Topical mitomycin effective in treatment of facial keloids

It saves time over hospital radiation treatments or in-office intralesional steroid administration.

Editor’s note: Ophthalmologists are frequently consulted to evaluate and care for patients with facial injuries, especially lacerations. In addition, many ophthalmologists feel comfortable about excising facial lesions. Keloids can form in susceptible patients regardless of the surgical technique used. When they occur, they pose a significant cosmetic problem to the patient. Steroid injections can be helpful; however, in black patients unsightly pigmented areas my develop. Steroid treatment of keloids is not effective in all patients.
In this report, Jerome R. Klein, MD, an oculoplastic surgeon who does much cosmetic surgery, describes the treatment of facial keloids using mitomycin. The article is well worth reading and keeping as a reference.

Stephen M. Soll, MD

photograph ---Preoperative photo of the surgical excision of recurrent postauricular keloid with mitomycin.

Mitomycin, a strong inhibitor of fibroblast production, has been used by ophthalmologists for years in the treatment of glaucoma patients undergoing trabeculectomy and in pterygium patients as well as in the treatment of hypertrophic conjunctival scars after strabismus surgery.

In a study by Urban and Kaufman, in patients who developed hypertrophic conjunctival scars over the operated-on muscles, excision followed by corticosteroid eye drops resulted in a scar recurrence rate of 33%. However, in patients treated with adjunct mitomycin eye drops/topical solution (0.2 to 0.4 mg/ml), none showed significant scar recurrence. Postoperative follow-up ranged from 16 to 56 weeks.

Most eye surgeons have had a wealth of experience with mitomycin and are comfortable with its use and risks. It is relatively easy to obtain and is ideal for areas that may develop radiation morbidity, such as auricular, periocular and paranasal areas. Mitomycin is also easy for patients to administer themselves, saving time from hospital radiation treatments or office visits for intralesional steroids. Furthermore, the effect of mitomycin is more localized than repeated intralesional steroids.

Three pulses

photograph ---Postoperative photo of surgical excision of recurrent postauricular keloid.

My technique has been refined to three pulses of mitomycin 0.4 mg/cc or 0.04% after sharp excision of the keloid. The first pulse of topical mitomycin is administered on a sponge to the keloidal bed for 3 to 5 minutes. The bed is then copiously irrigated with BSS. I close the incision with non-buried sutures — that is non-multilayered and non-absorbable — to minimize any extrinsic inflammatory stimulus.

A second pulse of mitomycin 0.4 mg/cc or 0.04% is given in the form of drops/topical solution to be administered by the patient for the first two postop weeks.

Finally a third pulse of mitomycin drops/topical solution is given at 6 to 12 weeks for 2 weeks to prevent late keloidal activity. The exact restart time is tailored to each patient’s known time of onset for the late inflammatory period.

The total cost to the patient at my medical center is approximately $152 for a 10 cc container of 0.04% mitomycin drops. I have had great success with this regimen rather than straight intralesional and/or topical steroids, radiation or silicone patches without mitomycin.

Technique

Sharp excision of keloid
1st pulse
Topical mitomycin on sponge to bed for 3 to 5 minutes
Irrigate copiously with balanced salt solution
Close with sutures non buried, ie. non-multilayered
2nd pulse
Mitomycin drops × 2 weeks post op for 1week
3rd pulse
Mitomycin at 6 to 12 weeks for 2 weeks to prevent the late keloid activity

For Your Information:

Jerome R. Klein, MD, FACS, can be reached at Trump Tower, 16th Floor, 725 Fifth Ave., New York NY 10022; (212) 371-7373; e-mail: plastic-surgeon@prodigy.net.

Stephen M. Soll, MD, FACS, is associate clinical professor of surgery/ophthalmology, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Camden, NJ. He can be reached at Soll Eye Associates, 5001 Frankford Ave., Philadelphia, PA 19124; (215) 288-5000; Fax: (215) 288-5601.

Reference:

Urban RC Jr, Kaufman LM. Mitomycin in the treatment of hypertrophic conjunctival scars after strabismus surgery. J Pediatr Ophthalmol Strabismus. 1994 Mar-Apr;31(2):96-8.