Keloid

Question 1

What is a keloid?

Answer 1

• Abnormal proliferation of scar tissue
• Forms at site of an injury
• Projects beyond original wound margins and does not regress

Question 2

Pathophys of keloid scarring

Answer 2

• Normal wound healing = balance between apoptosis and remodelling of ECM
• In keloid, there is prolonged inflammatory phase (due to immune cell infiltration into scar tissue) = excess fibroblast activity
• = increased ECM deposition
• = tissue projecting beyound original wound margin

Question 3

RF for keloid scar formation

Answer 3

• Ethnicity - Black African or Caribbean and Asian
• Age - 20-30s
• Cause of injury - burns carry highest risk
• Anatomical site - ear lobe, shoulders, sternal notch
• Previous keloid formation

Question 4

Clinical features of keloid scar

Answer 4

• Characteristic visual appearance - erythematous, then become brown and turn pale as they age
• Not usually any other symptoms but sometimes patients get pain, itching or burning in scar tissue

Question 5

What can be used to quantify features of scars?

Answer 5

• Vancouver scar scale

Question 6

Differential for keloid scar

Answer 6

• Hypertrophic scarring
• Rarer - dermatofibroma, dermatofibrosarcoma protuberans

Question 7

Hypertrophic scarring vs keloid scar

Answer 7

Hypertrophic:
* Confined to wound margins
* Regress over time
* Improves with surgical intervention
* No association with skin colour
* Develops soon after injury
* Not spontaenous
* Develop in wound locations under high tension eg shoulders, neck, knees and ankles

Keloid:
* Projects beyond wound margins
* Does not regress
* Outcome worse with surgical intervention
* Associated with darker skin tones
* Can be several months after injury
* Can be spontaenous - without injury
* Occur anywhere on body - mostly ear lobes, upper arms, sternal notch and deltoids

Question 8

Investigation for suspected keloid scar

Answer 8

• Clinical - none needed

Question 9

Management keloid scar - is surgery done?

Answer 9

Surgical excisions rarely performed - poor results ith high recurrence rate, stimulates collagen synthesis so regrowth of larger keloid after

Question 10

Non-surgical management keloid scar

Answer 10

• Intralesional steroids
• Silicone gel
• Radiation therapy

Question 11

How do intralesional steroids work?

Answer 11

• Act as anti-inflammatory =
• inhibits fibroblast and glucocorticoid receptors
• = downregulation of proliferation of fibroblasts and inhibits collagen synthesis

Question 12

What do you do with silicone gel?

Answer 12

• Topical gel or elastic sheet - wrap keloid scar in for at least 12hrs per day

Question 13

Problem with radiation for keloid scars

Answer 13

Reduces recurrence BUT
could induce malignancy theoretically
This limits its use