Keloids, also referred to as Keloidal scars, are an extreme random overgrowth of collagen formation at the site of a healed skin injury. Keloids are harmless, benign (non-cancerous) skin lesions resulting from an overgrowth of granulation tissue during the healing process. They sometimes cause itching and pain and can limit skin movement in some people. Keloids are a serious form of scarring as they can continue to grow indefinitely into large growths beyond the borders of the original wound. Keloidosis is a term used when multiple or repeated instances of keloids are formed on the skin.
Keloid Scars can result from any of the following:
- Minor scratches
- Surgical incisions
- Traumatic wounds
- Vaccination sites
Symptoms of Keloids include the following:
- Raised mound of scar tissue at the site of an healed skin injury
- Pigmentation of the skin
Keloid scars have two main predisposing risk factors:
- Location of the scar
- Genetic background of the patient
Keloids are more common in the upper part of the body and are rare in the eyelids, soles of the feet, palms of the hand and genitals. Keloids are most likely to develop:
- In the earlobe after ear piercing
- Along the border of the jaw
- The shoulder
- The skin over the breast bone
- Keloids are uncommon in people with fair skin. These patients are more likely to develop hypertrophic or thick scars which eventually fade. The difference between these two types of scar is often hard to determine.
- Keloids are more common in patients with dark skin.
- Women are more likely to develop Keloidal scars.
- Young people under the age of thirty are at highest risk.
Other Risk Factors:
- Keloids are more likely to form when the wound is closed under tension or where there is an infection or hematoma (bleeding) after surgery.
- If a foreign body is present in the wound, as may occur after an accident, keloids also seem to be more likely to develop.
- In cosmetic surgery some scars are more likely to become thicker, these include the scars associated with: otoplasty (ear pinning), breast reduction and abdominoplasty (tummy tuck).
Scar tissue may be minimized to a degree by proper attention to the injury and proper care during the healing process. Preventing complications such as infection and treating medical conditions that affect healing such as diabetes can help minimize scarring. Minimizing swelling and increasing the blood supply to the injured area also help in the healing process and minimize scarring. Other measures to minimize scarring may include the following:
- Occlusive Dressings
Occlusive dressings include silicone gel sheets and dressings, non-silicone occlusive sheets, Cordran tape, and Scarguard. These measures have been used with varied success. Anti-keloidal effects appear to result from a combination of occlusion and hydration, rather than from an effect of the silicone.
- Compression Therapy
Compression therapy involves pressure, which has long been known to have thinning effects on skin. Reduction in the cohesiveness of collagen fibres in pressure-treated hypertrophic scars has been demonstrated by electron microscopy. Compression treatments include button compression, pressure earrings, ACE bandages, elastic adhesive bandages, compression wraps, Lycra bandages, and support bandages. Other pressure devices include pressure-gradient garments made of lightweight porous Dacron, spandex (also known as elastane), or bobbinet fabric (usually worn 12-24 hours/day for up to 4-6 months) and zinc oxide adhesive plaster.
No single therapeutic modality is best for all keloids. The type of therapy used is determined by:
- The location, size, and depth of the lesion;
- The age of the patient;
- The past response to treatment.
Prevention is key, but therapeutic treatment of keloids includes the following:
- Intralesional corticosteroid injections
- Interferon therapy
Talk to your physician about other possible treatments that could be used in your particular situation. Research in the treatment of Keloidal scars is on-going and new innovations may be indicated for your situation.
Intralesional corticosteroid injections
Corticosteroids, specifically intralesional corticosteroid injections, have been the mainstay of treatment. Corticosteroids reduce excessive scarring by reducing collagen synthesis, altering glucosaminoglycan synthesis, and reducing production of inflammatory mediators and fibroblast proliferation during wound healing. Steroids are injected directly into the scar tissue to help decrease the itching, redness, and burning sensations that these scars may produce. Sometimes, the injections help to actually decrease the size of the scar.
This involves the scar being “frozen” off by a medication applied to the Keloid. Cryosurgical media (e.g., liquid nitrogen) affects the microvasculature and causes cell damage via intracellular crystals, leading to tissue anoxia. Generally, 1, 2, or 3 freeze-thaw cycles lasting 10-30 seconds each are used for the desired effect. Treatment may need to be repeated every 20-30 days. The physician will take care to administer liquid nitrogen in short application periods because of the possibility of reversible hypopigmentation. Cryotherapy can cause pain and depigmentation in certain patients.
Interferon therapy, including interferon alfa, interferon beta, and interferon gamma, has been demonstrated in vitro studies to reduce keloidal fibroblast production of collagen. Interferon injected into the suture line of keloid excision sites may be prophylactic for reducing recurrences.
If the Keloid scar is not responsive to non-surgical management options, surgery may be suggested. Scar revision surgery may improve the appearance of the scar but will not remove it entirely. It is important to understand that some types of Keloid scarring can actually be made worse by surgery. Your surgeon will discuss your options with you based on the size, depth, colour and thickness of your scar. One type of surgery directly removes the scar formation with an incision, and stitches are placed to help close the wound. Sometimes, skin grafts are used to help close the wound. This involves replacing or attaching skin to an area that is missing skin. Skin grafts are performed by taking a piece of healthy skin from another area of the body (called the donor site) and attaching it to the needed area. Another option is laser surgery. Scars may be treated with a variety of different lasers, depending on the underlying cause of the scar. Lasers may be used to smooth a scar, remove the abnormal colour of a scar, or flatten a scar. Most laser therapy for scars is done in conjunction with other treatments, including injections of steroids, use of special dressings, and the use of bandages. Multiple treatments may be required, regardless of the initial type of therapy.
Surgical Keloid excision is performed as day surgery either in the hospital or outpatient surgery centre under general, regional, or occasionally local anaesthesia depending on the type of procedure performed and the surgeon’s preference.
Your surgeon makes an incision at the site of the Keloid. The Keloid is shaved down with special instruments and scar tissue is cut out.
Your surgeon may use a skin graft if there is not enough skin to cover the incision that was made to remove the scar tissue. The skin graft is obtained by removing a thin layer of skin from another part of the body (referred to as the donor site) and placing it over the incision site.
The surgeon then carefully sutures the incision closed and covers the area with a sterile dressing. Scar revision surgery removes the Keloid and improved suturing technique minimizes the possibility of a new Keloid developing. For severe Keloids, excisional surgery may be combined with radiation to prevent their return.
After surgery your surgeon will give you guidelines to follow depending on the type of surgery performed and the surgeon’s preference. Common guidelines include:
- You will need someone to drive you home after you are released as the anaesthesia may make you feel groggy and tired.
- You should rest for the first couple days after surgery.
- Avoid any lifting or pulling that puts tension or pressure on the new incision.
- Avoid exposing the incision to sunlight especially during the first year of healing.
- If sutures were used, these will be removed at your doctor’s appointment.
- Follow your surgeon’s guidelines on bathing and showering.
- If a skin graft was used, monitor the donor site as well as the incision for symptoms of infection such as redness, swelling, pain, and drainage. Report any such symptoms to your doctor right away.
Risks and Complications
As with any surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to scar revision surgery. Medical complications include those of the anaesthetic and your general wellbeing. Almost any medical condition can occur so this list is not complete. Complications include:
- Allergic reactions to medications
- Blood loss requiring transfusion with its low risk of disease transmission
- Heart attacks, strokes, kidney failure, pneumonia, bladder infections
- Complications from nerve blocks such as infection or nerve damage
- Serious medical problems can lead to on-going health concerns, prolonged hospitalization, or rarely death.
Complications are rare after scar revision surgery, but unexpected events can follow any operation. Your surgeon feels that you should be aware of complications that may take place so that your decision to proceed with this operation is taken with all relevant information available to you. After excision of Keloids, there is a risk of recurrence. After excision, the use of steroids and/or radiation therapy may help to prevent the return of the Keloid.
The main risks specific to scar revision surgery are that the scar may grow, change colour, or appear worse than before surgery.