International Journal of Biological Sciences and Applications

2015; 2(4): 37-41

Published online July 30, 2015 (http://www.aascit.org/journal/ijbsa)

ISSN: 2375-3811

Keywords Keloid,

Hirudotherapy,

Bioactivity Substances,

Leech

Received: May 28, 2015

Revised: June 27, 2015

Accepted: June 28, 2015

Management of Keloid by Hirudotherapy: A Latest Non Surgical Approach

Arsheed Iqbal1, *

, Afroza Jan1, Huma

1, Arjumand Shah

1,

Zahood Ahmad1, Naquibul Islam

1, Mohammad Naime

1, M. A. Wajid

1,

Sheikh Tariq2, Imran Nazir Salroo

3

1RRIUM, NaseemBagh Faculty of Medicine, Kashmir University, Srinagar City, Jammu and

Kashmir, India

2JLNM Hospital, Department of plastic surgery, Kashmir University, Srinagar City, Jammu and

Kashmir, India 3Govt Medical College, Department of Radiology Kashmir University, Srinagar City, Jammu and

Kashmir, India

Email address iarsheed@yahoo.com (A. Iqbal), danish242@gmail.com (A. Iqbal)

Citation Arsheed Iqbal, Afroza Jan, Huma, Arjumand Shah, Zahood Ahmad, Naquibul Islam, Mohammad

Naime, M. A. Wajid, Sheikh Tariq, Imran Nazir Salroo. Management of Keloid by Hirudotherapy:

A Latest Non Surgical Approach. International Journal of Biological Sciences and Applications.

Vol. 2, No. 4, 2015, pp. 37-41.

Abstract According to Greek classical books leech therapy is the best way to overcome chronic

inflammatory conditions. It has been proved that intervention causes reduction in

oedema, pain and conjunction. Keloids were described by Egyptian surgeons around

1700BC. Alibert called the Keloid first cancroids and later cheloide. Keloid usually

grows beyond the borders of the original wound in claw-like growths and can develop

after acne, body piercings, burns, laceration, surgical wounds etc. The aim of present

study was to assess the effect of leech therapy in resolving the Keloid without surgical

intervention and to avoid the scar formation and recurrence. The present study has been

conducted at Regional Research Institute of Unani Medicine, Srinagar, to evaluate the

Keloid resolving activity by the bioactive substances present in the leech saliva. The

study has proved very effective by giving the Hirudotherapy to a young female patient

with post traumatic Keloid above the knee joint, The Keloid was completely resolved

and leaving the skin surface very smooth without scar formation .there was no recurrence

of Keloid even after one year of post leech therapy follow ups.

1. Introduction

Keloids were described by Egyptian surgeons around 1700 BC. The great Greek

physicians Majoosi and sheikh discussed about the leech therapy in their era of practice.

Louis Alibert identified the Keloid as an entity in 1806. Change in the cellular signal that

control growth and proliferation leads to Keloid formation17

.It expands claw- like growth

over normal skin16

. They are more commonly seen in central chest, back, shoulders,

earlobules, arm, pelvic region and collar bone. Keloids are elevated fibrous scars that

extend beyond the borders of the original wound, do not regress, and usually recur after

excision. The term is coined from the Greek word cheloides, meaning “crab's claw.”1

Hypertrophic scars are similar, but are confined to the wound borders and usually regress

over time.1,2

Scar hypertrophy usually appears within a month of injury, whereas keloids

38 Arsheed Iqbal et al.: Management of Keloid by Hirudotherapy: A Latest Non Surgical Approach

may take three months or even years to develop.3 Both

represent abnormal responses to dermal injury, with

exuberant deposition of collagen developing over three basic

stages: (1) inflammation (first three to 10 days); (2)

proliferation (next 10 to 14 days); and (3) maturation or

remodeling (two weeks to years).1

2. Risk Factors and Etiology

The primary risk factor for keloids is darkly pigmented

skin, which carries a 15- to 20-fold increased risk, perhaps

because of melanocyte-stimulating hormone anomalies.4

Familial predisposition, with autosomal dominant and

recessive genetic variants is recognized.5 Black, Hispanic,

and Asian persons are far more likely to develop keloids than

white persons.6,7

Keloids are more common in persons younger than 30

years, with risk peaking between 10 to 20 years of age, and in

patients with elevated hormone levels (e.g., during puberty or

pregnancy).8 Sternal skin, shoulders and upper arms, earlobes,

and cheeks are most susceptible to developing

keloids.9Certain types of trauma and delayed healing (longer

than three weeks) heighten Keloid incidence however burns

carrying the highest rate.

2.1. Epidemiology

Keloid affects both sexes equally. The incidence in young

females is more than young males and is more common in

dark skinned people especially African races and shows

genetic trait transmitted by mother or father with the children

having 50% possibility of developing a Keloid scar.18

In

certain syndromes like Rubinstein-taybi and Goeninne, it has

been found that there is increased incidence of Keloid

formation. Keloid may develop from pseudofolliculitis

barbae, razor bumps and is also speculated to be hereditary. it

is estimated that up to 4.5% of general population suffer from

hypertrophic scarring. The incidence is 15% higher in high

pigmented people. People of any age can develop and

children under ten are less likely to develop Keloid.

Incidence and prevalence of Keloid in United States is not

known. Indeed, there has never been a population study to

assess the epidemiology of this disorder. In his 2001

publication, Marneros12

stated that “reported incidence of

keloids in the general population ranges from a high of 16%

among the adults in Zaire to a low of 0.09% in England,”

quoting from Bloom’s 1956 publication on heredity of

keloids.13

However , from clinical observations it is found

that the disorder is more common among Africans, African

Americans and Asians with wide estimated prevalence rates

ranging from 4.5-16%14,15

.

2.2. Aim of the Studying and Applying

Leeches

Although Keloid disorder has been known for centuries, it

is one of the most under-researched and poorly understood

human medical conditions, and for the most part neglected by

the medical research community. This has resulted in our

current lack of understanding of various aspects of this

disorder, from its genetics, to its epidemiology, from it path

physiology, to its treatment. With this reason a study based

on Hirudotherapy for the treatment of Keloid was conducted

at RRIUM/CCRUM, J&K India.

2.3. Genetics

Most patients, especially Africans and African Americans

have a positive family history of Keloid disorder.

Development of keloids among twins also lends credibility to

existence of a genetic susceptibility to develop keloids.

Marneros et al.1 reported four sets of identical twins with

Keloids, Ramakrishnan et al.11

Also described a pair of twins

who developed keloids at the same time after vaccination.

Case series have reported clinically severe forms of keloids

in individuals with a positive family history and black

African ethnic origin.

The variable phenotype of the disease mimics a multi gene

inheritance, with certain individuals perhaps having only one

mutations or one genetic abnormality and present with one or

very few Keloid lesions, to those who have inherited two or

more genetic mutations, whereby the disease appears in its

most severe form. An analogy can be made to thalassemia,

whereby various phenotypes, thalassemia traits, minor, inter-

media and major; are linked to various genetic abnormalities

involving two sets of alleles for alpha and beta globin genes

and numerous genetic abnormalities of the two distinct genes.

2.4. Morphological Classification

Keloid lesions take on a variety of shapes and forms, and

appear in any part of the skin. Keloid lesions can be

classified according to their appearance as “Keloidal

Papules”, “Nodular Keloid”, “Keloid Tumors”, “Linear

Keloid”, “Flat Keloid , Keloidal Plaque”, “Butterfly Keloid”,

“Guttate Keloid”, “Hyper-inflammatory Keloids”,

“Superficially Spreading Keloids”, “Pedunculated Keloid”,

“Bulky Keloids”, and ”Massive Keloids”

2.5. Topographical Classification

Keloid lesions can form in unique and well defined parts

of the skin; and in each part, the Keloid lesions can display a

unique shape and form.“Scalp Keloids”, “Ear Keloids”,

“Earlobe Keloids”, “Posterior Auricular Keloids”, “Facial

Keloids”, “Neck Keloids”, “Chest Wall Keloids”, “Upper

Arm Keloids”, “Umbilical Keloids”, “Pubic Keloids”

3. Treatment and Prevention Options

for Keloid

3.1. Corticosteroid Injections

• Corticosteroid injections for prevention and treatment

of keloids and hypertrophic scars are perhaps the first-

International Journal of Biological Sciences and Applications 2015; 2(4): 37-41 39

line option for family physicians. Corticosteroids

suppress inflammation and mitosis while increasing

vasoconstriction in the scar. Triamcinolone acetonide

suspension (Kenalog) 10 to 40 mg per mL (depending

on the site) is injected intralesionally, which, although

painful, will eventually flatten 50 to 100 percent of

keloids, with a 9 to 50 percent recurrence rate.9

Lidocaine (Xylocaine) may be combined with the

corticosteroid to lessen pain, whereas using adjunctive

cryotherapy immediately before injection may make the

procedure easier by softening the scar (based on expert

opinion).10

Combining cryotherapy and corticosteroid

injections also improves outcomes more than either

modality alone, although hypopigmentation is always a

significant concern • Surgery: This is risky, because cutting a keloid can

trigger the formation of a similar or even larger keloid.

Some surgeons achieve success by injecting steroids or

applying pressure dressings to the wound site for

months after cutting away the keloid. Radiation after

surgical excision has also been used. • Laser: The pulsed-dye laser can be effective at

flattening keloids and making them look less red.

Treatment is safe and not very painful, but several

treatment sessions may be needed. Treatment of keloids

with short-pulsed, 585-nm pulsed dye laser has shown

limited promise, with a 57 to 83 percent improvement

rate. • Silicone sheets: This involves wearing a sheet of

silicone gel on the affected area continuously for

months, which is hard to sustain. Silicone elastomer

sheeting is a noninvasive and extensively studied

approach to the prevention and treatment of keloids and

hypertrophic scars. Silicone sheets are thought to work

by increasing the temperature, hydration, and perhaps

the oxygen tension of the occluded scar, causing it to

soften and flatten. • Cryotherapy: Freezing keloids with liquid nitrogen may

flatten them but often darkens or lightens the site of

treatment. • Interferon: Interferons are proteins produced by the

bodies immune systems that help fight off viruses,

bacteria, and other challenges. In recent studies,

injections of interferon have shown promise in reducing

the size of keloids, though it's not yet certain whether

that effect will be lasting. • Fluorouracil: Injections of this chemotherapy agent,

alone or together with steroids, have been used as well

for treatment of keloids. • Radiation: Some doctors have reported safe and

effective use of radiation to treat keloids.

3.2. Combination Therapy Following Surgery

The use of corticosteroid injections following keloid

surgery reduces the recurrence rate to less than 50 percent. A

“triple keloid therapy” combining surgery, corticosteroids,

and silicone sheeting has been shown to be even more

effective, with only a 12.5 percent recurrence rate after 13

months.

3.3. Imiquimod

Imiquimod 5% cream (Aldara), an immune response

modifier that enhances healing, has also been used to help

prevent keloid recurrence after surgical excision.

3.4. Other Therapies

• Intralesional verapamil (2.5 mg per mL) in conjunction

with silicone sheeting reduced keloid postsurgical

recurrence by 90 percent.

• Calcium antagonists appear to work by reducing

collagen production and may be a reasonable and safe

alternative to corticosteroid injection in the future.

• Intralesional fluorouracil (50 mg per mL, two to three

times per week) appears to shrink keloids safely.

• Combining fluorouracil with corticosteroid injections

and pulsed dye laser produced superior results more

rapidly than corticosteroid injections alone or

corticosteroids with fluorouracil.

• Bleomycin is another useful chemotherapeutic agent

used for the treatment of Keliods.

• Intralesional interferon alfa-2b reduced keloid size by

50 percent over nine days, proving superior to

intralesional corticosteroids.

4. Material and Methods

A 30 year old female patient came with keloid on her right

leg above the knee joint anteriorly. She had opted for

different treatment modalities except surgery but no

improvement was observed. Finally Leeching was done in

our research institute after undergoing certain investigations

including heamogram, ESR, blood sugar, KFT and LFT to

rule out any pathology. After screening, leeching was done

on day one. leeches were applied to the site under all aseptic

conditions .Leeches were allowed to suck on the Keloid

lesion till they get belly filled and fall of their own. After

detaching of leeches antiseptic bandaging was done. four

sittings of leeching were done after every twenty days.post

treatment follow up was done every after one month for a

period of one year .complete disappearance of Keloid lesion

was found after one month of last sitting of leach therapy.

5. Discussion

Keloids are fibrotic tumors characterized by atypical

fibroblasts with excessive deposition of extracellular matrix

components. It can cause significant pain, pururitis and most

importantly physical disfigurement. Different treatments are

available for Keloid like surgery, radiotherapy, cryotherapy,

steroids, lasertherapy, interferon therapy, pulsed dye lamp

treatment, use of selecon gel, retenoids, cytotoxic medicine

etc (18-21). The above said modatilities of treatment has side

effects like telangiectasia (steroids),thinning of surrounding

40 Arsheed Iqbal et al.: Management of Keloid by Hirudotherapy: A Latest Non Surgical Approach

skin (steroids), cancer (radio therapy), paleness of skin

(cryotherapy), pain in the scar (cytotoxic medicine). Keeping

in view, the side effects and the chance of recurrence and

ulceration it has been decided to use Hirudotherapy as an

alternative treatment for the treatment of the Keloid. It has

been observed that three and half centimeter long and one

centimeter thick Keloid was completely resolved and there

was also no scar formation.

Pictorial View of Leech Therapy in Keloid and Its

Complete Cure by Leaving the Skin Surface Smooth without

Scar Formation.

Fig. 1. Patient with Keloid at the time of clinical examination.

Fig. 2. Depicts the first sting of leech application.

Figure 1 depicts the patient with Keloid at the time of

clinical examination and registration. Figure 2 depicts the

first sting of leech application. After the first follow up, that

is after twenty days the Keloid region starts regressing, which

is shown in figure 3 and on the same day second sting of

leeching was done which is shown in the figure 4.Figure 5

shows the further regression of the Keloid lesion at second

follow up .After completing third and fourth sting of leeching

the Keloid was fully vanished and after one week the scar

mark also completely disappeared which is shown in figure 6

and figure 7. After completing the treatment (leech Therapy)

the patient was followed up monthly for a period of one year

and it was observed that there was no recurrence of Keloid

lesion.

Fig. 3. Keloid starting Regressing.

Fig. 4. Second sting of leeching on Keloid lesion.

Fig. 5. Shows the further regression of the Keloid.

International Journal of Biological Sciences and Applications 2015; 2(4): 37-41 41

Fig. 6. Complete regression/Disapperance of Keloid, However shows minor

scar formation.

Fig. 7. Shows smooth skin surface without scar.

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