Wound Care Articles

A keloid is a type of bulky scar that develops in the skin as a result of injury, infection or inflammation and spreads beyond the borders of the original field of skin damage. The definition is helpful to differentiate from hypertrophic scars, which do not spread floridly outwards from the original wound site.

The word keloid derives from the Greek word ‘chele’ meaning crab’s claw since some scars (especially those over the chestbone) have extensions resembling claws; the bulk of the keloids is due to excessive amount of collagen laid down during the healing process.

Risk factors for the development of keloid scars

• Young age (peak: 10-30 years)
• Family history/genetics (half of affected individuals have a positive family history)
• Afrocaribbean type skin (15-20 times more prone to keloids, compared to fair complexions)
• Tension across the scar site; this explains the greater propensity for keloids to develop over the chest/shoulder/back areas.
• There is a well-established link between severity of keloids and the following:
  - Puberty
  - Pregnancy
  - Hypertension
  - Thyroid disorders
  - Inflammatory diseases

Typical symptoms and natural history of keloids

• Shiny, rubbery skin outgrowths that can have significant impact on quality of life and lead to low self esteem
• Painful in the centre and itchy where the keloid meets normal skin at the edges
• Can develop anytime after injury/inflammation to the skin – sometimes years down the line following procedures (e.g. body piercing/tattoos, vaccination, surgery) or skin diseases (e.g. acne, chickenpox, burns)
• Unpredictable evolution; they can start or stop growing at any time following the original injurious event

Treatment options

Keloid scars can be treated in a specialist setting with satisfactory outcomes; the management options can be divided into those that aim to:

a) Remove the keloid lesion and replace it with a fine symptom-free scar

• Surgery and postoperative radiotherapy. This is the gold standard treatment for keloids, and there are many studies with long-term follow up to support this. Surgery needs to be performed by a specialised plastic surgeon and in such a way that tension is released from the wound. Radiation carries a very small risk of long-term development of cancer, which is less than 0.07%. This value is three times smaller than the risk of developing a chest malignancy from a diagnostic CT scan of the chest.

b) Decrease symptoms and bulk, but the outline of the scar remains

• Steroid injections. Benefits include a flatter scar with less pain and itch. Reported side effects include skin thinning, white translucent plaques, visible blood vessels, and changes in the color of the skin.
• Steroid tape. This is a very useful addition to injectable steroids especially in thin scars and represents the mainstay of management in the Orient.
• 5 fluorouracil (chemotherapy). A combination of this cancer-fighting drug and steroid has been shown to be more efficacious than steroids alone.
  

What are treatment options for which there is limited evidence at present?

• Silicone. There is no strong evidence that silicone products can significantly reduce the size and symptoms of keloids; nevertheless this product can be considered as prophylaxis to prevent the development of bulky scars.
• Steroid ointments. Clinical studies are not supporting the wide use of ointments alone for keloids and steroid injections/tape should be considered instead in appropriately selected scars.
• Cryosurgery. Freezing keloids with a specialised probe can be a valid option especially if the scar has a narrow base.
• Lasers. This is a form of treatment that is gaining in popularity and offered by a variety of skin clinics. The evidence base is not strong enough at present and the risk of making the keloid worse needs to be considered.
  

I already have a keloid scar, what should I do/avoid?

• Identify the precipitating factors for your keloid scarring (e.g. folliculitis, acne) and if possible treat them to prevent the development of new keloids.
• Avoid preventable injury to the skin, e.g. piercings, tattoos, unnecessary surgery.
• Tell your surgeon that you have a tendency for keloids if an operation is planned; certain steps can be taken to minimise the chances of getting a keloid postoperatively.
  

References

Al Aradi IK, Alawadhi SA, Alkawaja FA. Earlobe keloids: A pilot study of the efficacy of keloidectomy with core fillet flap and adjuvant intralesional corticosteroids. Dermatol Surg 2013;39:1514-9.

Cheng LH. Keloid of the earlobe. Laryngoscope 1972 Apr;82(4):673-81.

Goutos I, Ogawa R. Steroid tape: A promising adjunct to scar management.
Scars, Burns & Healing, Volume 3, 2017; DOI: 10.1177/2059513117690937.

Mustoe TA, Cooter RD, Gold MH, et al. International Advisory Panel on Scar Management. International clinical recommendations on scar management. Plast Reconstr Surg 2002; 297: 433-8.
Ogawa R, Yoshitatsu S, Yoshida K, et al. Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis. Plast Reconstr Surg 2009; 124: 1196-1201.
Ogawa R, Akaishi S, Kuribayashi S, Miyashita T. Keloids and hypertrophic scars can now be cured completely: Recent progress in our understanding of the pathogenesis of keloids and hypertrophic scars and the most promising current therapeutic strategy. J Nippon Med Sch 2016; 83 (2) 46-53.

Ogawa R. Keloid and hypertrophic scars are the result of chronic inflammation in the reticular dermis. Int J Mol Sci 2017 18, 606, doi:10.3390/ijms18030606