Intralesional vitamin D injection for management of keloids

Dear Editor, We read with interest the recent review article by Naik, describing novel targets and therapies for keloid.1 We congratulate the author on this informative review summarizing various upcoming therapeutic modalities for keloids. Intralesional vitamin D is another promising treatment option for keloids that has garnered significant interest from clinicians due to easy availability, low cost and favourable safety profile. We would like to add to this exhaustive list of novel therapies for keloid by describing our experience of managing keloids with intralesional vitamin D injection in two patients. Patient 1 was a 19‐year‐old woman with a 3‐year history of a single keloid 40 mm in size on the deltoid region. She had received intralesional triamcinolone in the past with good response, but the keloids had recurred upon therapy cessation. We treated the keloid with intralesional vitamin D injection (0.2 mL of 200 000 IU/mL for each 10‐mm distance) every 4 weeks. Significant improvement was noted after four sessions, with decrease in Vancouver Scar Scale (VSS) from 10 at baseline to 6 at Week 4, without any adverse effects (AEs) (Fig. 1), at which point the treatment was stopped. No recurrence was noted at the follow‐up visit 3 months after treatment cessation. (a,b) Patient 1: keloid on the arm (a) before treatment, showing Vancouver scar scale (VSS) score of 10, and (b) after four sessions of intralesional vitamin D3 injection, showing improvement of VSS to a score of 6. Patient 2 was a 32‐year‐old man with a 1‐year history of a keloid on his chest. We treated him with the same regimen of intralesional vitamin D injection as for Patient 1. Again, significant improvement was noted after four sessions; in this patient's case, with reduction in VSS from 9 to 5. Transient injection site pain was the only observed AE. No increase in size was noted 2 months after treatment cessation, and the patient remains under follow‐up. Vitamin D is a fat‐soluble vitamin involved in calcium homeostasis, cell proliferation inhibition, cell differentiation promotion, inflammation and apoptosis. The antifibrotic potential of vitamin D has been demonstrated in kidney, lungs and liver, probably resulting from the modulation of genes involved in epithelial mesenchymal transition. Vitamin D also inhibits extracellular matrix production, which in turn inhibits keloid fibroblast proliferation. Expression of the vitamin D receptor (VDR) has been studied in keloidal skin, and reduced nuclear localization of VDR has been observed in keloidal scar tissue compared with normal skin.2 Terzi and Güven observed a significant negative correlation between vitamin D levels and modified VSS score at 1 year in 25 patients with extensive burns.3 The severity of keloids has been reported to be higher in patients deficient in vitamin D.4 Overall, evidence suggests that vitamin D deficiency predisposes a patient to develop keloids and that vitamin D may have a role in management of scarring. This was supported by the study of Mamdouh et al., who observed significant reduction in VSS in a case series of 40 patients with keloids treated with four sessions of weekly intralesional vitamin D injections.5 In conclusion, vitamin D is a safe, effective and inexpensive treatment modality for keloids. Its lack of AEs such as pigment alteration, atrophy, telangiectasias, etc. seen with conventional therapies makes it an attractive alternative for keloid management. The authors declare that they have no conflicts of interest. None. Ethics approval was not applicable. The patient has provided informed consent to publication of their case details and images. Not applicable.