Keloid 733
• Puberty.
BASIC INFORMATION
DESCRIPTION
Keloid may be defined as a benign growth
of dense fibrous tissue developing from an
abnormal healing response to cutaneous injury,
extending beyond the original borders of the
wound or inflammatory response (Fig. K1-6).
In 1806, Alibert used the term cheloide, derived
from the Greek chele, or crab’s claw, to describe
lateral growth of tissue into unaffected skin.
ICD-9CM CODES
701.4  Keloid scar
ICD-10CM CODES
L91.0  Hypertrophic scar
EPIDEMIOLOGY
• Keloid is seen 5 to 15 times more often in
pigmented ethnic groups than in whites.
• Its prevalence is 16% in blacks and Hispanics.
• The highest incidence is seen in the second
decade.
• It affects both sexes equally.
• Combined incidence of keloid and hypertro-
phic scar ranges from 40% to 70% following
surgery to up to 91% following burns.
ETIOLOGY
• Wounds from trauma, surgery, or body pierc-
ing (Fig. K1-7).
• Burn.
• Other injuries such as insect bites, vaccina-
tion, folliculitis, or acne.
• Rarely can be spontaneous without obvious
injury.
• Familial predisposition seen in some patients.
RISK FACTORS
• Family history of keloids.
• Personal history of keloids.
• Blacks, Hispanics, and Asians.
• Pregnancy.
FIGURE K1-6  Keloids. An abnormal reparative
reaction to skin injury, keloids are characterized by
proliferation of fibroblasts and collagen that extends
beyond the margins of the original wound. (From
Zitelli BJ, Davis HW: Atlas of pediatric physical
diagnosis, ed 5, Philadelphia, 2007, Mosby.)
• Desmoid tumor.
• Patients with blood group A.
• Injury over bones.
PATHOGENESIS
• Pathophysiology of keloid is not completely
understood.
• Caused by benign dermal fibroproliferation
because of disorder in the regulation of cel-
lularity during the wound healing process.
CLINICAL FEATURES
• Keloids usually appear within a few months
of the injury, in contrast to the hypertrophic
scars, which develop within a few weeks.
At times it could take up to a year to appear
because the growth is slow.
• Keloids are often symptomatic in the early
stages. Common complaints are pruritus,
burning, pain, and tenderness.
• Keloids are commonly seen on the shoulders,
sternum, upper back, nape of neck, ear lobes,
mandibular border, and cheek. Hands and
feet are often spared.
• Skin lesions vary from papules to nodules
to large tuberous lesions. They have the
normal skin color most of the time with well-
defined borders. Early on they can appear
erythematous, whereas older lesions may be
hypopigmented or hyperpigmented. They can
be firm to hard in consistency with smooth
surface and are tender to touch. Hair follicles
are absent in these keloids.
• Unlike with hypertrophic scar, in keloids the
scar extends beyond the margin of the initial
wound.
DIAGNOSIS
Workup is usually not necessary because it is
a clinical diagnosis.
• 
Biopsy is usually avoided because it may
increase the keloid size. When biopsy is
done, the histology shows randomly orga-
nized large collagen fibers in a dense con-
nective tissue matrix. In fact, both major
components of extracellular matrix, collagen
and glycosaminoglycans, are increased.
DIFFERENTIAL DIAGNOSIS
• Hypertrophic scar.
• Dermatofibroma.
• Dermatofibrosarcoma protuberance.
FIGURE K1-7  Keloid of ear lobe after piercing.
(From Kliegman RM et al. Nelson textbook of pediat-
rics, Philadelphia, 2011, Saunders.)
• Foreign body granuloma.
K
• Scar with sarcoidosis.
• Lobomycosis.
TREATMENT
• There is no universally accepted treatment
protocol. Prevention is the best strategy.
• Combination treatment is most effective.
• Surgical excision using cold knife followed by
intralesional steroids is the preferred method.
and Disorders
Diseases
• Treatment outcome is the best when it is
initiated shortly after the keloid formation.
• Different treatment options include:
1. Unlike with hypertrophic scars, surgery
alone is associated with a 55% to
100% recurrence rate in patients with
keloids. Results are significantly better
when it is followed by intralesional ste-
I
roids, radiotherapy, pressure therapy, or
silicone application. Both complete and
near total excision has been advocated.
Few recommend core extirpation. Use
of Z-plasties or any wound lengthening
techniques is strongly discouraged.
2. Intralesional steroid every 2 to 4 wk is
administered either alone or following
surgery. Duration of treatment depends
on the treatment response. Triamcinolone
is the most studied steroid and is used at
a concentration of 10 to 40 mg/ml. Higher
concentration is used for denser, more
recalcitrant lesions, and those located in
trunks or extremities. It could be used in
combination with lidocaine to reduce the
discomfort. A 27- to 30-gauge needle
is used for its administration. To distrib-
ute the suspension evenly, it should be
injected while continuously advancing
the needle. No more than 20 to 30 mg of
the drug is used during each treatment.
Liquid nitrogen is applied to the injection
briefly for 2 to 4 seconds about 10 to 15
min before steroid injection for better
dispersal of the steroid and to mini-
mize deposition into surrounding normal
tissue. Hypopigmentation, skin atrophy,
ulceration, and telangiectasia are the side
effects associated with this treatment.
3. Cryotherapy has been used for smaller
lesions. When this treatment is chosen,
the entire lesion is treated with 2 to 3
freeze-thaw cycles of 30 second dura-
tion each. Most lesions need 2 to 10
treatment sessions at 4-wk intervals.
Pain and hypopigmentation are the main
adverse events.
4. Silicone gel sheeting or cushioning can
prevent keloids from recurring after sur-
gery. These are applied as soon as
reepithelialization is achieved and are
worn for at least 12 hr/day for 2 to 4 mo.
5.  Application of pressure by compres-
sion devices has been advocated in the
treatment of keloids. These compression
treatments include button compression,
pressure earrings, pressure gradient
734 Keloid
garments, ACE bandages, elastic adhe-
sive bandages, compression wraps,
Spandex or Elastane bandages, and
support bandages. About 24 to 40 mm
Hg pressure must be maintained. It must
be instituted for long periods (>23 hr/
day for 6 to 12 mo) before significant
effect can be achieved. Unfortunately,
many parts of the body are not amena-
ble to this pressure. Patient discomfort
frequently reduces compliance.
6. Radiation following surgery can also
reduce the recurrence rate. X-rays of
700 to 1500 cGy in fractions over 5 to 6
treatments are the most frequently used
treatment. Radiation is usually initiated
within 10 days, preferably within 24 hr
of surgery. It is avoided in pediatric
and pregnant patients. At times brachy-
therapy with interstitial iridium 192 is
used. Most physicians use radiation only
for keloids over the extremities. The
reported risk of radiation-induced malig-
nancy is theoretical.
7. 5-Fluorouracil can be used as an indi-
vidual agent, following surgery, or in
combination with intralesional steroids.
Weekly injection of 0.5 to 2 ml at a 50
mg/ml concentration of 5-fluorouracil
for 12 wk is the recommended dose.
8. Superiority of laser use to simple exci-
sion currently has not been demon-
strated.
9. Topical 5% imiquimod cream has some
role when used following surgery locally
every night for a minimum of 2 mo.
10. Other treatments include Cordran tape,
bleomycin, interferon, vitamin A, nitrogen
mustard, antihistamines, zinc, tacrolim-
us, sirolimus, allantoin, botulinum toxin,
colchicine, salicylic acid, calcipotriol,
NSAIDs, d-penicillamine, relaxin, quer-
cetin, dinoprostone, doxorubicin, ACE
inhibitors, hyaluronidase, pentoxifylline,
tranilast, mitomycin-C, tamoxifen, silver
sulfadiazine, onion extract, vitamin E,
intralesional verapamil.
FOLLOW-UP
Because of the high risk of recurrence, a follow-
up of at least 12 mo is necessary to fully
evaluate the effectiveness of therapy.
PREVENTION
• Avoid nonessential surgery such as body
piercing, which carries a high risk for keloid
formation.
• LASIK eye surgery and CO2 laser resurfacing
should be avoided in patients with a tendency
for keloids.
• Use a laparoscopic approach when surgery is
needed.
• Avoid making incisions over joint spaces or
over midchest, and ensure that they follow
skin creases.
• Handle tissue gently during surgery.
• Ensure good hemostasis intraoperatively.
• Use tension-free primary wound closure.
• Use monofilament, synthetic permanent
sutures.
• Use adhesives instead of sutures when pos-
sible for closure of wounds.
• Compressive pressure dressing is preferred
in high-risk patients following surgery.
• Avoid wound infection.
• Avoid tattoos.
• Aggressively treat inflammatory acnes.
COMPLICATIONS
• Psychological effects secondary to disfigure-
ment.
• Contracture from keloids may result in loss of
function if overlying a joint.
PROGNOSIS
• Unlike hypertrophic scars, keloids do not
regress with time. However, they may con-
tinue to expand in size for decades.
• Regardless of the type of treatment there is a
high recurrence rate.
• Keloids never become malignant.
SUGGESTED READINGS
Available at www.expertconsult.com
RELATED CONTENT
Keloids (Patient Information)
AUTHOR: HEMANT K. SAPATHY, M.D.
Keloid 734.e1

SUGGESTED READINGS
Al-Attar A et al.: Keloid pathogenesis and treatment, Plast Reconstr Surg
117(1):286–300, 2006.
Atiyeh BS et al.: Keloids or hypertrophic scar: the controversy: review of the
literature, Ann Plast Surg 54(6):676–680, 2005.
Leventhal D et al.: Treatment of keloids and hypertrophic scars: a meta-analysis
and review of literature, Arch Facial Plast 8(6):362–368, 2006.
Robles DT et al.: Keloids: pathophysiology and management, Dermatol Online J
13(3):9, 2007.
Slemp AE et al.: Keloids and scars: a review of keloids and scars, their pathogen-
esis, risk factors, and management, Curr Opin Pediatr 18(4):396–402, 2006.