Dermatologic Therapy, Vol. 25, 2012, 273276 2012 Wiley Periodicals, Inc.

Printed in the United States All rights reserved

DERMATOLOGIC THERAPY
ISSN 1396-0296

THERAPEUTIC HOTLINE
Intralesional cryosurgery and
intralesional steroid injection:
a good combination therapy
for treatment of keloids
and hypertrophic scars
Ahmed Hany Weshahy & Rania Abdel Hay
Dermatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt

ABSTRACT: Hypertrophic scars and keloids exhibit high recurrence rates following surgical excision.
Intralesional cryosurgery (ILC) can achieve a higher degree of effectiveness than the surface cryo-
therapy. The aim of this study is to assess the clinical efficacy of ILC using Weshahy cryoneedles followed
by IL steroid in a trial of getting rid of the fibrous mass by destruction, not by surgery to avoid being
under tension of the new scar. This study included 22 patients. Evaluation of the volume reduction of
the lesions was done after a single ILC session followed by IL steroid injections. There was a significant
decrease in the volume of the lesions after 4 months (P < 0.01), with a volume reduction of 93.5%. By
using ILC at the base of keloids or hypertrophic scars, we can change the old fibrous tissue into a recent
scar or granulation tissue which will respond more successfully to IL steroid injection.

KEYWORDS: hypertrophic scars, intralesional steroid, keloids

Introduction oid intralesional (IL) injections can only soften and

Hypertrophic scars and keloids are benign, fibrous
proliferations that exhibit high recurrence rate
following surgical excision (1). Various treatment
modalities are available, and treatment has to be
individualized depending upon the distribution,
size, thickness, consistency of the lesion and asso-
ciation of inflammation (2).
A combination approach to therapy seems to be
the best option (2). When used alone, corticoster-
Address correspondence and reprint requests to: Rania Abdel
Hay, MD, Consultant Dermatologist, Dermatology
Department, Faculty of Medicine, Cairo University, 13th Abrag
Othman, Kournish el Maadi, Cairo 11431, Egypt, or email:
omleila2@yahoo.com.
flatten keloids but cannot make keloids disappear
or narrow wide hypertrophic scars (3). Surface
cryosurgery as a monotherapy regimen for the
management of hypertrophic scars and keloids
had been tried with a beneficial effect (48).
However, multiple sessions are required to achieve
good results.
Cryotherapy has been found to modify collagen
synthesis and differentiation of keloidal fibroblasts
in vitro toward a normal phenotype (8). These find-
ings explain the absence of recurrence after cryo-
surgery of keloids (9,10).
In 1993, Weshahy (11) described his new tech-
nique for applying cryosurgery in depth, i.e.,
intralesional cryosurgery (ILC), by using Weshahys
cryoneedles in order to achieve a higher degree of

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Weshahy & Abdel Hay
effectiveness and avoid many of the disadvantages
of the conventional surface techniques.
Although some trials have been published using
the ILC for treatment of keloids and hypertrophic
scars (9,10,1214), our aim in this article was to
publish the experience of the inventor of such
technique on 22 patients with long follow-up
period (more than 3 years).
Aim of the work
This study was designed to assess the clinical safety
and efficacy of ILC using Weshahy cryoneedles in
the treatment of hypertrophic scars and keloids in
a trial to get rid of the fibrous mass by destruction,
not by surgery, to avoid under tension of the new
scar, and to convert the hard fibrous tissue into a
recent scar easier for IL steroid injection for better
spreading of the steroid injected and decreasing
the resistance faced with the IL steroid injection.
Materials and methods
This pilot study included 28 patients with skin pho-
totype II to IV. They had a total of 35 hypertrophic
scars and keloids. Of the 28 patients who were
enrolled into the study, 22 completed the study,
their age ranged from 2553 years with a mean
SD of 35.64 8.791 years. They had a total of 25
hypertrophic scars and keloids. The duration of the
lesions ranged from 0.6 to 6 years with a mean
SD of 2.84 1.525 years.
The study protocol conformed to the ethical
guidelines of the 1975 Declaration of Heliniski.
Each patient signed a written informed consent,
and alternative treatments were explained before
the procedure.
Each patient was subjected to a single ILC
session, followed by one session of IL steroid injec-
tion (Triamcinolone 1:2 saline i.e 10 mg/cc) after
1 month; this IL steroid injection session was
repeated every 3 months for 4 sessions, then every
6 months for 4 sessions, to avoid any tendency of
recurrence.
Evaluation of the volume of the hypertrophic
scars and keloids was done by a blinded observer
before, 4 months and 3 years from the start of our
treatment protocol. Measurement of the volume
was made using Alginoplast (alginate; Heraeus-
Kulzer Company, Hanau, Germany) and saline
(15). In addition, objective parameters (hardness,
elevation, and redness) and subjective complaints
(itching, pain, and tenderness) were recorded on a
scale of 0 (none) to 3 (maximum) (10), with the
274
score 0 revealing minimum complaint and score 3
revealing maximum complaint, before and 7
months from the start of our treatment protocol.
Photographs were taken before, within 2 weeks,
and in each visit as well as recording of any side
effects.
The technique was applied by using Weshahy
cryoneedles (specially designed angled or hook
shaped needles) that were introduced into the skin
as previously described (11).
Statistical analysis
Data were coded and entered using the statistical
package for social science (SPSS) version 17 (SPSS
Inc., Chicago, IL, USA). Data were summarized
using mean SD for quantitative variables and %
for qualitative variables. Comparisons between
groups were done using Wilcoxon Signed Ranks
test. P < 0.05 was considered statistically
significant.
Results
There was a significant decrease in the volume of
the lesions in all patients 4 months after a single
session of ILC compared to baseline (P < 0.01), with
a volume reduction of 93.5% (Table 1, Fig. 1).
A significant softening of lesions versus baseline
was observed (P < 0.01), with a significant decrease
in height of lesions and in redness score in the 7th
month compared to baseline (P < 0.001) in all
patients. All patients mentioned a significant
reduction of their subjective complaints after the
treatment that persisted during the follow-up
period (Table 1).
The IL treatment was generally well tolerated.
Minor bleeding from the penetration points was
detected and disappeared after 515 minutes of
compression. Infection was not reported. 712
days following ILC, the lesion began to become
necrotic. Within 34 weeks, the necrotic tissue was
separated leaving an erythematous area of new
healed tissue which would be subjected to IL
steroid. No adverse textural changes were observed
at the cryosurgical site; however, 21 lesions (84%)
showed temporary hypopigmentation for 36
months. Fourteen cases of them (66.7%) showed
repigmentation, while seven cases of them (33.3%)
showed hyperpigmentation at the periphery which
improved almost by time with IL steroid. A small
scar recurrence (0.51 cm3) was noted at the
periphery of three lesions (12%) during the
 Intralesional cyosurgery

Table 1. Clinical assessment of the patients before and after treatment

Range Mean SD P value
Volume/cm 3
Before treatment 1.48 3.39 1.791 <0.001
4 months after treatment 01 0.18 0.252
% volume reduction 75100 93.54 8.067
3 years after treatment 01 0.1 0.289 <0.001*
Hardness (score 03) Before 23 2.84 0.374 <0.001
7 months after treatment 01 0.24 0.436
Elevation (score 03) Before treatment 23 2.88 0.332 <0.001
7 months after treatment 01 0.24 0.436
Redness (score 03) Before treatment 23 2.8 0.408 <0.001
7 months after treatment 02 0.52 0.714
Itching (score 03) Before treatment 03 1.28 0.843 <0.001
4 months after treatment 0 0
Pain (score 03) Before treatment 03 0.84 0.8 <0.001
7 months after treatment 0 0
Tenderness (score 03) Before treatment 03 0.88 0.781 0.001
7 months after treatment 01 0.12 0.332
P < 0.05 is significant.
*P-value when compared these values to the baseline values (before treatment).

FIG. 1. A female patient (a) with a keloidal lesion at her left ear with 6 cm3 volume (b) during the intralesional cryosurgery (ILC)
session with the frost denoted at the base of the lesion (c) 4 months after the session with complete keloidal disappearance.

follow-up period which disappeared gradually by
repeated IL steroid injection on the successive
follow-up visits.
Discussion
Cryosurgery has been successfully used to treat
keloids and hypertrophic scars (48,10,1214). In
this study, all indices were significantly improved
for all cases (Table 1).
The results of our study are comparable with
those reported previously (10,13,14,16,17). Our
better results may be explained by the more
timewe gave until the ice cylinder formed
extended 2 mm outside the clinical borders of the
lesions, and by the deep insertion of our cry-
oneedles at or immediately under the base of the
lesions, targeting the blood supply of the lesion,
others might do the procedure more superficially.
The therapeutic effects of cryosurgery depend
on direct cell damage and changes in the microcir-
culation provoked by freezing that cause vascular
damage and blood stasis within the keloid tissue
leading to cell anoxia (18), the keloid is composed
mainly of fibrous tissue that resists the freezing
process (8).
The contact and spray techniques are the
two mostly practiced methods for cryosurgery.
However, the depth of freezing attained by these
two techniques is not enough to complete the
operation in one or two sessions (19), and cant
reach the base of the lesion effectively leading to
high rates of recurrence. Surface cryotherapy also
produces an open, oozing wound which is consid-
erably larger than the size of the lesion due to the
lateral extension of cryodestruction that usually
takes several weeks to heal. In addition, a certain
degree of skin atrophy and longer hypopigmenta-
tion is also inevitable with this approach because

275
Weshahy & Abdel Hay
of melanocyte sensitivity to low temperatures.
Therefore, this characteristic probably renders
surface cryotherapy in dark-skinned patients less
than optimal (16).
Our technique transfers the maximum intensity
of cold to the deeper tissues directly. It destroys the
core of the keloid immediately due to destruction of
the cellular element and blood vessels at the base
which are more sensitive to the cryoprocess than
the fibrous core causing its necrosis, with a minimal
limited damage to the superficial tissue and mel-
anocytes. In contrast, the lethal zone, which is
created by the contact probe, includes the epider-
mis, melanocytes, upper dermis, and to a lesser
extent, the deeper dermis due to the counteracting
heating effect produced by the blood vessels so the
efficacy is minimal and the rate of recurrence is
high. Our technique can transfer the maximum
intensity of cold directly to the base avoiding that
counteracting heating effect of the blood vessels.
The Weshahy cryoneedles allows subhorizontal
freezing with maximum cryodestruction at the base
of the lesion, and hence less surface reaction (11).
The problem of nerve destruction is overcome by
pulling both visible parts of the needle up, in this
way, compression of the blood vessels of the tissues
of the lesion and its separation from the underlying
structures was achieved (11).
Similar to the results of Har-Shai et al. (10,17),
we didnt report major side effects. A small scar
recurrence was noted at the periphery of three
lesions (12%) during the follow-up period which
disappeared by IL steroid injections, these few
patients most probably had tendency for recur-
rence. In the present study, pigmentary alteration
was noticed but it was transient; and at the end of
the study, most patients showed satisfactory results
better than the presence of the scar itself. The suc-
cessful repigmentation noted in our study could
be explained by the survival of islands of normally
pigmented skin that resisted the freezing process
and gradually spread (14).
Conclusion
Our message is that by using ILC, we can change
the old fibrous tissue into a recent scar or granula-
tion tissue which will respond more successfully to
the IL steroid injection with better spreading of the
steroid injected and decreasing of the resistance
faced with the IL injection. However, this is a small
pilot study, and further larger, randomized, con-
trolled trials need to be done to evaluate ILC.
276
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