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Keloid, also known as keloid disorder and keloidal scar, (2025). 9781416029991, Mosby. ISBN 9781416029991 is the formation of a type of scar which, depending on its maturity, is composed mainly of either type III (early) or type I (late) collagen. It is a result of an overgrowth of granulation tissue (collagen type III) at the site of a healed skin injury, which is then slowly replaced by collagen type I. Keloids are firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to the color of the person's skin or red to dark brown. A keloid scar is benign and not contagious, but sometimes accompanied by severe itchiness, pain, and changes in texture. In severe cases, it can affect the movement of the skin. In the United States, keloid scars are seen 15 times more frequently in people of sub-Saharan African descent than in people of European descent. There is a higher tendency to develop a keloid among those with a family history of keloids and people between the ages of 10 and 30 years.
Keloids should not be confused with hypertrophic scars, which are raised scars that do not grow beyond the boundaries of the original wound.
Keloids typically form within scar. Collagen, used in wound repair, tends to overgrow in this area, sometimes producing a lump many times larger than that of the original scar. They can also range in color from pink to red. Although they usually occur at the site of an injury, keloids can also arise spontaneously. They can occur at the site of a piercing and even from something as simple as a pimple or scratch. They can occur as a result of severe Acne vulgaris or chickenpox scarring, infection at a wound site, repeated trauma to an area, excessive skin tension during wound closure or a foreign body in a wound. Keloids can sometimes be sensitive to chlorine. If a keloid appears when someone is still growing, the keloid can continue to grow as well.
According to the US National Center for Biotechnology Information, keloid scarring is common in young people between the ages of 10 and 20. Studies have shown that those with darker complexions are at a higher risk of keloid scarring as a result of skin trauma. They occur in 15–20% of individuals with sub-Saharan African, Asian, or Latino ancestry, significantly less in those of a Caucasian background. Although it was previously believed that people with albinism did not get keloids, a recent report described the incidence of keloids in Africans with albinism. Keloids tend to have a genetic component, which means one is more likely to have keloids if one or both of their parents have them.
No single gene has yet been identified as a causing factor in keloid scarring, although several susceptibility loci have been discovered, most notably in Chromosome 15.
The development of keloids among twins also lends credibility to the existence of a genetic susceptibility to develop keloids. Marneros et al. (1) reported four sets of identical twins with keloids; Ramakrishnan et al. also described a pair of twins who developed keloids at the same time after vaccination. Case series have reported clinically severe forms of keloids in individuals with positive family history and black African ethnic origin.
Keloids affect all sexes equally, although the incidence in young female patients has been reported to be higher than in young males, probably reflecting the greater frequency of earlobe piercing among women. The frequency of occurrence is 15 times higher in highly pigmented people. People of African descent have an increased risk of keloid occurrences.
Treatments (both preventive and therapeutic) available are pressure therapy, silicone gel sheeting, intra-lesional triamcinolone acetonide (TAC), cryosurgery (freezing), radiation, pulsed dye laser (PDL), interferon (IFN), fluorouracil (5-FU) and surgical excision as well as a multitude of extracts and topical agents. Appropriate treatment of a keloid scar is age-dependent: radiotherapy, anti-metabolites, and would not be recommended to be used in children, to avoid harmful side effects, like growth abnormalities.
In adults, corticosteroids combined with 5-FU and PDL in triple therapy enhance results and diminish side effects.
Cryotherapy (or cryosurgery) refers to the application of extreme cold to treat keloids. This treatment method is easy to perform, effective, safe, and has the least chance of recurrence.
Surgical excision is currently still the most common treatment for a significant number of keloid lesions. However, when used as the solitary form of treatment, there is a large recurrence rate of between 70 and 100%. It has also been known to cause a larger lesion formation on recurrence. While not always successful alone, surgical excision when combined with other therapies dramatically decreases the recurrence rate. Examples of these therapies include but are not limited to radiation therapy, pressure therapy, and laser ablation. Pressure therapy following surgical excision has shown promising results, especially in keloids of the ear and earlobe. The mechanism of how exactly pressure therapy works is unknown at present, but many patients with keloid scars and lesions have benefited from it.
Intralesional injection with a corticosteroid such as triamcinolone acetonide does appear to aid in the reduction of fibroblast activity, inflammation and pruritus.
Tea tree oil, salt, or other topical oil does not affect keloid lesions.
A 2022 systematic review included multiple studies on laser therapy for treating keloid scars. There was not enough evidence for the review authors to determine if laser therapy was more effective than other treatments. They were also unable to conclude whether laser therapy leads to more harm than benefits compared with no treatment or different kinds of treatment.
Another 2022 systematic review compared silicone gel sheeting with no treatment, treatment with non-silicone gel sheeting, and treatment with intralesional injections of triamcinolone acetonide. The authors only found two small studies (36 participants in total) that compared these treatment options, so they were unable to determine which (if any) was more effective.
Extensive burns, either thermal or Radiation burn, can lead to unusually large keloids; these are especially common in firebombing casualties and were a signature effect of the atomic bombings of Hiroshima and Nagasaki.
The true incidence and prevalence of keloid in the United States are not known. Indeed, there has never been a population study to assess the epidemiology of this disorder. In his 2001 publication, Marneros stated that “reported incidence of keloids in the general population ranges from a high of 16% among the adults in the Democratic Republic of the Congo to a low of 0.09% in England,” quoting from Bloom's 1956 publication on heredity of keloids. Clinical observations show that the disorder is more common among sub-Saharan Africans, African Americans and Asians, with unreliable and very wide estimated prevalence rates ranging from 4.5 to 16%.
The famous American Civil War-era photograph "Whipped Peter" depicts an escaped former slave with extensive keloid scarring as a result of numerous brutal beatings from his former overseer.
Intralesional corticosteroid injections were introduced as a treatment in the mid-1960s as a method to attenuate scarring.
Pressure therapy has been used for the prophylaxis and treatment of keloids since the 1970s.
Topical silicone gel sheeting was introduced as a treatment in the early 1980s.
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