Invited Discussion On: Efficacy and Safety of Intralesional Triamcinolone Versus Combination of Triamcinolone with 5-Flu
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EDITOR’S INVITED COMMENTARY
Invited Discussion On: Efficacy and Safety of Intralesional Triamcinolone Versus Combination of Triamcinolone with 5Fluorouracil in the Treatment of Keloids and Hypertrophic Scars: A Systematic Review and Meta-Analysis Thomas A. Mustoe1
Received: 26 May 2020 / Accepted: 26 May 2020 Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2020
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. The authors conduct a careful meta-analysis of randomized controlled trials comparing standard triamcinolone acetonide (TAC) treatment for hypertrophic scars and keloids versus a less widely and new treatment with triamcinolone and 5-fluorouracil (5FU). After a thorough search 6 trials, totaling 398 patients (approximately 200 in each treatment group) were included. The statistical analysis was rigorous, and the outcomes were very clear: There was highly significant treatment superiority to the combination treatment versus TAC alone, although the subgroup of keloids did not show a treatment benefit for combination therapy. In addition, the local treatment complications (although relatively minor) were less in the combination group. Although the conclusions of this review are solid and reasonable, some perspective of complexities and limitations is useful. Studying scar outcomes has been historically challenging for several reasons. First, scars improve over time (except keloids) and are very heterogeneous, often even areas within the same scar, and so comparison of treatment groups within the same study is critical. An international group of clinicians [1] recognized these limitations and conducted an evidenced based analysis in 2002 & Thomas A. Mustoe [email protected] 1
Clinical Faculty, Feinberg School of Medicine, Northwestern University, 737 N. Michigan, Suite 1500, Chicago, IL 60611, USA
for the first time. At that time based on some Level 1 evidence and much more Level 2 and Level 3 evidence, recommendations were made for the use of topical silicone gel as first line therapy, and TAC for failures to respond to silicone gel. With less evidence, there was also strong clinical consensus in the absence of rigorous trials for the use of pressure therapy for hypertrophic burn scars, and radiation therapy for keloids and recalcitrant severe hypertrophic scars. There was a limited consensus on the utility of laser treatments, hampered in part by a lack of consensus on type of laser and treatment protocol, and an absence of Level 1 or Level 2 evidence. Since then, there have been subsequent reviews [2, 3] with additional RCT supporting the use of silicone gel either as gel strips or silicone cream, and increasing acceptance of laser therapy, with some Level 1 evidence for laser treatment of hypertrophic burn scars. In additi
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