Keloids

When a wound heals, it leaves a scar. A keloid (also called a keloid scar) is the name given to a scar that overgrows and becomes more extensive than the original wound. It is not uncommon for a scar to become slightly thick and raised. This condition is called a hypertrophic scar.

Unlike hypertrophic scars, keloids:

• It can develop after minor skin damage, such as an acne spot, or sometimes without any obvious trauma to the skin (spontaneous keloids).
• Spread beyond the original area of skin damage.
• May be permanent.

This condition is not fully understood, but keloids happen when there is an overproduction of collagen (its structural protein). Most people’s skin scars naturally, and only a minority of people develop keloids. Keloids are not contagious.

Some risk factors increase the likelihood of a person developing keloids. Keloid scars; 

• Can affect anyone, but they are more common in people with dark skin (especially those of African, Hispanic, or Chinese descent) 
• Are more common after skin injury on the upper chest, breastbone (sternum), shoulders, chin, neck, lower legs, and earlobes (especially after ear piercing)
• Are most likely to form following burns, acne scars, and wounds that become infected or are under tension while healing 
• May develop from surgical scars
• Are more likely to affect people who have previously had a keloid if their skin is damaged again 
• Most commonly arise between puberty and 30 years of age
• May appear or enlarge during pregnancy Are keloids hereditary? Not usually, but the tendency to develop keloids can run in families. Studies have shown that 5-10% of Europeans with keloids have a positive family history (i.e., at least one other member of their family has keloids).

While keloids are growing, they may feel itchy, prickly, or sore. Once they have stopped growing, there is usually no discomfort. If they are located over or near a joint, they can restrict movement.

Keloids are enlarged, raised scars, and can be pink, red, skin-colored, or darker than surrounding skin. They usually feel firm and smooth. They are shiny and hairless. A keloid can appear within 3-4 weeks of a skin wound but can take a year or longer to appear. 

It may continue to grow for months or years, enlarging beyond the edges of the actual skin damage. Multiple keloids may develop, especially after acne or chickenpox, although most people only have one or two

The doctor will usually make the diagnosis of a keloid just by looking at the skin, so no tests are needed. If the diagnosis is uncertain, a skin biopsy (a procedure in which a sample of skin tissue from one of the patches is removed under local anesthetic, processed, and examined under a microscope) can be taken under local anesthetic. 

Surgically removing/ excising or “cutting out” a keloid is rarely a success as this causes a more massive wound and the keloids are likely to regrow in it. If excised, the risk of regrowth may be reduced by compression dressings or steroid injections following the procedure (see below). How can a keloid be treated? Unfortunately, there is no cure for keloids.

Treatment can sometimes help to flatten them and reduce irritation. There is currently no evidence that any single form of treatment is better than another, and keloids often regrow in the same place.

Treatment options include: 

• Injection of a steroid is given into the keloids, i.e., intralesional injection. This is the most common treatment. Injections can be repeated, e.g., monthly for 4-6 months. Steroids can make the skin thin, fragile, and pale. Up to 50% of keloids grow back. 
• Applying a strong steroid cream or steroid-containing tape requires a prescription.
• Silicone dressings or gel is safe and can be bought from a pharmacist without a prescription. If used for several months, they can be reducing the thickness and make the keloid paler.
• Compression with bandages or devices (such as clips or splints) may sometimes help, particularly on the earlobe and for lesions on the torso. 
• Radiotherapy can be given after surgical removal of keloid scars. However, it carries a small risk of causing skin cancer due to exposure to radiation, so it is rarely used. 
• Cryotherapy can be tried alone or in combination with other treatment methods. It can cause loss of skin pigment • Laser therapy can help, especially if combined with injected steroids. 
• Other experimental treatments include injections of the anti-cancer drugs 5-fluorouracil (5-FU) or bleomycin. These are not routinely available.

People with risk factors (outlined above) for getting keloids are advised to avoid skin trauma such as tattooing, body piercing, and unnecessary surgical procedures / cosmetic skin surgery, particularly on high-risk areas such as the chest or earlobes. In acne, prompt and effective medical therapy is vital to limit the risk of scarring.