> ## Content Index > Fetch the complete content index at: https://www.theplasticsfella.com/llms.txt > Use this file to discover other available public pages before exploring further. # Keloids: Causes, Clinical Features, & Treatment - URL: https://www.theplasticsfella.com/keloid-scars/ - Published: 2024-12-16T19:18:08.000Z - Updated: 2024-12-16T20:39:14.000Z - Description: Keloids are fibrotic scars extending beyond the original wound, driven by genetic predisposition, inflammation, and abnormal fibroblast activity. Treatment involves non-surgical options like lasers and silicone sheeting, pharmaceuticals like corticosteroids, or surgery with adjuvant therapy. - Author: PlasticsFella - Tags: Skin and Soft Tissue, Core Principles #### Summary Card [****Definition**](https://www.theplasticsfella.com/keloid-scars/#definition-of-keloids) Keloid is a dermo-fibroproliferative disorder thought to result from abnormal proliferation of fibroblasts. [****Pathophysiology**](https://www.theplasticsfella.com/keloid-scars/#pathophysiology-of-keloids) Development involves genetic predisposition, inflammation, mechanical stress, and chronic inflammation of the reticular dermis, causing dysregulated fibroblast activity and excess ECM production. [****Clinical Features**](https://www.theplasticsfella.com/keloid-scars/#clinical-features-of-keloids) Keloids extend beyond the original wound boundary and may present with pain, itching, or burning. [****Treatment**](https://www.theplasticsfella.com/keloid-scars/#treatment-of-keloids) Keloid treatment includes non-pharmaceutical options like lasers and surgery and pharmaceutical options like corticosteroids and 5-FU. ****Primary Contributor:** Dr Waruguru Wanjau, Educational Fellow. --- ## Definition of Keloids ****Key Point** Keloid is a dermo-fibroproliferative disorder thought to result from abnormal proliferation of fibroblasts. Keloid scars are an **abnormal response** to dermal injury, characterized by persistent **fibroblast** hyperactivity and excessive **extracellular matrix** (ECM) deposition. Unlike typical scars, keloids **extend beyond** the boundaries of the original wound and fail to regress over time ([Wanjala](https://pubmed.ncbi.nlm.nih.gov/34642061/?ref=theplasticsfella.com), 2022). At a cellular level, keloid scars have the following features ([Lee](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com), 2023): - **Collagen Composition:** Keloids are marked by excessive Type I and III collagen, with an altered matrix composition compared to normal scar tissue. - **Persistent Inflammation:** Chronic activation of inflammatory pathways sustains fibroblast proliferation and ECM accumulation. - **Prolonged Remodeling Phase:** Unlike normal wound healing, where remodeling resolves fibrosis, keloids remain in an active state of tissue remodeling and expansion. Large keloid scars on the back are illustrated below. ![Large keloids on the back](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/11/Main-Article-Images---2024-11-26T160614.776.png) Large keloids on the back ### 😎 ****Fun Fact:** The ****proliferative phase** persists unchecked in keloid scar formation. ([Lee](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com), 2023). --- ## Pathophysiologyof Keloids ****Key Point** Keloid formation results from a combination of genetic predisposition, environmental triggers, and chronic inflammation that disrupts normal wound healing. The primary pathology involves dysregulated fibroblast activity and excessive extracellular matrix (ECM) deposition. Keloids arise from **chronic inflammation** in the reticular dermis ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). It usually has a triggering event which is then influenced by genetic predisposition, inflammatory processes, and mechanical stress. - **Triggering Event:** Skin injuries (e.g., surgery, burns, acne) commonly trigger keloids. - **Fibroblast Dysregulation:** Overactive fibroblasts synthesize excessive collagen and resist apoptosis, leading to persistent scarring ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). - **Cytokine Imbalance:** Elevated TGF-Ξ² levels drive fibroblast recruitment and chronic inflammation ([Lee](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com), 2023). - **Hormonal Influences:** Estrogen-induced vasodilation, especially during pregnancy, aggravates keloid formation ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). - **Metabolic and Environmental Factors:** Hypoxia, mechanical stress, and conditions like vitamin D deficiency or hypertension exacerbate keloid progression. πŸ’‘ ****Tip:** Hypercytokinemic diseases (e.g., Castleman disease) ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021) and genetic syndromes like Rubinstein-Taybi syndrome increase keloid risk ([Lee](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com), 2023). --- ## Clinical Features of Keloids ****Key Point** Keloids extend beyond the original wound boundary and are often associated with symptoms such as pain, itching, or burning. Keloid scars are **pathological** scars that **extend beyond the boundaries** of the original wound & persist indefinitely, often causing physical discomfort & psychological distress. Diagnosis is primarily clinical, confirmed by histologic findings such as keloidal collagen and fibroblast density. ### Clinical Features Their key **clinical features** include, - **Locations:** Deltoid, pre-sternal chest, upper back, and ear regions. - **Color:** erythematous in early stages to hyperpigmented over time. - **Onset:** 1–3 months after trauma but can develop up to a year later. - **Symptoms:** Pruritus, pain, and burning are reported. ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). **Risk Factors** for keloid scar formation include, - **Family history** increases keloid risk. - **Gender:** Female predominance is linked to estrogen's role in vasodilation and scar inflammation. - **Ethnicity:** Black 2.4%, Asian 1.1%, Caucasian 0.4% ([Ung](https://pubmed.ncbi.nlm.nih.gov/36598763/?ref=theplasticsfella.com), 2023). The table below categorizes keloids and hypertrophic scars along with their differences. ![Differences between keloids and hypertrophic scars](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Scars--1-.png) Differences between keloids and hypertrophic scars 😎 ****Fun Fact:** Malignant tumors, such as dermatofibrosarcoma protuberans, **may* mimic keloids clinically and require biopsy for confirmation ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). ### Histologic Features Histologically, keloids are characterized by large, irregular, hyalinized collagen bundles, known as **keloidal collagen**, and an abundance of fibroblasts, which are central to their pathological structure ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). Even in the absence of keloidal collagen, keloids can be identified by the following diagnostic features: 1. **Standard Epidermis and Papillary Dermis:** The epidermis appears normal, with no significant abnormalities in the papillary dermis. 2. **"Tongue-Like" Advancing Edge:** A projection of fibrous tissue extending below the papillary dermis is a hallmark of keloid expansion. 3. **Horizontal Fibrous Band:** A dense, horizontal band of fibrous tissue in the upper reticular dermis is typically observed. 4. **Prominent Fascia-Like Band:** A thick, fascia-like structure in the deep dermis contributes to the rigidity and persistence of keloids. A micrograph of a keloid is illustrated below. ![Micrograph of keloid](https://storage.ghost.io/c/a0/9f/a09fd7b4-d396-4b28-aed3-b87e20483292/content/images/2024/12/Main-Article-Images---2024-12-16T145636.254.png) Micrograph of keloid πŸ’‘ ****Tip:** Differences in clinical presentation and histology between keloids and hypertrophic scars arise from variations in the intensity and duration of reticular dermis inflammation​​ ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). --- ## Treatment of Keloids ****Key Point** Keloid management integrates non-pharmaceutical approaches like lasers, silicone sheeting, cryotherapy, and surgery with pharmaceutical treatments such as corticosteroids, 5-Fluorouracil (5-FU). Keloid treatment requires a tailored approach based on the lesion's characteristics, including size, number, and patient-specific risk factors. Both conservative and surgical strategies are often combined with adjuvant therapies to enhance outcomes and minimize recurrence. ### Conservative Options These methods target the physical and biological properties of keloids, improving outcomes in smaller or isolated lesions. - **Scar Massage:** Increases blood flow, releases tissue adhesions, and induces mechanotransduction to aid scar remodeling. - **Pressure Therapy via Taping:** Realigns collagen fibers, reduces collagen nodules, diminishes fibrotic activity, and reduces edema. - **Silicone Sheeting or Gel:** Enhances scar pliability and color, reduces collagen production through occlusion, and hydrates the stratum corneum. - **Laser Therapy:** Pulsed-dye laser (PDL), non-ablative fractional lasers, and carbon dioxide lasers. Laser-assisted topical steroid application for improved aesthetics. πŸ’‘ ****Tip:** Incomplete therapy can lead to worsening keloids ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). ### Procedural Options - **Intralesional Corticosteroid** injections at \~6-week intervals. Enhanced efficacy when paired with 5-FU or laser therapy but may cause pigmentation changes or tissue atrophy. - **Corticosteroid Tape** is a painless alternative to corticosteroid injections. These include ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021) Fludroxycortide tape or Deprodone propionate plaster (strong steroid). - **Cryotherapy** Reduces collagen synthesis by inducing tissue necrosis.This can be applied through direct contact, sprays, or intralesional probes. Limitation include post-treatment pigmentation changes. - **Surgical Excision:** Small keloids may be radically excised; large lesions require partial or core excision. Surgery alone has high recurrence rates (45–100%) and must be paired with adjuvant therapy such as radiation or steroids. - **Radiation Therapy** inhibits fibroblast activity and angiogenesis, making it effective in preventing keloid recurrence. It should Administered within 24–28 hours post-surgical excision via electron beam radiation or brachytherapy ([McGinty](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com), 2023). πŸ’‘ ****Tip:** Monitor surgical sites prone to hypertrophic scars or keloids for 3–12 months. Start steroid tape or plaster at the first sign of induration, switching to steroid injections if it persists ([Ogawa](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com), 2021). Other, currently less commonly used agents include, 1. **5-Fluorouracil (5-FU):** Effective when combined with steroids, reducing erythema and elevation. 2. **Bleomycin:** Promotes apoptosis in fibroblasts. 3. **Retinoids:** Enhances new scar remodeling by suppressing sebum and excessive fibroblast activity. There are anecdotal reports of tissue-engineered allografts ([Jones](https://pubmed.ncbi.nlm.nih.gov/27300360/?ref=theplasticsfella.com), 2016) and platelet-rich plasma for the treatment of keloids ([Oswald](https://pubmed.ncbi.nlm.nih.gov/12522384/?ref=theplasticsfella.com), 2003). --- ## Conclusion Upon completing this article, you will have accomplished the following: ****1\. Definition:** Keloids are a dermo-fibroproliferative disorder caused by abnormal fibroblast activity and excessive ECM production, resulting in scars that extend beyond the wound boundary. ****2\. Pathophysiology:** Keloids arise from genetic predisposition, mechanical stress, chronic reticular dermis inflammation, and dysregulated fibroblast activity. ****3\. Clinical Features and Diagnosis:** Keloids commonly appear on the chest, back, shoulders, and ears, presenting as firm, raised scars with pain or itching. Diagnosis is clinical, supported by histologic findings. ****4\. Treatment:** Management involves non-pharmaceutical methods (lasers, silicone sheeting, cryotherapy, surgery, radiation) and pharmaceuticals (corticosteroids, 5-FU, bleomycin). ****5\. Prevention:** Preventative strategies include tension-free wound closure, silicone gel application, scar massage, and avoiding elective procedures like tattoos or piercings in predisposed individuals. --- ## Further Reading 1. McGinty S, Siddiqui WJ. [Keloid](https://www.ncbi.nlm.nih.gov/books/NBK507899/?ref=theplasticsfella.com). \[Updated 2023 Jul 17\]. In: StatPearls \[Internet\]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. 2. Lee CC, Tsai CH, Chen CH, Yeh YC, Chung WH, Chen CB. [An updated review of the immunological mechanisms of keloid scars](https://pubmed.ncbi.nlm.nih.gov/37033989/?ref=theplasticsfella.com). Front Immunol. 2023 Mar 22;14:1117630\. doi: 10.3389/fimmu.2023.1117630\. PMID: 37033989; PMCID: PMC10075205. 3. Ung CY, Warwick A, Onoufriadis A, Barker JN, Parsons M, McGrath JA, Shaw TJ, Dand N. [Comorbidities of Keloid and Hypertrophic Scars Among Participants in UK Biobank](https://pubmed.ncbi.nlm.nih.gov/36598763/?ref=theplasticsfella.com). JAMA Dermatol. 2023 Feb 1;159(2):172-181\. doi: 10.1001/jamadermatol.2022.5607\. PMID: 36598763; PMCID: PMC9857738. 4. Ogawa R. [The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago](https://pmc.ncbi.nlm.nih.gov/articles/PMC8687618/?ref=theplasticsfella.com). Plast Reconstr Surg. 2022 Jan 1;149(1):79e-94e. doi: 10.1097/PRS.0000000000008667\. PMID: 34813576; PMCID: PMC8687618. 5. Jones ME, Hardy C, Ridgway J. [Keloid Management: A Retrospective Case Review on a New Approach Using Surgical Excision, Platelet-Rich Plasma, and In-office Superficial Photon X-ray Radiation Therapy](https://pubmed.ncbi.nlm.nih.gov/27300360/?ref=theplasticsfella.com). Adv Skin Wound Care. 2016 Jul;29(7):303-7\. doi: 10.1097/01.ASW.0000482993.64811.74\. PMID: 27300360; PMCID: PMC4915758. 6. Osswald SS, Elston DM, Vogel PS. [Giant right plantar keloid treated with excision and tissue-engineered allograft](https://pubmed.ncbi.nlm.nih.gov/12522384/?ref=theplasticsfella.com). J Am Acad Dermatol. 2003 Jan;48(1):131-4\. doi: 10.1067/mjd.2003.48\. PMID: 12522384. 7. Katta R, Kramer MJ. [Skin and Diet: An Update on the Role of Dietary Change as a Treatment Strategy for Skin Disease](https://pubmed.ncbi.nlm.nih.gov/29357214/?ref=theplasticsfella.com). Skin Therapy Lett. 2018 Jan;23(1):1-5\. PMID: 29357214. 8. Wanjala NF, Joseph G, Anthony M, Primus O, Ogeng'o JJ, Anzala O, Dohil I, Agak GW. [Keloids: Does patients' sex influence the presentation and recurrence post-excision?](https://pubmed.ncbi.nlm.nih.gov/34642061/?ref=theplasticsfella.com) J Plast Reconstr Aesthet Surg. 2022 Jan;75(1):366-368\. doi: 10.1016/j.bjps.2021.08.030\. Epub 2021 Sep 20\. PMID: 34642061. 9. Liu EK, Cohen RF, Chiu ES. [Radiation therapy modalities for keloid management: A critical review](https://pubmed.ncbi.nlm.nih.gov/35817711/?ref=theplasticsfella.com). J Plast Reconstr Aesthet Surg. 2022 Aug;75(8):2455-2465\. doi: 10.1016/j.bjps.2022.04.099\. Epub 2022 May 6\. PMID: 35817711. 10. Theplasticsfella. [Wound healing](https://www.theplasticsfella.com/wound-healing/) April 2022\. Accessed on 24th November 2024.