Keloid

Keloid
Classification and external resources
ICD-10	L91.0
ICD-9	701.4
MedlinePlus	000849
eMedicine	article/1057599 article/1298013
MeSH	D007627

Post-operative keloid

A keloid ( /ˈkilɔɪd/; also keloidal scar) is a type of scar, which depending on its maturity, is composed mainly of either type III (early) or type I (late) collagen. It is a result of an overgrowth of granulation tissue (collagen type 3) at the site of a healed skin injury which is then slowly replaced by collagen type 1. Keloids are firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to flesh-coloured or red to dark brown in colour. A keloid scar is benign, non-contagious, but sometimes accompanied by severe itchiness and pain, and changes in texture. In severe cases, it can affect movement of skin.

Keloids should not be confused with hypertrophic scars, which are raised scars that do not grow beyond the boundaries of the original wound.

Occurrence

Keloids expand in claw-like growths over normal skin. They have the capability to hurt with a needle-like pain or to itch without warning, although the degree of sensation varies from patient to patient.

If the keloid becomes infected, it may ulcerate. Removing the scar is one treatment option, however may result in more severe consequences i.e. the probability that the resulting surgery scar will also become a keloid is high, usually greater than 50%. Laser treatment has also been used with varying degrees of success.

Scars of whipped slave. "This specific whipping was made to appear more brutal by the subject's rare Keloid Cyst skin condition, causing excessive growth of scar tissue.""—Kathleen Collins

Keloids form within scar tissue. Collagen, used in wound repair, tends to overgrow in this area, sometimes producing a lump many times larger than that of the original scar. Although they usually occur at the site of an injury, keloids can also arise spontaneously. They can occur at the site of a piercing and even from something as simple as a pimple or scratch. They can occur as a result of severe acne or chickenpox scarring, infection at a wound site, repeated trauma to an area, excessive skin tension during wound closure or a foreign body in a wound. Keloids can sometimes be sensitive to chlorine. Keloid scars can grow, if they appear at a younger age, because the body is still growing.

Histologically, keloids are fibrotic tumors characterized by a collection of atypical fibroblasts with excessive deposition of extracellular matrix components, especially collagen, fibronectin, elastin, and proteoglycans. Generally, keloids contain relatively acellular centers and thick, abundant collagen bundles that form nodules in the deep dermal portion of the lesion. Keloids present a therapeutic challenge that must be addressed, as these lesions can cause significant pain, pruritus (itching), and physical disfigurement. They may not improve in appearance over time and can limit mobility if located over a joint.

Keloids affect both sexes equally, although the incidence in young female patients has been reported to be higher than in young males, probably reflecting the greater frequency of earlobe piercing among women. There is a fifteen times higher frequency of occurrence in highly pigmented people. Persons of African descent are at increased risk of keloid occurrences.

History in medicine

Keloids were described by Egyptian surgeons around 1700 BC. Baron Jean-Louis Alibert (1768–1837) identified the keloid as an entity in 1806. He called them cancroïde, later changing the name to chéloïde to avoid confusion with cancer. The word is derived from the Greek χηλή, chele, meaning "hoof", here in the sense of "crab pincers", and the suffix -oid, meaning "like". For many years, Alibert's clinic at L'Hôpital Saint-Louis was the world’s center for dermatology.

Intentional keloids

The Olmec of Mexico in pre-Columbian times used keloid scarification as a means of decoration. In the modern era, women of Egypt are intentionally scarified with facial keloids as a means of decoration. The Nuer and Nuba use lip plugs, keloid tattoos along the forehead, keloid tattoos along the chin and above the lip, and cornrows. As a part of a ritual, the people of Papua New Guinea cut their skin and insert clay or ash into the wounds so as to develop permanent bumps (known as keloids or weals). This painful ritual honors members of their tribe who are celebrated for their courage and endurance.

Locations of keloids

Keloids can develop in any place that an abrasion has occurred. They can be the result of pimples, insect bites, scratching, burns, or other skin trauma. Keloid scars can develop after surgery. They are more common in some sites such as central chest, the back and shoulders and the ear lobes. They can also occur on body piercings. Most common spots are earlobes, arms, and over the collar bone.

Incidence

People of all ages can develop a keloid. Children under 11 are less likely to develop keloids, even when they get their ears pierced. Keloids may also develop from pseudofolliculitis barbae, continued shaving when one has razor bumps will cause irritation to the bumps (a possible location for future cancerous growth), infection and over time keloids will form. It would thus be wise for a person with razor bumps to stop shaving for a while and have the skin repair itself first before undertaking any form of hair removal. It is also speculated that the tendency to form keloids is hereditary and may be passed down from generation to generation.^{[citation needed]}Keloids can tend to appear to grow over the years without even piercing the skin, almost acting out like a slow fungus growth, and the reason for this is unknown. If a Keloid shall grow too big, removal is the only solution, resulting in a scar or in worse cases amputation.

Treatments

The best treatment is prevention in patients with a known predisposition. This includes preventing unnecessary trauma or surgery (including ear piercing, elective mole removal), whenever possible. Any skin problems in predisposed individuals (e.g., acne, infections) should be treated as early as possible to minimize areas of inflammation.

• lntra-lesional corticosteroids — Intra-lesional corticosteroids are first-line therapy for most keloids. A systematic review found that up to 70 percent of patients respond to intra-lesional corticosteroid injection with flattening of keloids, although the recurrence rate is high in some studies (up to 50 percent at five years)
• Excision — Scalpel excision may be indicated if injection therapy alone is unsuccessful or unlikely to result in significant improvement. Excision should be combined with preoperative, intraoperative, or postoperative triamcinolone or interferon injections. Recurrence rates from 45 to 100 percent have been reported in patients treated with excision alone; this falls to below 50 percent in patients treated with combination therapy.
• Silicone gel sheeting — Silicone gel sheeting has been used for the treatment of symptoms (e.g., pain and itching) in patients with established keloids as well as for the management of evolving keloids and the prevention of keloids at the sites of new injuries. A systematic review of controlled trials found some evidence that silicone gel sheeting may reduce the incidence of abnormal scarring, but concluded that any estimate of effect was uncertain because the underlying trials were of poor quality and highly susceptible to bias. Treatment with silicone gel sheeting appeared in some studies to improve elasticity of established abnormal scars, but the evidence was again of poor quality and susceptible to bias.
• Cryosurgery — Cryosurgery is most useful in combination with other treatments for keloids. The major side effect is permanent hypopigmentation, limiting its use in people with darker skin.
• Radiation therapy — Most studies, but not all, have found radiation therapy to be highly effective in reducing keloid recurrence, with improvement rates of 70 to 90 percent when administered after surgical excision. A small randomized trial of treatments after surgery found recurrences in two of sixteen earlobe keloids (13 percent) treated with radiation therapy and in four of twelve earlobe keloids (33 percent) treated with steroid injections. However, concern regarding the potential long-term risks (e.g., malignancy) associated with using radiation for an essentially benign disorder limits its utility in most patients. Only a few cases of malignancy that may have been associated with radiation therapy for keloids have been reported. Although causation cannot be confirmed in these cases, caution should still be used when prescribing radiation therapy for keloids, particularly when treating younger patients. Radiation therapy may occasionally be appropriate as treatment for keloids that are resistant to other therapies. In addition, radiation therapy may be indicated for lesions that are not amenable to resection.
• Interferon alpha — Interferon alpha injections may reduce recurrence rates postoperatively. However, all currently available studies of interferon therapy suffer from methodologic problems, making an evidence-based recommendation regarding its use difficult.
• Pulsed dye laser — Pulsed dye laser treatment can be beneficial for keloids, and appears to induce keloid regression through suppression of keloid fibroblast proliferation, and induction of apoptosis and enzyme activity. Combination treatment with pulsed dye laser plus intralesional therapy with corticosteroids and/or fluorouracil may be superior to either approach alone.

Case presentation

This is a young male with bilateral keloid formation on the plantar surfaces of both feet. He has never been treated for this condition. There are other much smaller keloids located at small inlets on the glabrous (hairless) skin.

Plantar keloid formation

Plantar keloid formation

Plantar keloid formation

See also

• List of cutaneous conditions

External links

• Keloids and hypertrophic scars, german version (Rossmann N, 2004)
• MedlinePlus Encyclopedia Keloids
• Support Group for Keloid Sufferers
• Ogawa R, Mitsuhashi K, Hyakusoku H, Miyashita T (February 2003). "Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: retrospective study of 147 cases followed for more than 18 months". Plast. Reconstr. Surg. 111 (2): 547–53; discussion 554–5. doi:10.1097/01.PRS.0000040466.55214.35. PMID 12560675. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0032-1052&volume=111&issue=2&spage=547. 
• International Scar Meeting