Keloids

Keloids are benign fibroproliferative skin disorders characterized by excessive deposition of collagen during wound healing, resulting in scar tissue that extends beyond the original boundaries of the skin injury. Unlike hypertrophic scars, keloids continue to grow beyond the initial wound margins and rarely regress spontaneously.

Keloids may develop following surgery, trauma, burns, acne, ear piercing, vaccination, tattoos, insect bites, or inflammatory skin conditions, and in some individuals may occur with little or no obvious preceding injury. They are more common in people with darker skin pigmentation and usually develop between the ages of 10 and 30 years.

Although keloids are not malignant, they can cause significant cosmetic concerns, pain, itching, restricted movement when located over joints, and psychological distress.

Pathophysiology (Brief)

The exact cause of keloid formation is unknown. The condition results from an abnormal wound-healing response characterized by excessive fibroblast activity and overproduction of extracellular matrix, particularly collagen.

Contributing factors include:

• Genetic susceptibility

• Increased fibroblast proliferation

• Excessive collagen type I and III synthesis

• Prolonged inflammation during wound healing

• Increased transforming growth factor-beta (TGF-β) activity

• Mechanical tension across healing wounds

Risk factors include:

• Darkly pigmented skin

• Family history of keloids

• Previous history of keloid formation

• Ear piercing

• Surgical wounds

• Burns

• Acne

• Chest, shoulder, neck, jawline, and earlobe injuries

Signs & Symptoms

Typical lesions include:

• Firm, raised nodules or plaques

• Skin-colored, pink, red, or hyperpigmented scars

• Scar extending beyond the original wound margins

• Smooth, shiny surface

• Progressive enlargement over time

Common sites include:

• Earlobes

• Chest

• Shoulders

• Upper back

• Neck

• Jawline

Associated symptoms:

• Persistent itching (pruritus)

• Pain or tenderness

• Burning sensation

• Cosmetic disfigurement

• Reduced range of motion when located over joints

Diagnostic Criteria

Diagnosis is primarily clinical and based on:

• Raised scar extending beyond the original wound margins

• Progressive enlargement after wound healing

• Firm, rubbery consistency

• Typical anatomical distribution

• History of preceding skin injury or spontaneous development

Investigations

Diagnosis is usually clinical.

Recommended investigations

Routine laboratory investigations are not required.

Special investigations

• Skin biopsy is rarely required and should be reserved for atypical lesions or when malignancy or another skin disorder is suspected.

Treatment

The goals of treatment are to reduce scar size, relieve symptoms, improve cosmetic appearance, minimize functional impairment, and reduce the risk of recurrence.

Non-pharmacological Treatment

• Counsel patients regarding the chronic nature of keloids and the possibility of recurrence.

• Avoid unnecessary skin trauma, including cosmetic piercing, tattoos, and elective procedures in individuals prone to keloids.

• Minimize wound tension during surgical closure.

• Early treatment of new lesions improves outcomes.

• Silicone gel sheets or silicone gel may be used to reduce scar thickness and symptoms.

• Pressure therapy may be beneficial, particularly for earlobe keloids following piercing.

• Regular follow-up is recommended because recurrence is common.

Pharmacological Treatment

• S: Triamcinolone (intralesional) 2.5–5 mg/ml once monthly for 6–9 months,

• AND D: clobetasol propionate ointment once daily for 6–9 months.

• Other options: cryotherapy followed by intralesional triamcinolone; radiotherapy within 24 hours of excision; laser therapy.

Surgical Treatment

Surgery should generally be combined with intralesional corticosteroid therapy because excision alone is associated with a high recurrence rate.

• Perform complete excision or debulking of the keloid where indicated.

AND

• Triamcinolone (intralesional) 20 mg administered intraoperatively, followed by monthly postoperative injections for 3 months to reduce the risk of recurrence.

Complications

• Persistent pain or itching

• Cosmetic disfigurement

• Functional limitation when lesions occur over joints

• Psychological distress

• Recurrence after treatment

• Secondary infection (uncommon)

Prevention

Although not all keloids can be prevented, the risk may be reduced by:

• Avoiding unnecessary skin trauma in susceptible individuals.

• Using meticulous wound closure techniques to reduce skin tension.

• Early treatment of hypertrophic scars and developing keloids.

• Considering silicone gel or pressure therapy after high-risk procedures.

• Close follow-up after surgical excision to detect early recurrence.

Patient counselling (Important)

• Keloids are benign (non-cancerous) and are not contagious.

• They may continue to enlarge even after the original wound has healed.

• Treatment often improves symptoms and appearance but does not guarantee complete cure.

• Recurrence after treatment, especially surgery alone, is common.

• Multiple treatment sessions may be required to achieve the best results.

• Avoid unnecessary skin trauma or cosmetic procedures if you have a history of keloid formation.

• Seek medical review if the scar becomes rapidly enlarged, painful, ulcerated, or shows signs of infection.