A keloid scar is one in which there is overgrowth of dense fibrous tissue. This usually develops after the injury has healed. It extends beyond the borders of the original wound. It does not normally regress spontaneously and it will usually recur after excision. This contrasts with hypertrophic scars, which stay within the borders of the original wound.

The term ‘chéloïde‘ was coined by Alibert in 1806, from the Greek ‘chele‘, meaning crab’s claw – to describe the lateral growth of tissue into unaffected skin.

Epidemiology

• Keloid scars are more common in people with darker skins, especially African-American races.
• The incidence in African populations is 6-16%.
• There is equal sex distribution.
• The peak age is 20-30 years and keloids are less common at the extremes of age.
• Half of patients with keloid have a positive family history.

Aetiology

The cause is unknown, although there are various theories, including:

• Dysfunction of the extracellular matrix which controls growth factor activity.
• Abnormalities in collagen turnover.
• An inherited abnormal response to dermal injury.
• An immune reaction to sebum.
• Genetic susceptibility – a genome-wide association study (GWAS) suggested that the common genetic factor predisposing to the development of keloid was shared by the Chinese Han and Japanese populations.
• Hormonal factors – keloid is associated with pregnancy and puberty.

Presentation

History

• Symptoms: usually cosmetic, although the scar may be tender, painful, itch or produce a burning sensation.
• There is usually a history of trauma that may be accidental, surgical or cosmetic.
• Sites for keloid formation: the most common areas are the sternum, shoulder, earlobe and cheek.
• Burn scars or infected lesions, including acne, are more likely to form keloids.

Clinical features

• The scar has grown beyond the original line of trauma and may be raised and irregular.
• The texture is rubbery.
• It is red in the early stages but becomes brown or pale with age.
• There are no hair follicles or sweat glands within the scar.
• Keloids over a joint can contract and restrict movement.
• Clinical course – the natural history is variable:
  • Most lesions grow for weeks-months but growth can continue for years.
  • Growth is usually slow but some keloids can enlarge rapidly over months.
  • When they stop growing, they remain stable or regress slightly.

Assessment

• The diagnosis is made clinically; investigations are not required.
• Assess the patient’s concerns and the impact of the scar(s) on their life.
• Check if the scar reduces mobility – eg, near a joint.

Differential diagnosis

Hypertrophic scars are also red and prominent but do not extend beyond the wound border. Hypertrophic scars usually appear within a month of the injury, grow for several months and then regress, whereas keloid scars may appear later and continue growing for longer.

Management

Keloid scars are difficult to treat. There are various options. Reviews suggest that combinations of treatments are probably the most effective.

Local steroids

Intralesional steroid injections, with triamcinolone, are a mainstay of treatment and prevention – reviews suggest that it improves the majority of scars.

• Injections are given every 2-6 weeks until improvement.
• Side-effects: pigment changes, telangiectasias and subcutaneous atrophy (which may resolve).

Steroid-impregnated tape applied for 12 hours/day may flatten keloids.

Pressure or occlusive dressings

These are used both for treatment and prevention, with minimal adverse effects, provided they are practical and acceptable to the patient.

• Silicone gel – this is applied as topical gel or a gel-impregnated sheet.
• Compression earrings – are used after excision of earlobe keloids and give good rates of recurrence-free healing; they should be worn 24 hours/day.
• Other pressure dressings may be used.

Surgery

Surgical excision on its own has a very high recurrence rate and the recurring scar may even be larger than the original. Results can be improved by:

• Meticulous surgical technique.
• Additional treatments such as intralesional steroids, occlusive or pressure dressings or radiotherapy.

Other possible treatments

Laser treatment

• The evidence base supporting the use of lasers in keloid scars is not as large as that supporting their use in hypertrophic scars. Further research is required to determine the mechanism of action for different laser systems and to examine such outcomes as scar erythema, scar texture, degrees of symptom relief, recurrence rates and adverse effects.
• One study reported the successful use of carbon dioxide laser ablation followed by intralesional steroids.
• Pulsed dye lasers and Nd:YAG lasers are reported to give encouraging results, with few adverse effects. However, pulsed dye lasers are less effective on dark skin. Combination treatment of CO₂ fractional laser, pulsed dye laser and triamcinolone acetonide injection has been successfully used for refractory keloid scars on the upper back.
• Laser treatment may reduce the redness of keloids without shrinking them.
• A combination of intralesional steroids and intense pulsed light has been found to improve clinical outcome compared with intralesional steroids alone.

Prevention

For people at high risk of or with a history of keloids:

• Avoid body piercing, tattoos and unnecessary incisions such as cosmetic surgery – particularly to skin sites more prone to keloid formation (see under ‘Presentation’, above).
• Treat acne thoroughly to reduce lesions and potential for scarring.
• If surgery is required, it may be combined with dressings, intralesional steroids or other treatments (see under ‘Management’, above) to reduce the likelihood or size of keloid scarring. Care with surgical technique is important.

KELOID