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Keloid formation after circumcision and its treatment

      Abstract

      Circumcision is performed in many communities around the world for either medical, ethnic, or religious issues. It is a safe procedure when it is performed by a fully trained surgeon. However, complications such as bleeding, infection, diminished penile sensation, urethral injury and amputation of the glans are occasionally seen. Keloid is the result of excessive deposition of collagen in the dermis and subcutaneous tissues. It usually develops at the site of trauma or surgical injuries. Keloid formation on the penis is a very rare condition. In this study, we present a case of keloid formation after circumcision and review the related literature.

      Keywords

      Introduction

      Due to medical or religious reasons (in Jewish and Islamic faith; in some tribes in Africa, America, and Australia) circumcision is one of the most common surgical procedures performed around the world. Although the complication rate in circumcision is very low, bleeding, infection, diminished penile sensation, urethral injury or amputation of the glans may be seen [
      • Erdemir F.
      • Gokce O.
      • Sanli O.
      • Kadioglu A.
      • Parlaktas B.S.
      • Uluocak N.
      • et al.
      A rare complication after circumcision: keloid of the penis.
      ,
      • Bekerecioglu M.
      • Inaloz H.S.
      • Tercan M.
      • Isik D.
      Keloid formation on an inconspicuous penis.
      ,
      • Gürünlüoğlu R.
      • Bayramiçli M.
      • Numanoglu A.
      Two patients with penile keloids: a review of the literature.
      ].
      Abnormal wound healing which results in keloid formation is only seen in humans. Keloid is the result of excessive deposition of collagen in the dermis and subcutaneous tissues. It usually develops at the site of trauma or surgical injuries. The sternal area, deltoid region, back, and the posterior neck region are the most likely areas to develop keloid after surgical or traumatic injuries [
      • Gürünlüoğlu R.
      • Bayramiçli M.
      • Numanoglu A.
      Two patients with penile keloids: a review of the literature.
      ,
      • Mastrolorenzo A.
      • Rapaccini A.L.
      • Tiradritti L.
      • Zuccati G.
      A curious keloid of the penis.
      ,
      • Warwick D.J.
      • Dickson W.A.
      Keloid of the penis after circumcision.
      ].
      Keloid formation on the penis is a very rare condition. In this study, we present a case of keloid formation after circumcision and review the related literature.

      Case report

      A 3-year-old boy was admitted to our clinic with an enlarging mass on his penis 3 months after a circumcision procedure. During the early postoperative period no complication was seen. Then, a slow-growing mass began to develop at the circumcision site. The patient and the members of his family had no history of abnormal wound healing. On physical examination, an irregular shaped erythematous keloidal lesion was located at the penile ventral surface at the coronal sulcus level (Fig. 1). The lesion was assessed as keloid because it was spreading beyond the circumcision site especially at the ventral surface of the penile shaft. Intralesional injection of 0.5 ml of triamcinolone acetonide was performed and repeated three times for every other week. Enlargement of the keloid mass stopped and the mass softened. At the sixth postoperative month after circumcision, the keloid mass was resected and the coronal skin was closed primarily. Any tension at the suturing site was avoided. Starting at the first postoperative week, a silicone gel sheet and topical steroid application were used for 8 weeks. The patient showed no signs of recurrence of the keloid lesion at his 1-year follow-up (Fig. 2).
      Figure thumbnail gr1
      Figure 1View of patient at third month after circumcision. Keloid formation at the ventral surface of the coronal sulcus is seen.
      Figure thumbnail gr2
      Figure 2View at first postoperative year, after excision of the keloid mass and combination therapy (topical steroid silicone gel sheet and topical steroid application).

      Discussion

      Circumcision is performed in many communities around the world for either medical, ethnic, or religious issues [
      • Erdemir F.
      • Gokce O.
      • Sanli O.
      • Kadioglu A.
      • Parlaktas B.S.
      • Uluocak N.
      • et al.
      A rare complication after circumcision: keloid of the penis.
      ,
      • Bekerecioglu M.
      • Inaloz H.S.
      • Tercan M.
      • Isik D.
      Keloid formation on an inconspicuous penis.
      ,
      • Gürünlüoğlu R.
      • Bayramiçli M.
      • Numanoglu A.
      Two patients with penile keloids: a review of the literature.
      ,
      • Mastrolorenzo A.
      • Rapaccini A.L.
      • Tiradritti L.
      • Zuccati G.
      A curious keloid of the penis.
      ,
      • Warwick D.J.
      • Dickson W.A.
      Keloid of the penis after circumcision.
      ]. Some studies report that circumcision may reduce the incidence of urinary tract infection, sexually transmitted diseases, and penile and cervical cancer. It is a safe procedure when performed by a fully trained surgeon. However, even under ideal circumstances, complications may occur. Hemorrhage, urinary retention infections, and wound healing problems may be encountered among early complications. Necrosis of the glans or total penis, meatal stenosis, and complications related to anesthesia are very rare but disappointing complications.
      No single therapy exists for keloids. Silicone gel sheets, pressure therapy, intralesional steroid injections, and massage with topical steroids are proposed in the management of keloids [
      • Gürünlüoğlu R.
      • Bayramiçli M.
      • Numanoglu A.
      Two patients with penile keloids: a review of the literature.
      ,
      • Körmöczy I.
      Enormous keloid (?) on a penis.
      ,
      • Parsons R.W.
      A case of keloid of the penis.
      ]. Optimal treatment usually consists of a combination of these therapies. Surgical excision with intralesional steroid injection is the most common treatment modality [
      • Erdemir F.
      • Gokce O.
      • Sanli O.
      • Kadioglu A.
      • Parlaktas B.S.
      • Uluocak N.
      • et al.
      A rare complication after circumcision: keloid of the penis.
      ,
      • Gürünlüoğlu R.
      • Bayramiçli M.
      • Numanoglu A.
      Two patients with penile keloids: a review of the literature.
      ]. There is no doubt that surgical excision alone will result in local recurrence. However, if excisional surgery is combined with steroid injection the local recurrence rate reduces from 100% to 50% [
      • Paul Kelly A.
      Medical and surgical therapies for keloids.
      ]. Close follow-up of the patient is one of the other important factors that one should consider for a successful treatment [
      • Gürünlüoğlu R.
      • Bayramiçli M.
      • Numanoglu A.
      Two patients with penile keloids: a review of the literature.
      ,
      • Warwick D.J.
      • Dickson W.A.
      Keloid of the penis after circumcision.
      ].
      In this study, keloid formation on the penis after circumcision is presented. The keloid mass is resected after serial intralesional steroid injections. It is very important to close the wound edges without tension as otherwise recurrence may occur. In the postoperative period, the patient received combination therapy for 8 weeks. During the follow-up, it was considered to reuse intralesional steroid injections, but fortunately he showed no sign of recurrence.
      In keloid cases, surgical excision may result in larger keloid masses [
      • Körmöczy I.
      Enormous keloid (?) on a penis.
      ]. Thus, it is very important to control the enlargement of keloid before performing any surgical intervention. On the other hand, in very large keloid masses, excision can be performed prior to pressure therapy and/or steroid applications.

      Conclusion

      Keloid formation on the penis is usually seen after circumcision. It is a rare but disappointing complication. These cases should be followed up closely. We believe that surgical excision can be performed when the enlargement of the mass is controlled by serial intralesional steroid injections and pressure therapy. In the postoperative period, silicone gel sheet and topical steroid application should also be considered.

      Acknowledgments

      Funding: None. Competing interests: None declared. Conflict of interest: The authors have declared that no conflict of interest exists. Ethical Consent: An informed consent has been obtained from the patient. Since this is not an experimental research ethical consent for the animal care is not required.

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