Keloid Treatment

Keloid Treatments


Keloid Treatment

 

Surgical Removal of Keloids

Surgical removal of keloids is an area of great controversy. The biggest risk associated with keloid removal is the risk of recurrence after surgery. Keloids that re-occur after surgery are often bigger in size and much harder to treat.
The onset of a keloid is triggered by a minor wound in the skin. In surgically removing a keloid, a much bigger wound is induced to remove the keloid. This new and larger wound will obviously result in formation a much larger keloid. An online survey study was launched in November 2011. As of December 15, 2012, 670 patients have responded to this survey among whom 193 had surgery for their keloids. The graphs below show the outcome of surgery for this patient group. This study shows that surgery carries a very high risk of worsening the keloids. Only 5% of patients are cured with surgery. 10.4% relapse yet the keloid remains smaller. 11.4% relapsed and their keloids returned to the same size as before surgery. 73.1% (141 patients) noticed worsening of their keloids after surgery. So if you are thinking of having surgery for your keloid, study this chart carefully.

 

keloid-surgery-a3
Predicting the risk of recurrence of a keloid after surgical removal is impossible. What is greatly needed is a methodology to make a risk determination as to which keloids will recur and which will not. This is an area that needs to be properly researched.

The risk of recurrence after surgery for certain keloids such as chest wall, shoulder keloids is near 100%. Local injection of steroids after surgery reduces the risk of recurrence of certain keloids in the earlobe, not in other parts of the body. The degree of benefit from this intervention is unclear.

Radiation therapy is also utilized to reduce the risk of recurrence. Although it can reduce the risk of recurrence to some extent, Radiation carries a major risk of causing cancers and should not be used to treat keloids in young and healthy individuals.

Picture below depicts how a simple earlobe keloids can react to surgery.

Flat, small and minor keloids should never be treated with surgery. The result is almost always worse than the condition prior to surgery.

It is well understood that keloid is a genetic and an inherited disorder of the wound healing mechanisms of the skin. Surgery cannot change the genetic makeup of the person. Surgery only triggers the abnormal wound healing response, which is the core problem in keloid formation, and commonly results in development of a much more complex and bigger keloid.

Radiation can damage the organs that are under the area where keloid is locates. Radiating neck will result in total loss of thyroid function, making the person hypothyroid, requiring lifelong thyroid supplement medications. Radiation to the chest area can damage the heart and lungs. Radiating abdomen can damage the liver. Radiation the pelvis can damage the bone marrow, ovaries in women and testicles in men, potentially causing infertility. Despite all these risks, there is no guarantee that the addition of radiation can prevent recurrence of keloid. To date we do not have a method of predicting who will benefit and who will not.

There are reports from Far East, of successful multi-modality treatments of earlobe keloids, using surgery, steroid injections, magnetic pressure earrings, etc. These results are very encouraging, yet they need to be re-produced in individuals who are from African ancestry.

I do not recommend surgery for treatment of any form of keloid.  All keloids should be treated with non surgical methods.   As a general rule, much like many other medical conditions, keloid disorder is not a condition that should be treated with surgery.  Treatment of keloid disorder is an area of unmet medical need. Much more research is needed to figure out what drives this disorder and how best to treat it. Our current treatments for keloids are the same as they were 30 years ago. We have not made any progress in treating this condition.

 

Steroid Injection

Steroids have been long used in treatment of various skin disorders. Injecting steroids directly inside the keloid tissue, known as intralesional injection, is a commonly used method of treating small keloids. This treatment however, is only partially effective. Triamcinolone acetonide is the most commonly used drug for treatment of keloids.

Dr. Sexton reported the efficacy of intradermal injection of this fluorinated prednisolone derivative in 1960 . Applied intralesionally, triamcinolone acetonide is one of the most widely used treatments for keloids, whether alone or in combination with another type of treatment.

Steroid injections are not as effective as we would like them to be. About one third of patients give up treatment because of pain and lack of immediate improvement. Our own recent IRB approved keloid survey was launched in November 2011 with the goal of capturing detailed information about this disorder directly from patients [www.KeloidSurvey.com] . As of May 7, 2012, 221 patients with keloid disorder had completed this survey. 127 adults have reported that they have been previously treated with steroid.

Graphs below show summary of the findings reported by the patients. This study shows that steroids work in about one third of pateints and for most part, their efficacy is temporary with about 16% chance of causeing worsening the keloids.

Furthermore steroids injections can also cause worsening of keloids in some patients Keloids are often resistant to treatment and have high recurrence rates. Repeated corticosteroid injections can be very painful and may cause various complications such as loss of normal skin tissue, discoloration and Cushing’s syndrome, a condition that is due to excess systemic exposure to steroids.

Not all keloids respond to intralesional steroid injections. Some keloids are “Steroid Sensitive” and others are “Resistant to Steroids”.

In the video below case, you can see how I inject the length of a scar with steroids.

Bleomycin Tattooing

Chemotherapy drugs refer to medicines that are used in treatment of cancer. Some anti-cancer drugs such as 5-FU and Bleomycin have been studied and shown to be effective in treatment of keloids. 5-FU does have some efficacy and much like steroids, some keloids are sensitive to it, and some are resistant.

Bleomycin is a potent anti-cancer drug. It is primarily used intravenously for treatment of Hodgkin’s Disease and Testicular Cancer. Bleomycin has been tested in keloid disorder. Dr. Espana has published his experience in 13 patients. He used tattooing as his method of injecting very small amount of Bleomycin into the tissue. He reported complete flattening of keloids in six patients, and highly significant flattening in six other patients and significant flattening in one patient and disappearance of itching in all patients after only one treatment. He reported recurrence in two of his 13 patients. The treatment was well tolerated and was without any noticeable toxicity.

Dr. Naeini has published on her results in 17 patients.

Bleomycin has been used in other non cancer indications, such as keratoacanthoma, neurofibromas and certain warts. When used in very low doses and with tattooing procedure, Bleomycin seems to be well tolerated and free of systemic effects.

The video below depicts the method used to perform Bleomycin tattooing.

Cryotherapy for treatment of Keloids

Cryotherapy, also known as Cryosurgery is the application of extreme cold to treat, or destroy keloids. Cryotherapy is the most effective, safest, most economical, and easy-to-perform method of treating most keloid lesions as well as hypertrophic scars. See “Cryotherapy in the treatment of keloids.” The success of cryotherapy, like any other medical procedure is simply dependent on the expertise of physician using this method. Having treated over 800 keloid patients, and mostly with cryotherapy, Dr. Tirgan has developed his own unique method of applying cryotherapy which allows for successful removal of many keloid lesions. Please keep in mind that cryotherapy is indicated for certain types of keloids and its efficacy varies from patient to patient and from keloid to keloid.

Cryotherapy is Dr. Tirgan’s choice of treating most keloids in children, specially earlobe keloids in African American Children. Recurrence rate after successful removal of keloids with cryotherapy depends on a number of factor, including type, size and location of keloid lesions, as well as presence of keloids elsewhere and the family history of the disorder.

Cryotherapy is used to treat a number of skin conditions like warts, moles, skin tags, etc. Cryotherapy utilizes Liquid Nitrogen that is capable of producing extreme low temperatures. About 80% of the air we breathe is made of nitrogen. Nitrogen is an inert gas and does not react with anything. It is not flammable either. Under extreme pressure, air and specially nitrogen, transforms shape and becomes liquid. Upon evaporation, liquid nitrogen produces extreme cold, -196 Celsius.

Application of liquid nitrogen to keloid tissue results in freeze destruction of keloid tissue. Exposure to extremely cold temperatures for an extended period of time causes frostbites which can lead to loss of finger and toes in mountain climbers who are not well prepared. We utilize the same principal in treating keloids, and induce very precise frostbite in the keloid tissue by direct application of liquid nitrogen to the keloid. Videos below depict my standard method of applying Cryotherapy to Keloids.
Application of cryotherapy is an art. Every keloid has a unique shape and configuration. In freezing keloids, attention has to be given to the location, shape and size of keloids. Every patient poses a unique challenge; therefore a careful cryotherapy plan has to be devised for each patient.

Prior to initiating cryotherapy, several factors have to be taken into consideration. Application of cryotherapy can be uncomfortable and at times painful. Furthermore, everyone has a different pain tolerance is and each segment of skin has its own unique sensitivity to pain. Therefore, there cannot be one plan and one method of freezing that can be applied to all keloids and to all patients. Constellation of all these variables calls for design of an individualized cryotherapy plan, an art that can be mastered only by experience.

What Happens Afterwards

Upon application of Liquid Nitrogen to the skin, you may feel a slight burning sensation or pain. The degree of discomfort from cryotherapy depends on the location and size of keloid. Application of Liquid Nitrogen to the large keloids can be uncomfortable and require local anesthesia and pain medications. A large keloid should not be frozen in one session. After completion of cryotherapy, there can be a short term surge in pain within the first hour. This is triggered by the thawing process of frozen keloid.

After completion of therapy, the treated keloid and surrounding skin will feel sensitive. Pain and discomfort usually subsides the next day. The keloid will swell up and may even form a large blister in the first 24 hours. The keloid should be kept covered for the next few days with cotton gauze and paper tape. The swollen keloid will gradually ooze and leak yellowish and at times bloody fluid. The amount of swelling and oozing depends on the size of treated keloid. This continues for 5-7 days before the keloid tissue dries out and forms a dark or black color scab and starts to shrink. From this point on, and over next few weeks, the keloid will become gradually drier, transform into a black color scab, and gradually shrink in size.

After 2-3 weeks, the edges of the scab will start separating from the underlying keloid. O once the separation process is completed, the scab will fall off completely. This usually occurs about 4-6 weeks after the application of cryotherapy.

You should not force the separation of the scab from the keloid. The site of treated keloid should be kept clean and dry. Using a Q-tip or cotton swabs, the edges of keloid, and where it comes in contact with normal skin should be cleaned. Cleaning can be facilitated with using Hydrogen Peroxide or Iodine Solution. Gently moist the Q-tip in either solutions and clean the edges of keloid.

I advise patients to return to the office one week after Cryotherapy in order to assess the impact and efficacy of the treatment. At this visit, if the keloid still appears alive, a second Cryotherapy is applied to the keloid. It is also very important not to scratch or irritate the treated keloid. Treated area can be washed as usual. Shaving blades should not be used over or near the treated keloid.

Once the scab falls off, the keloid is considerably smaller and is ready for the next treatment. Most keloids need 2-3 treatments to achieve desirable results. After the scab falls off the underlying skin will appear pink and without any pigments. Time to normalization of skin color after Cryotherapy is variable. Skin color will gradually normalize over time. This process may take several weeks to months.

ScarFormula

For more than 5000 years, Panax ginseng has been highly treasured in Chinese traditional medicine, with the belief that this mysterious plant with its man-shaped, bifurcated root promotes longevity, helps to maintain equilibrium in the human body and enhances our body’s ability to resist various illnesses. For these reasons, Panax ginseng has been one of the most sought after natural medicines in the world. The genus Panax derives its name from the Greek words pan (all) and akos (healing).
Keloid Treatment

Panax ginseng has been extensively studied in numerous laboratories. Kimura [1] reported on the efficacy of topical Panax ginseng in promoting wound healing in laboratory animals. Morisaki [2] in 1995 showed that the local administration of ginseng extract markedly improved wound healing in diabetic and aging rats, proving the thousand year-old beliefs by modern scientific methodologies.

In laboratory experiments, Choi [3] reported on ginseng’s ability to promote and improve wound healing. In another study [4] Panax ginseng was shown to stimulate growth of skin cells during wound healing. Further studies by Pazyar [5] revealed that ginseng inhibits NF-kappa B, TGF-β, IL-6, ACE and MMP-2, factors that play a pivotal role in keloid and scar formation.

Based on scientific laboratory evidence, and until we discover better topical treatments for scars and keloids, ScarFormula® is the most logical choice for treatment and prevention of scars. ScarFormula® cream was carefully crafted for use in wound healing, scars and for keloid care. Image below depicts results that one of my patients has achieved using the cream twice per day for over two months. Several of the small keloid lesions have regressed. Each one of these tinny spots has the potential to increase in size and transform into a large keloid.
Panax Ginseng has been widely used in China, Japan and Korea to treat various conditions and to enhance resistance to many illnesses. Ginseng contains many bioactive constituents, including various ginsenosides that are believed to have antioxidant, immune-stimulatory, and anti-aging properties [3].

Further Laboratory studies by Lee [6] have revealed that Panax Ginseng has a significant Radio-protective effect and reduces photo-aging. Ginseng may also be useful in the prevention and treatment of skin photo-aging, wrinkles and as an anti-aging treatment. Other medical uses of ginseng have been reviewed and published in medical literature [7].
Based on our current understanding of wound healing, scars and keloid pathophysiology and laboratory research, topical usage and application of Panax Ginseng Cream, as an adjunct to standard treatments, is a logical choice for patinets with keloid and hyperthrophic scars. ScarFormula® should be applied twice per day over all scars and keloids, and continued for at least eight weeks. Continue beyond eight weeks only if the product shows activity for your keloid and improves the appearance or reduces the symptoms that you have from your keloid, symtoms such as itching, burning, pain, etc. ScarFormula® can also be used after application of cryotherpay to the skin.

Keloid Treatment

References:

1. Ginseng as a potential novel addition to the antikeloid weaponry. Pazyar N, Omidian M, Jamshydian N, Phytother Res. 2012 Oct;26(10):1579-80.

2. Effects of Ginsenoside Rb1 on Skin Changes. Yoshiyuki Kimura, Maho Sumiyoshi, and Masahiro Sakanaka; Journal of Biomedicine and Biotechnology, 2012: 946242.

3. Mechanism of angiogenic effects of saponin from Ginseng Radix rubra in human umbilical vein endothelial cells. N. Morisaki, S. Watanabe, M. Tezuka et al., British Journal of Pharmacology, vol. 115, no. 7, pp. 1188-1193, 1995.

4. Cultivated ginseng suppresses ultraviolet B-induced collagenase activation via mitogen-activated protein kinases and nuclear factor κB/activator protein-1-dependent signaling in human dermal fibroblasts. Hwang YP, Choi JH, Kim HG, Choi JM, Hwang SK, Chung YC, Jeong HG. Department of Toxicology, College of Pharmacy, Chungnam National University, Daejeon, Republic of Korea. Nutrition Research. 2012, June;32(6):428-38.

5. Epidermis proliferative effect of the Panax ginseng ginsenoside Rb2. S. Choi, Archives of Pharmacal Research, vol. 25, no.1, pp. 71-76, 2002.

6. Radioprotective potential of ginseng. Tung-Kwang Lee, Roberta M.Johnke, Ron R.Allison, Kevin F.O’Brien, Larry J.Dobbs,Jr, (East Carolina University) Mutagenesis vol. 20 no. 4 pp. 237-243, 2005

7. Panax Ginseng, a medical review David Kiefer, M.D., Traci Pantuso, B.S., University of Arizona College of Medicine, Tucson, Arizona Am Fam Physician. 2003 Oct 15;68(8):1539-1542.

Radiation Therapy for Keloids

Radiation therapy is a method of treating cancers. Radiation therapy uses high-energy particles or waves, such as x-rays, gamma rays, electron beams, or protons, to destroy or damage cancer cells. Same radiation is used for treatment of keloids often after the keloid is removed surgically.

Radiation therapy remains a rather controversial issue in treatment of keloid with the most important concern being the development of cancer and other serious medical complications following this method of treatment.

Using radiation therapy for treatment of benign skin conditions has long been abandoned due to excess rate of developing cancers in patients. Although effective, radiation therapy usage for treatment of facial acne and fungal infections of scalp was abandoned several decades ago, mostly due to excess number of cancers and leukemia seen in these patients.

Radiation therapy can cause cancer: Women will have a much higher risk of breast cancer if they receive radiation in their chest. Keep in mind that there is major opposition to performing routine mammograms in women, of the fear of mammogram causing breast cancer. The dose of radiation used in mammography is about 0.3 cGy. After 20 annual mammograms, a woman will receive only 6 cGy or radiation. The does used in treating keloids varies form 1,000-1,800 cGy. Despite the knowledge about the carcinogenic risk of radiation, some radiation therapy centers still provide this treatment to young keloid patients. We also know that exposure to radiation in Hiroshima and Chernobyl resulted in excess risk of various cancers and leukemia.

In my opinion, Radiation Therapy should not be used for treatment of keloids. Several decades ago, radiation therapy at even lower doses was used for treatment of acne and fungal infections of the scalp. Although very effective, these practices were banned because of documented increased risk of cancer among the treated patients. Perhaps economy plays a role in utilization of radiation therapy for keloid patients. Cost of delivery of radiation therapy to a keloid is in range of $10,000.
The patient below had surgery followed by radiation therapy to the keloid in her neck area. The treatment not only did not help her, but resulted in recurrence of a worse keloid. Radiation therapy also caused permanent damage to her thyroid gland and made her hypothyroid. She will have to take thyroid supplement medications for the rest of her life.
Patient depicted below also had surgery followed by radiation therapy to the keloid in his neck area. The treatment not only did not help him, but resulted in recurrence of a worse keloid that has now limited his ability to move his neck. Radiation therapy also caused a permanent damage and fibrosis of his neck tissue and serious abscesses under the keloid tissue and cause constant infections and drain pus at all times. Such complications can be totally avoided if radiation is not used in treating keloids. This patient, at age of 23, is also at risk of other long term complications from the radiation.
If you have received radiation therapy to your keloid, I strongly urge you participate in Keloid Radiation Registry. The goals of this registry are to accurately determine the safety and efficacy of radiation therapy in treatment of keloids.
Keloid Treatment

Do NOT do CryoShape

I am constantly asked to comment about CryoShape Procedure. This is a summary of my opinions and findings concerning this procedure. I have personally observed the procedure and do not endorse it. Below, I outline the reasons for my objections :

CryoShape is an invasive method of freezing keloid tissue, using a long, thick needle, much like a metallic knitting needle. This needle must be inserted into and pass through the keloid, or scar tissue, and pushed forward to exit from the opposite side of this tissue. The needle is then connected to a source of liquid nitrogen, allowing free flow of liquid nitrogen through the needle. This cools the needle, resulting in the freezing of the keloid tissue.

There are, however, several serious issues with this method of freezing keloids and scars.

1- Lack of Scientific Evidence : There is absolutely no evidence that freezing a keloid by CryoShape is any better than standard non-invasive Cryotherapy. The makers of this device have never performed any studies to compare the two techniques. That is nothing published in any medical literature that compares the two methods or proves that inserting a needle into a keloid would works better than the non-invasive cryotherapy method.

2- Highly Invasive Method: Puncturing keloids with a thick needle results in creating a deep injury, a longitudinal and wide tunnel, inside the keloid tissue with two open holes, the entry point and the exit site. Additional punctures and injections are also required to numb the tissue to allow for insertion of the CryoShape needle. I find these punctures to be unsafe and unnecessary. There is no need for radically invasive methods such as this when keloids can be frozen with cotton swabs.

3- Risk of Infection : Cryotherapy obviously results in tissue damage, blister formation, oozing, leaking etc,. The damage to the keloid and scar tissue from multiple puncture wounds required to insert the CryoShape needle puts the keloid at a greater risk for developing infection. There have indeed been cases of infection subsequent to CryoShape procedure. The advocates of the procedure never talk about this potentially serious complication.

4- Lack of Control over the Depth of the Freeze: With few exceptions, keloids and scars are never symmetrical. Each keloid, and each scar, has its own unique three dimensional shape. With the CryoShape needle in place, especially for long and wide keloids, a round and symmetrical ice ball forms around the needle, over which the operator has absolutely no control. He cannot force the shape of the ice ball to match the contour of a wide keloid or a scar. The operator of the device has absolutely no control over the depth of the freeze. The best he can do is to insert the CryoShape Needle somehow through the central axis of the keloid. The procedure is continued until the operator can visually see superficial freezing begin to occur; however, he cannot see how much of the normal tissue located under or around the keloid will become damaged by his freezing. Video below shows how invasive and how inprecise this procedure is.
The operator has no control over the extent of freezing damage that he is causing to the normal ear tissue. Pay attention to this video at 1:27 to 1:33 timeline and see how much of normal ear tissue is also frozen. There is no need to freeze normal ear tissue.

5- Injury from CryoShape needle can Trigger Keloid Formation: Keloid is a hereditary disorder. The formation of keloid is triggered by injury to the skin and most patients are prone to forming keloids after even slightest injury to their skin, such a pierceing their earlobes. The CryoShape needle is at least 20 times thicker than the needles used to puncture earlobes. The damage caused by the CryoShape procedure is severe enough to trigger keloid formation.

6- Cost: Obviously, a plastic surgeon who spends an hour performing this procedure in an operating room setting will charge the patient accordingly. This cost, coupled with that of the needle itself, which is several hundred dollars, must be taken into consideration.

7- Lack of Proper Research: CryoShape has never been studied properly to compare its efficacy to standard methods of Cryotherapy. Indeed, there is hardly any literature that discusses the effectiveness and safety of this extremely invasive method. The device has been in use for over a decade now, and there is hardly any peer reviewed medical literature about it. The Cryoshape.com website points to one study that was published in 2003, reporting on only ten patients with 12 scars or keloids. This study reports an average of 51.4 percent of scar volume reduction was achieved after one session of intralesional cryosurgery treatment. In my opinion, the cost, along with the tissue injury and risk of infection are not worth a 51.4 percent scar volume reduction. A more recent publication in 2008 that reported on 11 scars, concluding that there was a significant reduction in concern and deformity scores compared with those before the cryo treatment. The article is not at all clear about what a reduction in concern and deformity scores means and why did the investigator not use Reduction in Keloid Volume as an indicator of efficacy and instead they came up with a convoluted end point for their very small study. The report does not mention the response rate, or what percentage of patients had total disappearance of their scars.

The company marketing the device, before advocating this method of treatment and this procedure, has the duty of conducting proper randomized clinical trials to compare the efficacy and safety of the CryoShape treatment to standard Cryotherapy. I have personally alerted the company about the need for such studies.

The Cryoshape.com website, in its FAQ page, indicates that in over 97% of the cases performed to date, no scar recurrence was observed. Most patients require only a single procedure to significantly reduce the size and shape of keloid or hypertrophic scars. This claim is only made on the website and not published or even referenced in any peer reviewed medical literature. This claim contradicts the other reports that are cited on their website.

8- No Cure for Keloids: Keloids come in all forms, shapes, and sizes. Many keloids are extremely thin, even thinner that the CryoShape needle itself. To date, there is very little known about Keloid Disorder. Its biology, genetics, epidemiology, and pathophysiology, all remain obscure. Much research is needed to make advances in this field.

There is almost no evidence to support the claims made on the CryoShape website and no reason to believe that simply inserting a needle inside a keloid and freezing it from inside will cure this condition. Though the website indicates that this is true in 97% of all cases, they have not substantiated their claims with hard facts. These claims, along with other data, should be supported by peer reviewed medical research, which to this date has never been performed.

9- Lastly, it is CRYOTHERAPY that works not poking a thick needle inside a keloid. I strongly believe that Cryotherapy is a very effective method of treating keloids and scars. Effective cryotherapy can be safely applied to any keloid and any scar with using a cotton swab, without the need for injecting or injuring the keloid tissue by CryoShape procedure.

For all the reasons stated above, I strongly opine against using this invasive method. The medical and dermatology community has not endorsed this procedure either; hence after many years of marketing this procedure, hardly any physician in this country is using the device. There are only few places in United States that advocate or provide this costly procedure.

Images below depict the kind of precision that can be achieved with simple non-invasive standard cryotherapy. I challenge anyone who performs Cryoshape procedure to achieve and disclose similar precision in freezing any keloid. (Michael H. Tirgan MD)

CryoShape Testimonials

In an effort to shed more light on issues related to CryoShape, I encourage those of you have had CryoShape treatment for keloid to share your stories with us.

Here is the first true story shared with me.

My Cryoshape Experience
I read with every interest Dr Tirgan’s opinion on cryoshape, I couldn’t be more drawn to it because I have had cryoshape procedure. I make bold to say that I agree with Dr Tirgan’s take on the subject.

I am a Medic, thus, I made extensive research for the best treatment for my facial keloids. Different options came up, eventually I opted for cryoshape.

It was a harrowing 5-hour procedure, the pain was unbelievable, and the post procedure bleeding was alarming. I was willing to go through it all just to deal the problem (if you’ve had keloids, you would understand)

I was told to expect continuous improvement, even at 4-6months. I had patience, so I waited. Its past 6 months and I honestly regret the whole experience. The keloid is largely unchanged. However, the most frustrating aspect is that the channels the cryprobe created through the keloids have become persistent foci of recurrent infections.

I have resorted to contact cryotherapy, and the results look encouraging. I will keep at it and hopefully…….fingers crossed.

I’m not sure why the cryoshape thing didn’t work for me. Overall, it was expensive (thousands of dollars), invasive, and rather a traumatic experience.

DR.K.