A 28-year-old man comes to the physician due to pain in his left earlobe. He pierced his earlobe to be able to wear earrings 3 months ago. The puncture wound never healed well, and he has experienced itching and sharp pains there ever since. His medical history is otherwise unremarkable. He is currently not taking any medications. On physical examination, there is excessive scar tissue formation on the earlobe at the site of the piercing as shown.
What is the most appropriate means of treating this patient's lesion?

Question

A 28-year-old man comes to the physician due to pain in his left earlobe.  He pierced his earlobe to be able to wear earrings 3 months ago.  The puncture wound never healed well, and he has experienced itching and sharp pains there ever since.  His medical history is otherwise unremarkable.  He is currently not taking any medications.  On physical examination, there is excessive scar tissue formation on the earlobe at the site of the piercing as shown. 
What is the most appropriate means of treating this patient's lesion?

Quizplus · Accepted Answer

Explanation: Keloids are benign fibrous growths that develop in scar tissue secondary to an overproduction of extracellular matrix and dermal fibroblasts. These lesions can be highly disfiguring and painful. Keloids are thought to have a genetic predisposition and tend to cluster in families and certain ethnicities (eg, African Americans). The diagnosis is primarily clinical, and confirmatory biopsy is discouraged as it may lead to additional keloid formation. Intralesional glucocorticoids are the preferred means of treating most keloids, with up to 70% of patients responding. Many keloids require serial injection for satisfactory response, and surgical excision is occasionally needed if glucocorticoids fail (Choice B). The earlier the lesion is treated, the greater the chance of improvement. (Choice A) Cryosurgery is less effective than intralesional glucocorticoids. It may be considered as monotherapy, but it is often used as an adjunctive therapy in combination with other treatments. (Choice D) Radiation therapy is helpful in minimizing keloid recurrence, but the long-term risks (eg, malignancy) are of great concern and limit the popularity of this treatment method. (Choice E) Silicone gel sheeting is appropriate for reducing symptoms (eg, pain or itching) associated with established keloids. This treatment is also helpful in preventing the development of keloids in an area of injury. However, the therapeutic mechanism is poorly understood, and evidence to date has been of poor quality. Educational objective: Keloids are benign fibrous growths that develop in scar tissue secondary to an overproduction of extracellular matrix and dermal fibroblasts. Intralesional glucocorticoids are the preferred means of treating most keloids. References: Management of keloids and hypertrophic scars. (http://www.ncbi.nlm.nih.gov/pubmed/19621835) Silicone gel sheeting for preventing and treating hypertrophic and keloid scars. (http://www.ncbi.nlm.nih.gov/pubmed/24030657)

A 28-Year-Old Man Comes to the Physician Due to Pain