January 2019

Consultant Plastic Surgeon, Ioannis Goutos, explains what keloid scars are and how to deal with them.

The term keloid derives from the Greek word ‘chele’ meaning crab’s claw since a proportion of keloid scars have extensions creeping into the surrounding skin.

A keloid is a type of bulky scar that develops in the skin as a result of injury, infection or inflammation and spreads beyond the borders of the original field of skin damage. It is essentially an area of excessive collagen deposition.

What are the risk factors for the development of keloid scars

  • Family history/genetics
  • Young age
  • Dark type skin
  • Tension across the scar; this explains the greater propensity for keloid formation over the chest, shoulder and upper back areas.
  • Hormonal upsurges and systemic diseases including pregnancy, thyroid problems, hypertension.

Typical features of keloids

  • Shiny, rubbery skin lumps
  • Painful in the center and itchy where the keloid meets normal skin
  • Can develop anytime (sometimes years) after injury/inflammation to the skin
  • Unpredictable evolution; they can start or stop growing at any time following the original injurious event

Treatment options

Keloid scars should be treated in a specialist setting in order to reach satisfactory outcomes; the management options can be divided into those that aim to:

  a) Remove the keloid lesion and replace it with a flat symptom-free scar

  • Surgery and postoperative radiotherapy. This is the gold standard treatment for keloids, and there are many studies with long-term follow up to support this. Surgery needs to be performed by a specialised plastic surgeon and in such a way that tension is minimized during wound closure.  Radiation carries a very small risk of long-term development of cancer, which is less than 0.07%.  This value is three times smaller than the risk of developing chest malignancy from a diagnostic CT scan of the chest and equivalent to an extra six month background cosmic radiation over one’s lifetime.  This small risk needs to be weighed against the potential of surgery and radiotherapy offering a long term solution to keloid growth.

    b) Decrease unpleasant symptoms and bulk, maintaining the outline of the scar
  • Steroid injections. This is the most common modality for treatment; nevertheless results are not always permanent.  Reported side effects include skin thinning, white translucent plaques, visible blood vessels, and changes to the color of the skin.
  • Steroid tape. This is a very useful addition to injectable steroids especially in small to medium sized scars and works best if a product of adequate steroid strength is used.
  • 5 fluorouracil (chemotherapy). A combination of this cancer-fighting drug and steroid has been shown to be more efficacious than steroids alone.

What are treatment options for which there is limited evidence at present?

  • Silicone. There is no strong evidence that silicone products can significantly reduce the size and symptoms of keloids.
  • Pressure garments. Any beneficial effect tends to be short lived with most keloids growing back in size after the garments are discontinued.
  • Steroid ointments. Clinical studies are not supporting the wide use of ointments alone for keloids.
  • Cryosurgery. Freezing keloids with a metallic probe can be a valid option especially if the scar has a narrow base.
  • Lasers. This is a form of treatment that is gaining in popularity and offered by a variety of skin clinics.  The evidence base is not strong enough at present and the risk of making the keloid worse needs to be considered especially in patients with strong genetic predisposition.

Are there any new treatments for keloid scars?

  • Botulinum toxin, which is popular as a wrinkle reducing injectable, has been shown to be more effective in reducing pain and itch in troublesome scars and can also reduce keloidal bulk.

I already have a keloid scar, what should I do/avoid?

  • Identify the precipitating factors for your keloid scarring (e.g. folliculitis, acne) and if possible treat them to prevent the development of new keloids.
  • Avoid preventable injury to the skin, e.g. piercings, tattoos, unnecessary surgery.
  • Tell your surgeon that you have a tendency for keloids if an operation is planned; certain steps can be taken to minimise the chances of getting a keloid postoperatively.

Ioannis Goutos, Consultant Plastic Surgeon
Specialist Interest in Scar Management

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References

Al Aradi IK, Alawadhi SA, Alkawaja FA.  Earlobe keloids: A pilot study of the efficacy of keloidectomy with core fillet flap and adjuvant intralesional corticosteroids.  Dermatol Surg 2013;39:1514-9.

Cheng LH.  Keloid of the earlobe.  Laryngoscope 1972 Apr;82(4):673-81.

Goutos I, Ogawa R. Steroid tape: A promising adjunct to scar management. Scars, Burns & Healing, Volume 3, 2017; DOI: 10.1177/2059513117690937. 

Mustoe TA, Cooter RD, Gold MH, et al.  International Advisory Panel on Scar Management.  International clinical recommendations on scar management.  Plast Reconstr Surg 2002; 297: 433-8.

Ogawa R, Yoshitatsu S, Yoshida K, et al.  Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis.  Plast Reconstr Surg 2009; 124: 1196-1201.

Ogawa R, Akaishi S, Kuribayashi S, Miyashita T.  Keloids and hypertrophic scars can now be cured completely: Recent progress in our understanding of the pathogenesis of keloids and hypertrophic scars and the most promising current therapeutic strategy.  J Nippon Med Sch 2016; 83 (2) 46-53.

Ogawa R.  Keloid and hypertrophic scars are the result of chronic inflammation in the reticular dermis.  Int J Mol Sci 2017 18, 606, doi:10.3390/ijms18030606

Sohrabi C, Goutos I.  The use of botulinum toxin in keloid management: a literature review.  Submitted for publication and currently under peer review.