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The Truth About Keloids

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Jeff Weinzweig, MD

Board-certified plastic and reconstructive surgeon who offers advice and information on all aspects of this specialty.

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What exactly are keloids?

Not every ugly scar is a keloid.  Only specific ugly scars are actually keloids.  The term has become much too commonly used and misused.  Alibert coined the term "cheloide" in 1806 from the Greek word meaning "crab claw" to describe the lateral expansion of keloid scarring onto surrounding normal tissue. Hypertrophic scars, in contrast, remain within the confines of the original wound border whereas keloids invade adjacent normal skin.  Hypertrophic scars generally arise after several weeks, are present for many months, and then regress.  Keloids may arise much later after wounding and may enlarge indefinitely. 


Historically, the first mention of keloid treatment is the Smith papyrus from Egypt in 1700 BC.  Keloid scars occur with either superficial or deep injuries, such as following ear or body piercing, surgical incisions, and lacerations, and are correlated with younger age and darker skin.   Although reports of spontaneous keloid development exist, it is generally accepted that all keloids are the result of trauma.  Synthesis and remodeling of the extracellular matrix by fibroblasts is thought to be the major determinant of dermal architecture after repair.  Hypotheses for keloid formation include wound hypoxia, growth factors, fibroblast proliferation, skin tension, anatomic location, genetic disposition, and alterations in extracellular matrix (increased fibronectin production). 

Whereas normal skin contains distinct collagen bundles parallel to the epithelial surface, in keloid scars collagen is present in randomly oriented dense sheets.  There is an increased proliferation of fibroblasts and an abnormally increased production of collagen up to 20 times that of normal skin and three times that of hypertrophic scars.   

An incidence of keloids between 4.5 and 16% has been reported in a predominately black and Hispanic population, and up to 16% in random samplings of black Africans.  Although keloids can occur at any age, they are most likely to occur between ages 10 and 30; the incidence is the same in both sexes. 

Some keloids are tender and some are painful.  Some patients may complain of pruritis (itching), due to an over-abundance of histamine producing mast cells.  If left untreated, keloids may continue to take up more "real estate", making their eventual treatment more difficult.  Cosmetic concern is the main reason patients seek medical intervention which includes the use of pressure earrings or gaments, steroid injection, surgical exicision, and radiation treatment.  Unfortunately, keloid recurrence following treatment is not an uncommon event.   

 

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5 Comments

SG said:

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For smaller keloids, which do you recommend: steriod injection or excision? Do you know which method has the most success?

lukav said:

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SG, In my opinion silicone is missing from Dr Weinzveig's recommendations. A year ago I underwent emergency surgery - the scar I was left with is a keloid, painful & very red/purple raw looking on my very pale skin. I have used several products over the last year to ease the pain of my scar & reduce the raw look, with little or no success - I have been using Strataderm silicone gel for over a month (started Nov. 09) and I can really see a difference in the appearance of my scar. It is softer, flatter & all around looks less nasty. I know my scar will never be completely gone, but it feels & looks a lot better. Based on my research of other options I can tell you that excision is risky as keloids tend to come back. Steroid injections, on the other hand, are quite painful and not very cheap. For smaller keloids I think you should try a silicone treatment.

Dr. Jeff said:

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SG and Lukav,

I appreciate both of your comments. Steroid injection and excision can both work equally well and equally poorly. Keloids tend to be unpredictable in their response to various treatments and can recur even more pronounced following excision than they were prior to surgery. For smaller keloids, it would certainly be reasonable to begin with a steroid injection and assess any improvement over the subsequent 3 months before considering a repeat injection or other treatment modality.

Thank you for suggesting the use of silicone sheeting. I have used this quite a bit with hypertrophic scars and burn scars with much success. However, their use for true keloids is limited. A "smaller keloid" may actually be a hypertrophic or thickened scar and I will agree that for such a scar benefit may be derived from the use of silicone sheeting.

Please keep in mind that without the luxury of directly evaluating any scar (keloid or hypertrophic) it is impossible for me to truly assess the nature of the scar and recommend definitive therapy. Please feel free to forward any additional questions about keloids or any other aspect of plastic surgery.

Dr. Jeff

Seeking Chicago's Best Doctors said:

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There is a doctor at University of Chicago named Dr. Ginard Henry, who specializes in treating Keloids.

You can find him at www.TopTierMD.com, which is a website that specializes in finding the best doctors in Chicago. They do this by surveying all the doctors in Chicago to see who amongst their peers is the best.

Here is the profile on TopTier

http://toptiermd.com/find-a-doc/Plastic-and-Reconstructive-Surgery/364375254-doctor-Ginard-Henry


lukav said:

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Thank you for the explanation, I understand the limitations of not being able to see the actual scar.

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