatment result and the positive evaluation of the aestheticoutcome by the patients indicate a strong relation of qualityof life and the treatment success of the previously visibleand disturbing skin pathology.

In our follow-up examination, two recurrent keloids (in17 patients; recurrence rate: 12%) were seen. Comparedwith other retrospective studies evaluating the recurrencerate after treatment of head and neck keloids, the recurrencerate in our study is small. Rosen et al. [19] described arecurrence rate of 23% after treatment of keloids with exci-sion and intraoperative and postoperative injection of ste-roids. Keloid excision and radiation has been associatedwith a recurrence rate of lower than 10% [20–22]. Lasertherapy was reported to lead to a recurrence rate of morethan 90% [23, 24]. In studies with 5-FU injection [6],

Fig. 2 Photographs of a retroauricular keloid after previous otoplastybefore and 20 months after successful keloid excision, inguinal skingrafting, and single intralesional injection of 10% triamcinolone

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bleomycin injection [9], and excision and imiquimod appli-cation [6], no recurrent keloids were observed.

These treatment regimes may be eYcient in avoidingrecurrence of keloids, but they may have potential sideeVects. Radiation is known to cause hyperpigmentation andteleangiectasia. This may be acceptable for skin areas thatcan be disguised, but in the head and neck area they cancause cosmetic problems. Irradiation of auricular keloidsmay cause cancer of the salivary glands, such as the parotidglands, which are located close to the ear. Although thereare insuYcient studies that substantiate an increased risk oflocal malignancies, it is, in our opinion, not acceptable totreat benign lesions of the skin with a potential cancer-causing regime. The same is true for local 5-FU injection orbleomycin injection, which may have a potential risk oflocal induction of malignancies.

Another problem in evaluating the rate of recurrence isthe interval of follow-up. Most studies have follow-uptimes of 2 or less years. Only few provide data of long-termresults, i.e. more than 5 years [1, 19].

To summarise, as mentioned above, the main limitationof our study is the small sample size of various treatmentarms and the retrospective sampling method. To furtherobtain valid data on wound healing, complications afterdiVerent treatment regimes in head and neck keloids, andlocal recurrence after diVerent therapies, a large prospective

randomized trial (stratiWed random sampling) and multi-centre study would be necessary to demonstrate possiblediVerences.

Conclusion

The size-related treatment strategy of auricular keloids,applied in the ENT Department of the University Clinic ofUlm, leads to a small rate of recurrence and a high level oflife quality and patient satisfaction. Larger keloids, espe-cially retroauricular keloids should be resected and thedefect, to ensure a tension-free wound closure, covered byfull thickness skin grafting. Smaller keloids, especiallyear lobe keloids, should be resected and a primary woundclosure is preferable. Because of the trend of increasedpatient satisfaction, an additional steroid injection isuseful.

References

1. Butler PD, Longaker MT, Yang GP (2008) Current progress inkeloid research and treatment. J Am Coll Surg 206:731–741.doi:10.1016/j.jamcollsurg.2007.12.001

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Table 1 Grading of aesthetics and well-being by the patients and one facial plastic surgeon after surgical and/or medical therapy of auricularkeloids

The mean values of each grading parameter is shown. Bold value highest value of each parameter tested in 4 treatment groups

Group Therapy No. of patients

POS cosmetic appearance

POS score satisfaction

SF 36 bodily functioning

SF 36 mental health

SF 36 physical component summary

Surgeon’s aesthetic rating

I Excision 4 26.8 6.5 52 56.3 56 2

II Excision and full skin grafting 3 26.3 8.7 57.3 55 59.5 3

III Excision, primary wound closure, and injection of triamcinolone

5 25 9 63 66.2 61.4 1.4

IV Excision, full skin grafting, and injection of triamcinolone

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I–IV All 17 27 8 58 61 60 1.9

Table 2 Localization and mean size of keloids according to treatment groups

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