A keloid is a raised, firm, progressively enlarging type of “scar”, projecting above the skin surface, and is a benign lesion. The diagnosis is based upon clinical appearance. It develops where the skin has been previously injured and usually appears as a shiny, dome shaped, pink to reddish nodule. There is no way to predict when a keloid will occur.
The mechanism under which a keloid forms is not clear. It seems to develop following a surgical incision, ear piercing, or any other, seemingly, minor injury to the skin; i.e. acne lesion, vaccination, burn, or insect bite. The concept of spontaneous development is questionable.
Although a keloid can occur in both men and women of all skin types, patients who have darker skin types appear to be more prone to keloid formation. Areas of involvement often include the chest, back, shoulders, ear lobes and jaw lines, but keloids almost never occur in the perineum. Common complaints involve itching, burning, tightness, and skin irritation, secondary to friction. In contrast to other types of scars, keloids rarely subside spontaneously. Keloids can be distinguished from hypertrophic scars; the latter do not extend beyond the site of injury, whereas keloids become much larger and grow beyond the initial site. Acne keloidalis will be discussed in another entry.
Therapy is directed towards shrinking the keloid and diminishing the annoying, even painful, symptoms. Outright surgical excision, alone, will lead only to a larger keloid. Currently, the best treatment involves the use of corticosteroids, utilizing potent topical ones and/or intralesional injections at frequent intervals (two to four weeks) for some time. When a keloid becomes flabby, then surgical excision can be attempted but with the knowledge that the keloid may recur. Other therapeutic methods include the use of a pulsed dye laser, external pressure and occlusion, and radiation. An innovative approach involves surgical removal without suturing of the defect and simultaneous application of imiquimod cream.
Maria M. Tsoukas, MD, PhD
Chicago, IL, USA