Q: Dr. Eppley, I came across your website in my search for 5fu injections. I have/had a cyst in my chin/jaw area last august. I have had it injected with cortisone/kenalog multiples times and it has helped but something is still there. I believe it is scar tissue because it’s hard and turning white. But because it never came to a head I’m not totally sure that theres nothing in there but scar tissue. So my question is this; are there any issues with having 5fu injections into a cyst or more likely a scar? Because I know cortisone has risks of fat atrophy and skin thinning. Does 5fu have any side effects like that? And also can you put 5fu in a scar that has had cortisone put into it? Thanks so much.
A: 5FU is not as significantly effective for scar reduction as steroids. This is also why is has none of the side effects of steriods and also why you will often see it combined with steroids for injectable scar therapies. It helps reduce the concentration of steroids needed to lessen their potential side effects as well as enhances the effects of 5FU. It works best in the early treatment of scar tissue formation. But it would not be an effective treatment for a true cyst. I am assuming that what you had may have been for cystic acne which is really an inflammatory condition so steroid injections would have been an appropriate treatment. But a true dermoid cyst is not going to go away long-term with any injectable scar therapy.
Dr. Barry Eppley
Q: Dr. Eppley, I have a question regarding injectable scar treatments. What is the difference between 5-FU and Kenalog? What do each of them do to help a scar/scar tissue?
A: There are two types of scar injections that are currently available. The use of steroids, specifically triamcinolone (kenalog), is an historic and classic injectable approach. Triamcinolone is a synthetic corticosteroid that has a significant anti-inflammatory effect. It works on scars by either inhibiting or breaking down the cross-linking of collagen fibers, which is the backbone of scar formation. Dosing and frequency of Kenalog injections is critically important as it can have side effects such as soft tissue atrophy and tissue thinning. For this reason, lower doses are usually used, such as K10 rather than the more concentrated K40, and injections sessions should not be spaced more than 3 or 4 weeks apart.
5-FU is a well-known drug used as a chemotherapy agent against cancer for several decades. It works by inhibiting DNA replication which is important in stopping cancer cells which usually multiply faster than normal cells. In dermatology, 5-FU is most commonly used topically (as a cream) for treating actinic (solar) keratoses and some types of basal cell cancers of the skin. (e.g., Efudex or Carac) It is thought that it works in scar problems because it blocks collagen synthesis which might help to control excessive scar formation. It does not have the side effects of corticosteriods but injections are still done only every month or so, mainly to see how it is working.
I often combine the two, Kenalog and 5-FU, as an injectble combination when either it is a known problematic scar or a scar that has failed to respond to Kenalog injections. It is unknown whether one is superior to the other as a primary scar therapy.
Dr. Barry Eppley
Q: Hi Dr. Eppley, I emailed you about a month ago about getting 5-FU injections for lumpy scar tissue underneath my nipple for a revision gynecomastia surgery I had about 4 1/2 months ago. I have been really busy at work and unable to get time off to make an appt. Last time you emailed me about a month ago you said I could schedule an appt. and possibly get a 5-FU or kenalog injection. I would really like to do this but an injection of kenalog makes me nervous due to the possibility of skin atrophy and other side effects I have heard about. I have heard that 5-FU mixed with a small amount of kenalog does not really carry these side effects and can work quite effectively. I have to travel about two hours or so to get there so I just want to make sure that 5-FU injections are a possibility before I make the trip. Also I have an issue about the scar I have from the surgery I had and I saw on your website that you deal with scar management. I know that the scar I have is only 4 1/2 months old but it does not seem to be getting any better and I was wondering if there are any non-surgical procedures or techniques, such as laser therapy, that you specialize in that could help to minimize this scar? Thank you for any help you may be able to give me.
A: We can certainly do 5-FU injections for scar therapy as that is an item I keep stocked her for injection treatments. While it is uncertain whether 5-FU is really better than Kenalog, it does have a higher safety profile. Kenalog done judiciously (low dose), however, can be done without significant side effects as well. As for scar management, there are numerous options regarding non-surgical approaches depending upon the scar issue such as hypertrophy or redness. Most commonly we do pulsed light therapy (Broad Band Light, BBL) or laser treatments. That decision would have to be made at the time of examination.
Dr. Barry Eppley
Q: Hi Dr. Eppley, I recently had a revison gynecomatia surgery to remove scar tissue about 3 months ago and now I have even more scar tissue buildup than I had before. I have a big lump under my left nipple and was wondering if I it was possible to get 5-FU injections to reduce the scar tissue because I heard that Kenalog can have significant side effects. My doctor does not offer 5-FU and I have heard that this needs to be injected within the first few months after surgery to have an effect so I would like to get this done if possible. I would appreciate hearing back from you and helping me out with this if possible. Thank you!
A: At this early point after your revisional surgery, it is reasonable to consider a non-surgical treatment for your recurrent scar tissue. If significant improvement was to occur, you should be seeing it by now. The standard injectable scar treatment is Kenalog. While there are potential side effects (fat and skin atrophy), these are very much dosage and location dependent. High and frequent injections of Kenalog in skin level scars can cause these problems. But low doses of Kenalog done judiciously for subcutaneous fibrosis is unlikely to create these potential problems.
5-FU scar injections are useful in scar issues that have proven resistant to Kenalog. While there is nothing wrong with using it as a first choice therapy, it may or may not be necessary. When administered it is mixed with either a small amount of Kenalog or local anesthetic since there is definite burning afterwards associated with 5-FU injections. You are correct in assuming that these injections should be done early as they work best when new scar tissue is forming as opposed to long-stand established scar tissue.
Dr. Barry Eppley
Q: I have a scar tissue under my cheek bone caused by injecting an Artefill or Sculptra filler. It’s been there since the filler was done 6 years ago. Now I’m been treated with 5-FU and Kenalog injections. I have done only 3 treatments so far but with no results. Do you think that the treatment can help to rescue the size of the scar or is there no hope?
A: Most likely your residual cheek mass is the result of an Artefill treatment and not Sculptra. Artefill is a filler that has a significant component of non-resorbable acrylic beads which settle into place by scar tissue forming through and around them. The beads are permanent. Sculptra is composed of resorbable poly-lactic crystals which causes temporary scar formation to occur which eventually goes away as the crystals eventually dissolve. After 6 years you have a residual mass that is, at least partly, due to the acrylic beads. While I think the 5-FU/kenalog scar injections are reasonable to try, I suspect they will ultimately prove unsuccessful as they are not going to make plastic beads disappear. Furthermore, this injectable scar treatment works best on scar that is newly forming not on established scar tissue.
That being said, 5-FU/kenalog scar injections often take a full course of treatment to know to be maximally effective. You have had only 3 injection treatments and the complete protocol is up to 10 injection sessions so it is too early to rule out completely that they will not work at all.
Depending upon the cheek mass/scar location, it may be more efficient to have it excised if it can be approached favorably through an intraoral (inside the mouth) incision.
Dr. Barry Eppley