Mitomycin C in the Treatment of Keloids: A Case and Review
June 2013 | Volume 12 | Issue 6 | Case Reports | 701 | Copyright © June 2013
Rebecca Kleinerman MD, Suzanne L. Kilmer MD, and Vera A. Chotzen MD
The Laser and Skin Surgery Center of Northern California, Sacramento, CA
Mitomycin C (MMC) is an antineoplastic antibiotic that has been used off-label in the treatment of hypertrophic scars and keloids.
Herein we report our successful use of this agent in a patient with sternal keloids refractory to other means of therapy. We further
review the literature regarding the use of MMC in the treatment of keloids.
J Drugs Dermatol.
Mitomycin C (MMC) is an antineoplastic antibiotic. It
is derived from the Streptomyces caespitosus bacterium,
and functions as an antiproliferative agent,
inhibiting DNA synthesis by cross-linking the strands of the
double helix.1 Recently, MMC has been used as an alternative
topical and intralesional agent in the approach to hypertrophic
scars and keloids. There is wide variability in the mode of usage
and the success of this agent in the literature, and no large trials
have been conducted regarding scars. Herein, we report a case,
discussing our experience with MMC, and we review the prior
usage of MMC in scar treatment.
A 27-year-old Caucasian female with a history of systemic lupus
erythematosus (not on systemic medications) presented large
and painful sternal keloids, recurring after two prior excisions
despite treatment with intralesional triamcinolone, 5-fluorouracil,
topical imiquimod, topical silicone gel, and pulsed-dye laser.
The patient’s superior sternal keloid was re-excised, and in light
of the patient’s unfavorable response to other agents, MMC
was used adjunctively. The skin was extensively undermined to
a distance of at least 3 cm on either edge of the wound. Intraoperatively
MMC (0.4 mg/ml; total of 50 ml soaked on gauze) was
placed on the wound edges for a period of four minutes and
then the treated area was irrigated with saline. The wound was
sutured with polyglycaprone and polydioxanone intradermal
sutures. 6-0 fast-acting gut cuticular sutures were used.
Thereafter, the patient underwent pulsed-dye laser treatments
at 2-month intervals. She tried to keep as much strain
off the wound as possible, bending her shoulders forward in
the post-operative period. Six months following the excision
she remained asymptomatic, with marked improvement of
the area that was excised. She also noted that at the superior
edge of her inferior sternal keloid had flattened, which
she attributed to the MMC application (Figure 2). At this point,
the inferior sternal keloid was excised and treated in a similar
manner with MMC intraoperatively.
For approximately 3 years postoperatively, the patient was relatively
asymptomatic, without recurrence of the keloids. Four years after her excisions, the patient began to feel itching and
burning in the affected area. Following a further discussion of
the agent and demonstrating an understanding of its off-label
use, the patient was injected with 0.4 cc of a solution of MMC
containing 0.4 mg/5 ml solution, with microdroplets placed approximately
1 cm apart along the margins of the suture line.
This treatment was repeated several months later, achieving
symptomatic improvement. At the present time the patient has
occasional flares of itching or pain in the treated area, mostly
at the edges, and was most recently treated with intralesional
triamcinolone injections (Figure 3).
Several in vitro and animal studies have attempted to characterize
the effect of MMC on the healing wound.1-3 Gray et al
indicated that MMC delays wound healing by down-regulating
the production of extracellular matrix proteins.2 They concluded
that if MMC is applied to the wound before the genetic
induction of a proliferative phenotype (ie, without delay after
surgery), it may be effective at inhibiting fibroblast proliferation
and consequent healing.
In an initial trial using MMC for the prevention of keloid recurrence
postoperatively, Talmi et al conducted eight keloid
excisions and placed a saturated pledget with MMC over the
wound prior to closure for 5 minutes.4 A concentration of 0.4 mg/
ml was used. The patients were followed monthly for six months
and again at 14 months. The authors stated that all patients improved
and there were no adverse effects. They indicated that
in all cases, scar thickness was substantially reduced, although
only 2/8 keloids showed complete remission. A limitation of
this small study was the lack of controls. Stewart et al provided
similar results using a 0.4 mg/5 ml concentration of MMC intraoperatively,
reporting a 90% success rate and no recurrences at
follow-up intervals ranging from 6-14 months.5 Again, no controls
were used. Soon after, Sanders et al performed a study
with the same concentration of MMC and the same time frame
for topical application in patients with multiple keloids who
served as their own controls.6 The authors excised 30 keloids
in 15 patients. Excision was followed by intralesional corticosteroid
injection at monthly intervals for 6 months, though this