Managing Keloids

Keloids are a result of abnormal wound healing due to skin trauma or inflammation. They affect patients with skin of color (SOC) at a higher rate than white patients. Dark-skinned patients are 15 times more likely to form keloids,1 and in patients of African, Asian, or Hispanic descent, incidence rates are as high as 16 percent.2 A familial history also increases the risk of keloid development. One study in patients of Afro-Caribbean descent showed that more than half of patients with keloids had a positive family history of keloidal scarring.3 While not dangerous, keloids are often symptomatically and cosmetically bothersome for patients. One study found that 86 percent of patients with keloids reported pruritis and 46 percent reported pain.4 Another study showed that 65 percent of patients suffered psychological impact due to their keloids.5 This article will review the most common procedural treatment approaches to keloids and nuances to consider when treating SOC patients.

DIAGNOSTIC CONSIDERATIONS: HYPERTROPHIC SCAR VS. KELOID

Unlike hypertrophic scars, which do not extend beyond the initial area of injury, keloidal tissue always extends beyond the initial site of trauma. Another clinical difference is that hypertrophic scars do not project above the skin surface beyond 4mm while keloids often do. Hypertrophic scars often form within 4 to 8 weeks following skin injury and grow rapidly for up to six months before regressing. Conversely, keloids can take years to develop following initial injury and do not spontaneously regress;6 thus, obtaining a patient’s history is a critical component of the diagnostic process. Hypertrophic scars favor the neck, presternum, shoulders, knees, and ankles, whereas keloids have a predilection for the chest, shoulders, posterior neck, upper back and earlobes.

FIGURES 1A AND 1B.

Intralesional corticosteroids, with which this patient’s chest was treated

(A: before, B: 1 month after 1st treatment), are considered first-line therapy for keloid management.

TREATMENT APPROACHES

Several procedural options exist for the treatment of keloids, although none have been consistently successful. Thus, when considering which treatment option(s) to implement, it’s important to take into account the patient’s unique clinical history and clinical findings, such as the size and location of keloid, age of patient, impact on the patient’s quality of life, and the patient’s treatment goals.

Intralesional corticosteroids. Intralesional corticosteroids are considered first-line therapy for keloid management. Intralesional triamcinolone 10-40 mg/cc is administered once or twice a month for several visits until desired outcome is achieved. Injection placement should be in the mid-dermis to avoid atrophy of the epidermis. The therapeutic response is variable, with 50- to 100-percent regression reported.7 Recurrence rate was found to be 33 percent at one year and 50 percent at five years.7 Common adverse effects include skin and subcutaneous fat atrophy, hypopigmentation, and telangiectasia. It’s important to discuss these side effects and patient expectations of treatment outcome prior to initiation of treatment.

Surgery. Consideration of surgery for keloid excision should be weighed cautiously. Recurrence rates following surgical excision are high, ranging from 45 to 100 percent.8 Use of adjuvant treatment, such as intralesional corticosteroid injection or radiation therapy, should be considered to minimize recurrence rates. For example, recurrence rates have been shown to drop to 22 percent when radiation therapy follows surgical excision.9 Counseling patients on surgical risks, such as potential worsening of existing keloid or new keloid formation, is imperative. While the decision for surgical excision is not an easy one, for some patients (Figure 2), this can arguably offer the best chance at returning to functional normalcy.

FIGURE 2.

While the recurrence rates for keloids following surgical excision are high, for some patients, such as the one pictured here, surgery may be the best option.

Lasers. Numerous laser options exist for keloid treatment. Nonablative lasers commonly used include the 585nm pulsed dye laser (PDL) and the Nd:YAG laser. These lasers work by inducing thermal injury to the keloid’s microvasculature and have been shown to induce flattening and regression of keloids.10 The 585nm PDL has been shown to have success rates ranging from 57 to 83 percent.11 Because the 585nm PDL also targets melanin, it has an increased risk of causing pigmentary changes.12 The Nd: YAG laser is thought to directly suppress fibroblast collagen progression. One study using the 1064nm Nd:YAG laser showed no pigmentary alterations in SOC patients.13 Furthermore, patients saw clinical improvement in their keloids, which was enhanced when combined with intralesional steroids.13 Another study comparing efficacy of PDL versus Nd:YAG laser showed no statistically significant differences between the two modalities. Both lasers were shown to significantly improve the appearance of keloids.14

CONCLUSION

Despite many treatment options, keloids continue to pose a challenge for clinicians. Given the significantly higher incidence rate among SOC populations, compared to lighter-skinned individuals, clinicians should be aware of the potential treatment side effects that impact this population. Having a risk-benefit conversation with patients prior to deciding upon a treatment plan is critical for optimal patient satisfaction.