KELOIDS
We commonly come across individuals with keloids in our practice. They range from individuals with few keloids mostly concerned about their appearance to those with large ones associated with pain and periodic discharge. It is usually possible to offer improvements in the appearance and functional symptoms in most patients.
What are keloids?
Scars follow injuries. The tissue that remains after an injury has healed is known as a scar. Keloids are a type of problem scars. In some cases, these scars tend to become large and extend beyond the initial site of injury. They become raised beyond the level of the adjacent healthy skin. They are different in color and texture. They can be either red, in early cases or become dark with time. They tend to be more smooth and glistening when compared to healthy skin.
One of the important characteristics of a keloid is its tendency to keep spreading and involve the adjacent uninjured skin. This local aggressive behavior is a hallmark of keloids. However, unlike cancer, it does not spread to distant parts of the body.
How are they different from hypertrophic scars?
Hypertrophic scars are also a particular type of prominent scar. These too can follow injury. Hypertrophic scars tend to become larger with time. But they do not spread to adjacent uninjured skin. This property differentiates it from a keloid.
However, this demarcation of a keloid from a hypertrophic scar is sometimes arbitrary. The clinical and microscopy of such scars tend to have overlapping features. It is generally agreed upon that hypertrophic scars tend to remain localized to the site of the initial wound whereas a keloid extends beyond the site of the original wound.
What are the problems associated with keloids?
Keloids result in both problems related to appearance and function. The keloid looks and behaves differently from the tissue it replaces. It has different biomechanical properties. The keloid tends to be less elastic when compared to healthy skin.
The following problems are attributed to keloids.
What are the risk factors for keloids?
There is a genetic predisposition to keloids The tendency to get keloids can run in families. People of African descent have the highest tendency to get keloids. Asians tend to get it at a lower rate. The least predisposition is seen among Caucasians. Keloids are prevalent among our population.
Some areas tend to give rise to keloids more than others. These include regions with constant stretching and movements. Examples include the anterior chest, shoulder, and earlobes. Some other areas tend not to develop keloids. Examples include the lower part of the nose and shins.
Pregnancy is associated with an increased risk of keloids.
What are the treatment options for keloids?
Even though it is not possible to eliminate the tendency to get keloids, it is usually possible to improve the appearance and symptoms associated with keloids. The treatment can be seen under conservative and surgical procedures. Conservative treatment refers to therapies that do not involve surgery.
Conservative treatment. These include the following,
Surgery. Surgical treatments for keloids are seldom carried out alone. They are usually combined with adjunctive treatments like intralesional steroids, pressure garments, etc. Surgery alone can lead to high incidence of recurrence of the keloids.
Can keloids be prevented?
Although there is no way to completely avoid the development of keloids, their incidence can be reduced among individuals with a tendency to get these scars. One would be to avoid getting any avoidable injuries like piercings and tattoos.
The second would be to start early treatments like silicone sheets and pressure garments over a young scar. The use of intralesional injections early on when the keloids start forming helps in their management.
What are keloids?
Scars follow injuries. The tissue that remains after an injury has healed is known as a scar. Keloids are a type of problem scars. In some cases, these scars tend to become large and extend beyond the initial site of injury. They become raised beyond the level of the adjacent healthy skin. They are different in color and texture. They can be either red, in early cases or become dark with time. They tend to be more smooth and glistening when compared to healthy skin.
One of the important characteristics of a keloid is its tendency to keep spreading and involve the adjacent uninjured skin. This local aggressive behavior is a hallmark of keloids. However, unlike cancer, it does not spread to distant parts of the body.
How are they different from hypertrophic scars?
Hypertrophic scars are also a particular type of prominent scar. These too can follow injury. Hypertrophic scars tend to become larger with time. But they do not spread to adjacent uninjured skin. This property differentiates it from a keloid.
However, this demarcation of a keloid from a hypertrophic scar is sometimes arbitrary. The clinical and microscopy of such scars tend to have overlapping features. It is generally agreed upon that hypertrophic scars tend to remain localized to the site of the initial wound whereas a keloid extends beyond the site of the original wound.
What are the problems associated with keloids?
Keloids result in both problems related to appearance and function. The keloid looks and behaves differently from the tissue it replaces. It has different biomechanical properties. The keloid tends to be less elastic when compared to healthy skin.
The following problems are attributed to keloids.
- Appearance.
- Keloids can be deforming due to their hyperpigmentation and bulky appearance. They are easily made out when they occur in exposed body parts like the face.
- Some of the keloids can have periodic malodorous discharge. This may lead to embarrassment for those affected.
- Function.
- Restriction of movements can occur when keloids are near a joint or a moving part of the body. This results in loss of function.
- Pain can be a prominent symptom in some individuals with keloids. This can lead to loss of sleep, loss of emotional well-being, and depression, and may prevent a person from pursuing gainful employment. Pain can be more severe when there is an underlying cyst or collection.
- Intense itching is a common symptom in keloids. It can result in loss of sleep in those affected by this condition.
What are the risk factors for keloids?
There is a genetic predisposition to keloids The tendency to get keloids can run in families. People of African descent have the highest tendency to get keloids. Asians tend to get it at a lower rate. The least predisposition is seen among Caucasians. Keloids are prevalent among our population.
Some areas tend to give rise to keloids more than others. These include regions with constant stretching and movements. Examples include the anterior chest, shoulder, and earlobes. Some other areas tend not to develop keloids. Examples include the lower part of the nose and shins.
Pregnancy is associated with an increased risk of keloids.
What are the treatment options for keloids?
Even though it is not possible to eliminate the tendency to get keloids, it is usually possible to improve the appearance and symptoms associated with keloids. The treatment can be seen under conservative and surgical procedures. Conservative treatment refers to therapies that do not involve surgery.
Conservative treatment. These include the following,
- Intralesional injections. Intralesional means injecting medicines into the substance of a keloid. Various medications have been used for this purpose. These include steroids, and other immunomodulators like 5 Fluorouracil, and Bleomycin. Other agents that have been described include Botox and Verapamil. These injections have to be repeated at periodic intervals till a desired result is obtained. The desired result may be an improvement in the size, color, and associated symptoms like pain, and itching. Most patients respond to these agents. However, some do not. The prolonged nature of such treatments leads to a reduction in patient compliance.
- Use of topical silicone sheet. The topical application of silicone gel sheets over the scar helps improve the scar. It results in softening and reduction in the size of the scar. The sheet needs to be applied continuously over many months. Topical silicone sheet is also used for the treatment of hypertrophic scars.
- Pressure garments. These help in the maturation of the scar. They have to be continuously used for long periods. They can be combined with intralesional injections and silicone sheets. The garments would have to be changed once they no longer provide the desired compression.
- Laser. Pulsed dye laser is effective in the management of some keloids. However, they are used in combination with other modalities.
Surgery. Surgical treatments for keloids are seldom carried out alone. They are usually combined with adjunctive treatments like intralesional steroids, pressure garments, etc. Surgery alone can lead to high incidence of recurrence of the keloids.
- Partial excision, debulking. These involve a reduction in the size of the scars. Some of the matured scar is left behind to reduce the chance of recurrence.
- Flaps. The use of local flaps to reduce and redistribute the tension leads to lesser recurrence. The choice of surgical treatment depends on the clinical findings.
- Skin grafts. The use of skin grafts may result in a reduction of symptoms in some cases. However, there is a risk of development of keloids along the margins of the grafted area.
- Surgery with perioperative external radiotherapy. In this treatment, an individual receives external radiotherapy in small fractions on the same day. The radiotherapy may be repeated over two or three more days. This is the most effective among all modalities in reducing the recurrence of the keloids.
Can keloids be prevented?
Although there is no way to completely avoid the development of keloids, their incidence can be reduced among individuals with a tendency to get these scars. One would be to avoid getting any avoidable injuries like piercings and tattoos.
The second would be to start early treatments like silicone sheets and pressure garments over a young scar. The use of intralesional injections early on when the keloids start forming helps in their management.
Sternal keloids
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Topical silicone sheet application
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Intralesional injection of steroid
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Periauricular keloid
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Periauricular keloid treated with serial excision and external radiotherapy
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Keloid of the earlobe
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Keloid treated with surgery and external radiotherapy
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