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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 47-51

Comparison of efficacy of intralesional triamcinolone acetonide at 2-, 4-, and 6-week intervals in hypertrophic scars and keloids


1 Department of Burns and Plastic Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
2 Department of Burns and Plastic Surgery, VMMC and Safdarjung Hospital, New Delhi, India
3 Department of Burns and Plastic Surgery, Max Hospital, New Delhi, India

Date of Submission10-Apr-2021
Date of Acceptance23-Nov-2021
Date of Web Publication08-Jun-2022

Correspondence Address:
Dr. Vaishali Srivastava
E-106, Nicklaus Drive, Paramount Golfforeste, Greater Noida - 201 311, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.206400

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  Abstract 


Context: Keloids and hypertrophic scars are a cause of severe impairment of quality of life. Intralesional triamcinolone acetonide has been used at different intervals at various centers.
Aim: This study was aimed to compare the efficacy of intralesional triamcinolone acetonide at 2-, 4-, and 6-week intervals in hypertrophic scars and keloids.
Settings and Design: This study was conducted in the plastic surgery outpatient department of a tertiary care hospital. This is an interventional prospective study, randomization was done using a computer-generated sequence.
Materials and Methods: In this study conducted from October 2015 to January 2017, administration of triamcinolone acetonide 40 mg/ml at 2-weekly, 4-weekly, and 6-weekly intervals was done in case of hypertrophic scars and keloids for up to 8 doses or till Vancouver Scar (VCS) scale of 4 was achieved. VCS, pain, and itching were noted and compared.
Statistical Analysis: VCS scale was used for comparison using analysis of variance test. The visual analog scale was compared using an unpaired t-test. Qualitative data were compared using the Chi-square test/Fischer's exact test. P < 0.05 was considered statistically significant.
Results: The 2-weekly regimen was found to show better results in terms of pain and scar improvement. It also required a lesser number of doses to produce the same effect. The response to itching was comparable in 2- and 4-weekly groups and was better than 6-weekly group. Minimal complications were noted in the three groups.
Conclusion: Two-weekly regimen of triamcinolone acetonide is recommended for intralesional use in hypertrophic scars and keloids.

Keywords: Dosage interval, hypertrophic scars, keloids, triamcinolone


How to cite this article:
Srivastava V, Sharma S, Rathore D. Comparison of efficacy of intralesional triamcinolone acetonide at 2-, 4-, and 6-week intervals in hypertrophic scars and keloids. Indian J Burns 2021;29:47-51

How to cite this URL:
Srivastava V, Sharma S, Rathore D. Comparison of efficacy of intralesional triamcinolone acetonide at 2-, 4-, and 6-week intervals in hypertrophic scars and keloids. Indian J Burns [serial online] 2021 [cited 2022 Dec 9];29:47-51. Available from: https://www.ijburns.com/text.asp?2021/29/1/47/206400




  Introduction Top


Hypertrophic scars (HTSs) and keloids are common problems arising after trauma, burns, or surgery. HTSs are raised above the skin surface and are limited to the concerned area, they can reduce in size on their own.[1]

On the other hand, keloids have a continuous growth curve, they do not reduce in size and have a tendency to spread outside the scarred area. They present as a spreading lesion with a smooth, glistening surface that may be mildly painful on the touch.[2]

The underlying cause appears to be an imbalance in the laying down and removal of certain proteins during the process of healing. There can be greater collagen, fibronectin, and proteoglycan deposition in the tissues, or there may be lesser degradation of these extracellular matrix proteinaceous products.[3]

At present, pressure garments, silicone gel sheets, cryotherapy, light amplification by stimulated emission of radiation, radiation, and surgery are all used for the management of these lesions.

Administration of intralesional triamcinolone acetonide is considered to be one of the best treatment options for both these conditions.[4] Although it is a proven therapy for this condition, the interval of administration has not been standardized.

In this study, it is our aim to determine the optimal time interval of giving intralesional triamcinolone acetonide in HTSs and keloids. The aim of this study is to compare the response to treatment by intralesional triamcinolone acetonide given at 2-, 4-, and 6-week intervals in cases of HTSs and keloids.


  Materials and Methods Top


This study was conducted from October 2015 to January 2017, duration of 18 months. It was a prospective interventional study. Clearance was obtained from the institute's ethical committee.

The inclusion criteria were as follows: patients between 15 and 60 years of age attending the outpatient department (OPD) in our facility. Scars from 0.5 cm to 5 cm, regardless of shape, and not more than 6 cm2 were included that have been stable for at least 3 months. HTSs arising after burns, trauma, surgery, or infection were taken into this study.

Pregnant females, malignant scars, and scars with an ulcer in or around them were excluded from the study.

Patients were initiated into the study at the time of attendance in OPD with written informed consent. A sample size of 90 was taken.

Patients were randomly allocated into three groups using a computer-generated random sequence.

A dose of 0.2 ml per square centimeter of triamcinolone acetonide (40 mg/ml) was given in each case to a maximum of 1.2 ml.

Group A received intralesional triamcinolone (TAC) at 2-week intervals. Group B received intralesional TAC at the interval of 4 weeks. Group C received intralesional TAC at the interval of 6 weeks.

Injection TAC 40 mg/ml maximum of 1.2 ml was given in all cases using a 1 ml syringe and 26 gauge needle till a Vancouver Scar (VCS) scale of 4 was achieved or 8 doses were completed, whichever was earlier. No sedation or analgesia was used. No other therapy such as pressure garment and silicone sheet was used concomitantly.

Basic epidemiological data such as age, sex, etiology of scar, size of scar/keloid, and site of scar/keloid were noted.

Assessment of scar was done by serial photographs and VCSscale at every visit till ninth visit. Follow-up was done till the ninth visit in all cases, irrespective of the number of injections given. The scar height was measured using a digital Vernier caliper with a least count of 0.01 mm.

The mean of VCS scores of nine visits was taken for comparison.

For assessment of itching and pain, visual analog scale (VAS) was used at all nine visits. The mean of VAS was used for comparison.

Other complications such as telangiectasia, hypopigmentation, and skin atrophy were noted.

MS Excel spreadsheet was used for data entry, and the results were analyzed using Statistical Package for Social Sciences (SPSS) version 21: IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.

The three regimens were compared for four aspects (height, pliability, pigmentation, and vascularity) of VCS scale using analysis of variance test. VAS was compared using an unpaired t-test. Qualitative data were compared using the Chi-square test/Fischer's exact test. P < 0.05 was considered statistically significant.


  Results Top


A total of 90 patients were part of the study, 30 in each group. The mean age was 30.6 years. There were 44 females and 46 males.

Chest was the most common site of scar in 27 cases (30%), followed by forearm in 14 cases (15.56%).

Postburn scarring was the most common etiology with 41 cases (45.56%), followed by postinfective with 20 cases (22.22%). Literature shows the incidence of postsurgical hypertrophic scar to be 40%–94% and postburn incidence to be 30%–91%.[5]

Mean number of doses needed to achieve scar flattening were 7.07, 7.67, and 7.87 in Group A, B, and C, respectively.[5] The difference between Group A and B was significant, with P value of 0.039. The difference between Group A and C was also significant, with P value of 0.004. The difference between Group B and C was not found to be significant [Figure 1].
Figure 1: X-axis depicts the group (a: 2 weekly, b: 4 weekly, c: 6 weekly). Y-axis depicts the number of doses given

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Itching

Mean VAS itching score was reduced from 4.4, 3.87, and 3.47 to 0.6, 1, and 1.87 for Group A, B, and C, respectively. Group A reported a greater decrease in itching than Group C (P value = 0.0001). Group B also showed significant improvement as compared to Group C (P value = 0.0002). Group A and B had no significant difference [Figure 2].
Figure 2: X-axis represents the first and final (ninth) visit of the patients in each group. Y-axis denotes the visual analog scale for itching

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Pain

Mean pain score was reduced from 1.57, 3.8, and 3.6 to 0.27, 1.1, and 1.93 for Group A, B, and C, respectively. Reduction in pain was significantly greater in Group A as compared to Group C (P value < 0.0001). Group B patients had lesser pain over the period of treatment than group C patients (P value = 0.002). Group A and B also had significant differences (P value 0.0002) [Figure 3].
Figure 3: X-axis represents the first and final (ninth) visit of patients in each group. Y-axis represents visual analog scale for pain

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Vancouver scar

The mean VCS score was reduced from 7.27, 7.77, and 7.57 to 4.5, 5.1, and 5.37 for Group A, B, and C, respectively. Reduction in VCS was significantly greater in Group A as compared to Group C (P < 0.0001). Group B showed no significant improvement as compared to Group C (P = 0.297). Group A and B also had significant differences (P = 0.005) [Figure 4].
Figure 4: X-axis represents first and final (ninth) visit of patients in each group. Y-axis represents Vancouver scar scale of hypertrophic scars and keloids

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Clinical photographs of patients of Group A, Group B, and Group C at first visit (a) and ninth visit (b) are shown in [Figure 5], [Figure 6], [Figure 7].
Figure 5: (a) Clinical photograph of 20-year-old female patient with postburn hypertrophic scar on breast, first visit. (b) Clinical photograph of 20-year-old female patient with postburn hypertrophic scar on breast. She received 8 doses of intralesional triamcinolone at 2-week interval, achieving a Vancouver scar scale: 6, visual analog scale pain: 2, visual analog scale itching: 3. ninth visit

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Figure 6: (a) Clinical photograph of 25-year-old-male patient with postburn hypertrophic scar on back. first visit. (b) Clinical photograph of 25-year-old male patient with postburn hypertrophic scar on back. He received 8 doses of TAC at 4-weekly interval, achieving Vancouver scar scale: 6, visual analog scale pain: 1, visual analog scale itching: 2. ninth visit

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Figure 7: (a) Clinical photograph of 25-year-old female patient with postburn hypertrophic scar on thigh first visit. (b) Clinical photograph of 25-year-old female patient with postburn hypertrophic scar on thigh. She received 8 doses of intralesional triamcinolone at 6-weekly interval, achieving Vancouver scar scale: 6, visual analog scale pain: 0, visual analog scale itching: 3. ninth visit

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  Discussion Top


HTSs and keloids are mostly seen in 10–30 years age group.[6] The patients are young, lesions are less commonly seen in older people.[7]

They are a cause of morbidity, especially in burn patients. Triamcinolone acetonide is approved for their management. This study has used this drug at variable intervals and seeks to find the best for maximum results and minimum complications.

Corticosteroids are anti-inflammatory agents. They tend to hinder the healing process, thereby preventing excessive deposition of extracellular matrix proteins and preventing fibroblast and keratinocytes to multiply. This prevents the unusual scar seen in both these lesions. They also have the vasoconstrictive effect, which reduces the blood supply to the scarred area, diminishing the growth of the scar.[8]

Treatment with corticosteroids can result in improvement in such patients from nearly half to almost all cases.[9] A multi-pronged approach where triamcinolone is used along with other modalities such as pressure garments, silicon pressure sheets, irradiation, and cryotherapy yields a better response than using the steroid alone.

Intralesional triamcinolone has been used at various intervals such as once in a week, fortnightly, once in 3 weeks, monthly, and in 6 weeks at various centers.[10] No study has been done to prove which interval is most appropriate for management of lesions.

It is used at varied dosage intervals at various centers, lesser dose requirement may be attributed to the sustained effect of the drug till 2 weeks. In longer intervals, the effect of triamcinolone on the suppression of inflammatory and fibroblast activity is diminished by the time the next dose is administered. This decrease in activity allows the inherent increased collagen synthesis and deposition to return, thereby showing lesser response and requirement of the increased number of doses.

It is known that therapeutic concentrations of a drug remain in the body for four to five half-lives (t½). The biological half-life of TAC is 18–36 h;[11] hence, therapeutic levels are present till around 8 days. However, the effects of steroids extend beyond their biological half-lives and to determine the exact duration for which this effect lasts requires further studies.

In a number of institutions, 3-weekly interval is chosen for administration of this drug in HTSs and keloids. In this study, we have sought to find out whether this interval can be increased or decreased to achieve maximum results with minimal complications. It is found that it is feasible to give this drug at 2-weekly intervals without risk of complications with good results.

It may be argued that weekly intervals may achieve even more superior results, but we believe there will be a higher risk of complications such as scar atrophy, hypopigmentation, and telangiectasias.[4]

Two-weekly administration of this drug appears to have a sustained effect on controlling the abnormal proliferative activity and hence has superior results with lesser dose requirement and less probability of complications.

Limitations of the study

A longer follow-up period is required to assess the complications in each group. This would determine the safety of using triamcinolone at frequent intervals. The difference in response of HTSs and keloids was not taken into consideration.


  Conclusion Top


Lesser number of doses is required in the 2-weekly groups to achieve the same result as compared to the 4-weekly and 6-weekly groups. There is improvement in itching in response to triamcinolone in all three groups, response is in the order 2 weekly = 4 weekly >6 weekly. There is relief from pain in all three groups, the response is in the order 2 weekly >4 weekly >6 weekly. There is a reduction in scar size in all the three groups as measured by VCS scale, the response is in the order 2 weekly >4 weekly = 6 weekly. Minimal complications such as hypopigmentation, scar atrophy, and interval menstrual bleed were noted.

Hence, it is observed that triamcinolone acetonide used at 2-weekly intervals give superior results in terms of itching, pain, and scar reduction, with minimum complications as compared to 4-weekly and 6-weekly groups and is recommended for use. However, a larger study with a greater sample size is necessary to establish this superiority of result as well as the absence of complication at this selected 2-weekly interval.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
English RS, Shenefelt PD. Keloids and hypertrophic scars. Dermatol Surg 1999;25:631-8.  Back to cited text no. 1
    
2.
Al-Attar A, Mess S, Thomassen JM, Kauffman CL, Davison SP. Keloid pathogenesis and treatment. Plast Reconstr Surg 2006;117:286-300.  Back to cited text no. 2
    
3.
Wang J, Ding J, Jiao H, Honardoust D, Momtazi M, Shankowsky HA, et al. Human hypertrophic scar-like nude mouse model: Characterization of the molecular and cellular biology of the scar process. Wound Repair Regen 2011;19:274-85.  Back to cited text no. 3
    
4.
Rabello FB, Souza CD, Farina Júnior JA. Update on hypertrophic scar treatment. Clinics (Sao Paulo) 2014;69:565-73.  Back to cited text no. 4
    
5.
Bombaro KM, Engrav LH, Carrougher GJ, Wiechman SA, Faucher L, Costa BA, et al. What is the prevalence of hypertrophic scarring following burns? Burns 2003;29:299-302.  Back to cited text no. 5
    
6.
Rockwell WB, Cohen IK, Ehrlich HP. Keloids and hypertrophic scars: A comprehensive review. Plast Reconstr Surg 1989;84:827-37.  Back to cited text no. 6
    
7.
Mustoe TA, Cooter RD, Gold MH, Hobbs FD, Ramelet AA, Shakespeare PG, et al. International clinical recommendations on scar management. Plast Reconstr Surg 2002;110:560-71.  Back to cited text no. 7
    
8.
Atiyeh BS. Nonsurgical management of hypertrophic scars: Evidence-based therapies, standard practices, and emerging methods. Aesthetic Plast Surg 2007;31:468-92.  Back to cited text no. 8
    
9.
de Oliveira GV, Nunes TA, Magna LA, Cintra ML, Kitten GT, Zarpellon S, et al. Silicone versus nonsilicone gel dressings: A controlled trial. Dermatol Surg 2001;27:721-6.  Back to cited text no. 9
    
10.
Arno AI, Gauglitz GG, Barret JP, Jeschke MG. Up-to-date approach to manage keloids and hypertrophic scars: A useful guide. Burns 2014;40:1255-66.  Back to cited text no. 10
    
11.
Corticosteroids. In: Tripathi KD, editor. Essentials of Medical Pharmacology. 6th ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2008. p. 282.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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