Keloid

What is a Keloid (Keloid scar)?

A keloid (keloid scar) is a raised or thickened scar that tends to grow rapidly above and beyond the surface of the skin at the site of an injury. Keloid may appear as a smooth surface, pink, red, purple or brown raised plaque or mass on the skin surface. Keloids tend to be irregularly shaped and may become progressively enlarged. Unlike other forms of scarring, keloids do not resolve or soften completely over time.

Keloid is an overgrowth of the scar tissue that develops around a wound or a specific site of skin injury. Keloid is sometimes being confused with a hypertrophic scar. Keloid usually grows beyond the original borders of the wound, whereas hypertrophic scar stays within the wound border.

When keloid was first described in 1806, the original term was 'cheloide', taken from the Greek word 'chele' , meaning crab's claw. This refers to the way the keloid grows sideways, beyond the normal wound edge and into the normal skin.

It can develop after acne spots and boils, body piercings, burns, lacerations and surgical wounds. Infection and excessive stretching of wound increases the risk of keloid formation.

CThe exact cause is not known. However, people with darker skins are more common to have keloids, especially African-American races. Studies of African people have shown that 6-16% develop keloid. Half of people with keloid will have other members of the family who have also developed keloids. There is an equal sex distribution. Keloids usually happen at 10-30 years of age and are less common at the extremes of age. Common sites for keloids are earlobe, cheek, shoulder and sternum.

Keloid typically starts to develop about 3 - 12 months after the original skin damage. Initially, the scar becomes rubbery, raised and expanded beyond the borders of the original damage. The color of the keloid may change and can be red, purple, pale, or brown. It may be tender, itchy, painful or sometimes produce a burning sensation. Most people can identify the cause of their keloids, but some keloids develops without any apparent skin injury. The common areas of keloids formation are the earlobe, face, shoulder and sternum. Keloids growing over a joint can cause joint range restriction. Sometimes, keloid can be infected.

Growth of keloids can be fast or slow and are unpredictable. Keloid may grow for a few weeks to a few months, fast or slow, and then stops growing. As keloids stop growing, they remain the same size or get a little bit smaller. A matured keloid may shrink slightly over time but almost never disappears completely.

It is diagnosed by the medical history and the physical properties of the keloid. Experienced doctors or surgeons can make most of the diagnoses by detail clinical examination.

Treatment

In the past, the treatment of keloid is not very effective. Some patients choose to live with an unsightful, itchy, painful, red and growing keloid. Nowadays, there are effective treatments available. Most patients can get rid of their keloids with the modern treatments. Most surgeons wound choose a combination of treatments to get rid of the keloids. Treatment options include:

• Steroids Injection
  Most keloids respond very well to repeated direct local injection of steriods (e.g. triamcinolone / methyprednisolone).
• Traditional Steroid Injection
  Traditional Steroid injection involves mixing steroid with local anesthetic. Injection directly to the keloid causes severe pain.
• Modern Nearly Painless Steroid Injection
  

  Injection related pain can be reduced to a minimum with the use of local anesthetic cream over the keloid 15 - 30 minutes before any injection, and injecting subcutaneous local anesthetic blocking the nerve sensation around the keloid. These will make the process of steriod injection to nearly painless.

  	Details of Minimal Pain Steroid injection to Keloid
  What happens before steroid injection?	Local anesthetic cream is applied to the keloid 15-30 minutes before any injection. An area of skin around the keloid is numbed by subcutaneous injection of local anesthetic. This makes the whole keloid injection procedure nearly painless.
  What happens during steroid injection?	The steroid is injected into the main bulk of the keloid from a distance of 1-2cm and at an angle. The steroid will be injected directly and at multiple spots inside the keloid tissue to allow the steroid to take effect locally. The keloid scar may look pale during injection.
  What happens after steroid injection?	Local compression is applied for 5-10 minutes to stop bleeding. Afterwards, dressing is applied and siliastic gel is applied daily over the keloid.
  How often can I have steroid injection to keloids?	Steroid injection can be repeated every 3-6 weeks until the keloid disappears.
  Do I need to have follow up after keloid disappears?	Yes. You should visit your doctor every 3-6 months after treatment for there is a chance for recurrence for about 1-2 years.
  Steroids	Methylprednisolone Triamcinolone
  Side Effects (less than few %)	Possible adverse effects: e.g. hypopigmentation, hyperpigmentation, dark red discoloration, or tissue atrophy/ indentation. Hypopigmentation usually reverses with time. Fat atrophy can be long lasting. Cushing's syndrome rarely happens

• Pressure and/or airtight (occlusive) dressings
  A dressing which applies pressure and/or prevents air from coming into contact with the scar is used. The dressing must be used for 12-24 hours a day for many weeks. Preparations used are silicone as a gel or impregnated sheet, or polyurethane self-adhesive patches. Other products are available. For keloids on the earlobes (usually arising from piercings) compression earrings are recommended. They are usually used once the original keloid has been removed by surgery and have to be worn 24 hours a day.

Surgery

• Traditional Surgery
  Traditional surgery, removing the keloid scar, can result in a bigger keloid.
• Modern Surgery
  Modern surgery treating keloids, combining excision- in-total of the keloid with a layer of healthy tissue margin and additional treatments such as antibiotics injection, steroid injections, occlusive or pressure dressings or radiotherapy.
• Cryotherapy
  Intralesional cryotherapy uses a probe to freeze keloid tissue from the inside and this method is approved by FDA. It can be performed under local anesthetic, monitored anesthetic control, or general anesthesia. Long acting local anesthetic is injected around the lesion to reduce the post operative pain. It is once off surgery with freezing probe piecing through the centre of the keloid. After the keloid is frozen, the cell dying process inside the keloid is triggered. The keloid will regress in 3- 6 months time. Post operatively, patients need to apply antibiotic cream to the lesion and take oral analgesic and antibiotic. Vesicle may form around the treated area and it regresses with time.
• Silicone/Silastic gel
  After surgery, applying silastic gel to the wound can reduce the chance of developing hypertrophic scarring or keloid.
• Radiotherapy
  Radiotherapy has the risk of causing cancers and should be reserved only for difficult cases. Radiotherapy can be used alone or after surgerical excision of keloid.

Prevention

People prone to develop keloid (e.g. dark skin color, having history of keloid, involving in lots of physical activities etc) should avoid piercings, tattoos and unnecessary surgery, e.g. cosmetic surgery. Avoid unnecessary operations, especially in earlobe, face, neck, shoulder and chest, where keloids are prone to develop.

If you are at risk of keloid formation and need a surgery, ask your surgeon to offer you keloid prevention dressings, steroid injections or other treatments to the wounds to reduce the risk of keloid developing. Patients at risk of keloid formation avoid wound stretching. If you get acne, treat early. If you develops keloid, treat early.