International Journal of Medical Physics, Clinical Engineering and Radiation Oncology, 2013, 2, 88-91 Published Online August 2013 (
A Case of Post Varicella Recurrent
Presternal Butterfly Keloid
Andre Vera1, Henry Weatherburn2, Kamalendu Malaker3,4*
1Radiotherapia Oncologica GURVE, Instituto Medico la Floresta, Caracus, Venezuela
2Parkside Oncology Clinic, London, UK
3ICM Department, Ross University School of Medicine, Portsmouth, Dominica
4Princess Margaret Hospital, Roseau, Dominica
Email: avera@, henryweatherburn@cancer, *
Received March 23, 2013; revised April 17, 2013; accepted May 27, 2013
Copyright © 2013 Andre Vera et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Presternal butterfly keloid management remains a clinical challenge. This case indicates, with hypo fractionated exter-
nal beam electron therapy a significant symptomatic and cosmetic benefit may be achieved without any unacceptable
acute, chronic or long term toxicity.
Keywords: Butterfly Presternal Keloid; Hypo Fractionated External Beam Radiotherap y
1. Patient
With 15 years prior history of varicella attack, a 31-year
Hispanic Venezuelan healthy male, presented in January
2011. He had several satellite keloids surrounding the
central major lesion, all being developed in a post vari-
cella scar in the anterior chest wall. Since then he has
been through three surgical excisions and on each occa-
sion the lesion recurred with worsening size and symp-
toms. His last resection was carried out in June 2010. By
the end of 2010 h e recurred again with further wor sening
symptom and progressive lesion. He was not considered
for further resection and was referred for radiotherapy.
He was seen in radiotherapy in January 2011. He pre-
sented with a large mid presternal butterfly keloid meas-
uring 8.5 cm × 4 - 6 cm. Surrounded by 5 satellite
keloids 0.5 - 0.75 × 0.75 - 1.5 cm. The lesions were pink,
tender, hard nodular, fibrotic, criss-crossing with hard
fibrotic bands especially in the main lesion. Height var-
ied between 3 - 10 mm. The total skin area that encom-
passes the main and satellite lesions is 9.5 × 9.5 cm2.
Aside his progressive symptoms of severe pain and itch-
ing not controlled by medications and topical applica-
tions; unsightly appearance restricting his social interac-
tion and personal embarrassment has led to depression
and voluntary isolatio n.
There was no other keloid or hypertrophic scar in his-
body, did not give any specific history of allergy or
atopic condition. He was not diabetic, nor had an y keloid
formers in the family. He did not have any African or
south east Asian genetic her i tage as far he knows.
Keloids arising in varicella scar are particularly resis-
tant to available treatments [1]. Presternal butterfly
keloids respond poorly to conventional radiotherapy or
other form of supportive treatments. Multiple surgical
resections make the keloid size bigger more fibrotic and
hypoxic [2]. Hence this particular lesion had all the risk
factors against achieving any reasonable result from con-
ventional radiotherapy or combinations of modalities [3,
4]. So it was decided to treat him with H ypo fractionated
external beam radiotherapy [5] primarily for sympto-
matic relief and secondarily for cosmesis by achieving
some degree of size reduction and flattening of the le-
sion/s. For measurement of reaction and response, clini-
cal photographs were taken, before, during, after each
fraction and frequently during follow up to 12 months.
2. Radiotherapy Planning and Prescription
Anticipated risk of treating presternal region with mega-
voltage radiotherapy is the radiation dosage to the heart
and other mediastinal structures. Hence it was decided to
check the dosimetry with CT scans for Radiotherapy do-
simetry using appropriate Electron Beams. Electron
beam was chosen to reduce medistinal radiation and
achieve better cosmesis [5,6]. Cosmesis is a major con-
cern in this patient.
*Corresponding author.
opyright © 2013 SciRes. IJMPCERO
6 MeV Electron beam, using a 15 × 15 cm2 field with
lead cut out for an area of 11.5 × 11.5 cm2 was prepared.
Since the maximum height of the lesion is approximately
10 mm thick; a 0.5-mm wax bolus was added on the sur-
face of lesion (Figures 1(a) and (b)).
In absence of CT scan of the chest of this patient; in-
stead of using a phantom, we chose to use a CT scan of a
male of comparable age, ethnicity, BMI and chest di-
mensions etc., to work out the dosimetry. A CT scan of
the chest both transverse and longitudinal section was
used to verify the likely depth dose and dosage to the cri-
tical mediastinal structures (Figures 1(c) and (d)). Thus
Fig 1c
Fig 1d
Figure 1. (a) Presented with presternal butterfly keloid with multiple satellite keloids on 8th February 2011; (b) Shows the
outline of the entire area of the skin to be treated encompassing the primary butterfly keloid and its satellite lesions adding 2
mm to the outer border of all keloids [5]; (c) Depth dose in CT scan on Transverse section; (d) CT scan in sagittal section of
the central sagittal axis of the lesion: cardiac and mediastinal structures.
Copyright © 2013 SciRes. IJMPCERO
the detail of prescription and dosimetry are as follows:
Total dose prescribed—3750 cGy in 5 weekly frac-
tions at 750 cGy per fraction at 95% depth dose, over
4 weeks.
6 MeV electron beam on linear accelerator was gi v en.
A 15 × 15 cm2 field was chosen to cover 11.5 × 11.5
cm2 fields with lead cut out.
0.5-cm thick wax bolus was used on the surface of the
Skin surface dose (under 0.5 cm bolus) = 89% i.e.
3340 cGy (3750 cGy at 100%).
Maximum dose at rear of the lesion (at 0.7 cm depth
in the lesion, i.e. 1.2 cm from the surface of the bolus
= 100%, i.e. 3750 cGy.
Dose at the rear of the lesion (at 1.0 cm depth, i.e. 1.5
cm from the surface of the bolus) = 96%, i.e. 3600
Dose at the rear of the sternum (Approx. 1.75 cm as
per the CT scan, i.e. 2.25 cm from the surface of the
bolus) = 48%, i.e. 1800 cGy.
Dose at the anterior aspect of the heart (Approx. 2.5
cm as per the CT scan, i.e. 3 cm from the surface of
the bolus) = 4% i.e. 150 cGy.
(We calculated the radiation dose, taking sternum
to be of unit density.)
He was prescribed at 95% level. So the Tumor dose
was 3750/0.95 = 3950 cGy, at the rear of the lesion to
3600/0.95 = 3790 cGy.
The cardiac dose will range from 250 - 300 cGy over a
period of 4 weeks or 28 days .
Depth dose to the mediastinum are displayed both in
transverse and sagittal plane at the mid-level of the cen-
tral lesion.
3. Tolerance and Response to
Hypo Fractionated Radiotherapy
Patient tolerated the treatment well. Just after the first
fraction, he experienced some allev iation of his symptom.
Figure 2(a) (22.6.2011) shows skin reaction 1 week after
first fraction, mild erythema without any desquamation
or edema. Figure 2(b) (21.7.2011) shows extent of skin
reaction on the last or the 5th fraction i.e. 28 days after
treatment started, significant bright erythema with coa-
lescence of moist desquamation, especially on the main
lesion on higher thickness of the lesion. There was no
detectable keloid regression or flattening were noted,
there was some dry desquamation noted (Gr3), No sig-
nificant pain or discomfort from the reaction, reported by
the patient Figure 2(c) (12.8.2011) shows extent of skin
reaction 3 weeks after last fraction, persistent deep but
fading erythema, areas of dry desquamation, less exten-
sive, coalesced moist desquamation, but contracted area,
patchy areas of keloid flattening was noted. There was no
detectable edema or pain/tenderness noted (improving
Gr3). Figure 2(d) (31.7.2012) shows 12 months after
treatment completed. All satellite keloids regressed by
80% of their height and areas to some extent. Main pre
sternal butterfly lesion also regressed between 30% and
50% of itsheight. Erythema remains as slight pigmenta-
tion, desquamated areas healed completely, the lesions
are softer. Patient keloid sympto ms had resolv ed o n co m-
pletion of his last fraction. He did not feel socially re-
stricted or compromised, felt very happy to return to his
social life and commitments.
Figure 2. (a) (22.6.2011) shows skin reaction 1 week after
first fraction; (b) (21.7.2011) shows extent of skin reaction
on the last or the 5th fraction; (c) (12.8.2011) shows extent
of skin reaction 3 weeks after last fraction; (d) (31.7.2012)
shows 12 months after treatment completed.
Copyright © 2013 SciRes. IJMPCERO
Presternal butterfly keloids are very difficult to treat.
Symptomatic relief with standard external beam radio-
therapy may be achieved to some exten t, but reduction of
keloid bulk happens rarely, specially of the presternal
keloids, keloids arising in varicella scars [7] and one’s
had multiple surgical resections [2] tends to respond
poorly to any form of treatment. Intra-lesional injections
of medications, compression with or without silicone gel
sheets, radiotherapy of any form, fares with very limited
success [3,4]. This lesion is a clinical challenge having
several poor prognostic indicators and little documented
record reporting management of such a lesion. Using
combinations of concurrent multi-modality treatment,
Malaker et al. [8] in a series of 71 cases of recurrent or
“difficult to treat keloids” reported some success. But in
their series of 71 cases, 5 presternal butterfly keloids,
none had multiple poor prognostic indicators like this-
case. They injected the entire lesion with combination of
triamcinolone, dexamethasone and hyaluronidase, weekly
for 6 - 8 weeks. Immediately after the injection the le-
sions were covered with silicone gel sheets and com-
pressed with 1.5 - 2 cm thick hard bee wax blocks cus-
tomized to the shape of the keloid, and compressed and
retained with elastoplast bandage, for one week and re-
peat the pr oced ure we ekly [9-11 ]. It is ch eap an d suitab le
for, children, adolescence and women. But the intra le-
sional injections are painful and 6 - 8 weeks of elasto-
plast compression is some challenge to patients for their
comfort and tolerance. No other specific reports available
particularly were focusing on the management of prest-
ernal keloids. But general consensus is that these are very
difficult lesions to treat or to achieve an y mean ingfu l pal-
This particular case indicatesbutterfly presternal kel-
oids may be treated with hypo fractionate delectron ex-
ternal beam therapy, to achieve meaningful symptomatic
and cosmetic benefit. This patient will continue to im-
prove from cosmetic point of view for next few years,
with further regression and flattening of all the lesions.
5. Acknowledgements
I wish to thank Irus Toussaint for technical assistance
and Ms. Kristen Campbell for editorial help and Ms. Joan
Joseph for secretarial assistance.
[1] N. Kluger, A. Mahe and B. Guillot, “Eruptive Keloids
after Chickenpox,” Dermatology Reports, Vol. 3, No. 2,
2011, p. 35.
[2] A. Bayat, G. Arscott, W. E. R. Oliver and M. W. J. Fer-
guson, “‘Aggressive Keloids’: A Severe Variant of Famil-
ial Keloid Scaring,” Journal of the Royal Society of Med-
icine, Vol. 96, No. 11, 2003, pp. 554-555.
[3] M. A. Daizi, N. A. Chowdri, S. K. Kaul and M. Khan,
“Evaluation of Various Methods of Treating Keloids and
Hyper Tropic Scars,” British Journal of Plastic Surgery,
Vol. 45, No. 5, 1992, pp. 374-379.
[4] O. Rei, “Most Current Algorithms for Treatment and
Prevention of Hypertrophic Scars and Keloids,” Plastic
and Reconstructive Surgery, Vol. 125, No. 2, 2010, pp.
[5] K. Malaker, V. Vijayragavan and I. Hodson, “Retrospec-
tive Analysis of Treatment of Unresectable Keloids with
Primary Radiation over 25 Years,” Clinical Oncology,
Vol. 16, No. 4, 2004, pp. 290-298.
[6] O. Rei, M. Kioshi, et al., “Postoperative Electron Beam
Irradiation Therapy for Keloids,” Plastic and Reconstruc-
tive Surgery, Vol. 111, No. 2, 2003, p. 547.
[7] N. Sceinfield and S. R. Cohen, “Varicella Causes Skin
Pits and Keloids—More Reasons for Varicella Vaccine,”
Pediatrics, Vol. 106, No. 1, 2000, p. 160.
[8] K. Malaker, M. Zaidi, F. Ridda and T. Al Yafi, “Con-
comitant Multimodality Treatment of Keloids (CMTK)
Unmanageable by Conventional Post-Operative Radio-
therapy,” 9th Congress of the Pan Arab Association of
Burns and Plastic Surgery, Bahrain, 11-13 April 2006.
[9] K. Malaker, M. Zaidi, F. Ridda and T. Al Yafi, “Update
on Concomitant Multimodality Treatment of Keloids
(CMTK) Unmanageable by Conventional Postoperative
Radiotherapy,” 17th Annual Meeting of the European As-
sociation of Plastic Surgeon (EUROPAS), Istanbul, 25-27
May 2006.
[10] K. Malaker, M. Zaidi and F. Ridda, “‘Tripoli Protocol’: A
Developing Nation’s Challenge in Managing Some Dif-
ficult Keloids,” International Scar Meeting, Tokyo, 30
November-1 December 2010.
[11] K. Malaker, M. Zaidi, M. R. Fra nka and T. Al Y af i, “Co n-
current Multi-Modality Treatment of Keloids (CMTK)
Not Manageable by Conventional Postoperative Radio-
therapy,” International Journal of Clinical Medicine, Vol.
4, No. 5, 2013, pp. 273-281.
Copyright © 2013 SciRes. IJMPCERO