Keloid Scars

Keloid scars represent a hyperproliferative response of connective tissue to trauma (22). Known stimuli include burns, inflammatory acne, surgery, and ear piercing. The tendency to form keloids is inherited, although a precise mode of transmission has not been defined. There is a racial predisposition, and African-American people are more susceptible. The most frequent locations are the chin, earlobe, neck, shoulders, upper back, and sternum, probably in relation to skin tension and mobility. The posterior scalp may also be involved (acne keloidalis nuchae). By definition, keloids spread beyond the area of initial trauma. Lesions are firm, thick, hyperpig-mented papules, nodules, or plaques. They have a characteristic shiny surface and may be confluent. Histological examination shows dense fibrous tissue composed of thick collagen bundles and variable inflammatory infiltrates.

Surgery followed by radiation therapy has a 75% response rate (23-25). How- -g ever, keloids larger than 2 cm and those that have failed to respond to previous therapy are likely to recur.

Surgical excision alone has been disappointing. Essentially 100% of keloids c recur within 4 years. At least 50% regrow even when flaps or grafts are used. ^

Intralesional triamcinolone (10-40 mg/ml every month alone or in combina- 3

tion with surgery) is moderately effective. When given as an adjunct to surgery, |

the triamcinolone is injected at the time of excision, at 2 weeks, and monthly there- o after for several months. Adverse effects include skin atrophy, telangiectasias, necrosis, and Cushingoid features. @

Compression therapy can be combined with surgery and steroids. Results are good, although recurrences occur after the pressure is released. Best results are obtained in earlobe keloids.

Cryotherapy with liquid nitrogen alone or in combination with intralesional steroids is moderately effective. Injections are maintained for several months to prevent recurrences.

Electrosurgery in combination with intralesional steroids shows results similar to other therapies.

Silicone patch occlusive therapy is moderately effective for some keloids. Studies show favorable results when the patch is used at least 12 h daily for 8-12 weeks.

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