Keloids and Hypertrophic Scars

Exuberant Healing of Wounds Leads to Unsightly Scarring

Aug 14, 2009 Stephen Allen Christensen

Abnormal wound healing can lead to scarring that presents cosmetic, functional, and therapeutic challenges.

Keloids (KEE-loids) are elevated, fibrous scars that extend beyond the edges of the original wound, do not resolve spontaneously, and usually return after treatment, regardless of the method employed.

Keloids form as the result of an abnormal response to skin injury, involving heightened inflammation, exaggerated proliferation of collagen fibers, and aberrant remodeling. (Jackson I, et al. Investigation of recurrence rates among earlobe keloids utilizing various postoperative therapeutic modalities. Eur J Plast Surg. 2001;24[2]:88-95)

Hypertrophic scars result from a process similar to that of keloids, but they are confined to the original wound margins and tend to regress over months to years.

When keloids or hypertrophic scars form on the face or in other areas that are not usually covered by clothing, they can be cosmetically disfiguring. If they develop over joints or other movable body parts, they can be painful and interfere with normal movement.

Differences Between Keloids and Hypertrophic Scars

Keloids:

• Extend beyond original wound borders
• Most commonly occur on the skin over the sternum, cheeks, earlobes, shoulders and upper arms
• Contain copious amounts of thick collagen fibers
• Often contain a mucoid matrix
• Grow for years and remain elevated above surrounding skin
• Commonly take three months or more to appear
• Are more common in persons with darker skin
• Tend to recur when treated, no matter what modality is used

Hypertrophic scars:

• Remain confined to the edges of the original wound
• Can occur in any location on the body, but commonly appear on the extensor surfaces of joints
• Contain fewer thickened collagen fibers
• Exhibit little or no mucoid content
• Usually regress and flatten over time, although this can take many months
• Typically begin to appear within a month of skin injury
• Are less associated with darker skin
• Are more amenable to treatment

Risk Factors for Keloid Formation

• Darkly-pigmented skin is the primary risk factor (15 to 20 times the risk of lighter-skinned individuals)
• Heredity (both autosomal dominant and recessive genetic variants have been described)
• Age (persons younger than 30)
• Hormonal status (increased risk during puberty or pregnancy)
• Wound type (any process that delays healing, such as acne or ear piercing; burns; certain vaccinations [e.g., BCG]; chickenpox; biopsies, etc.)
• Wound location (see above)

(From Juckett G. Management of keloids and hypertrophic scars. Am Fam Phys. 2009;80[3]:253-60)

Treatment for Keloids and Hypertrophic Scars

Both keloids and hypertrophic scars are treated similarly, but keloids are less likely to respond favorably.

Of the wide variety of treatments available, there is no evidence that a single method works better than any others. Some physicians have reported better success when combining several methods.

• Repeated corticosteroid injections for prevention and treatment are probably the most commonly employed treatment and will eventually flatten most keloids; recurrence rate is up to 50%.
• Intralesional injections with verapamil, fluorouracil, bleomycin, or interferon or topical treatment with imiquimod appear to be beneficial, but these methods aren’t yet well studied.
• Cryotherapy (local freezing) is useful for smaller scars—like those caused by acne—but may cause pigmentation changes.
• Surgical removal, while temporarily successful, is almost invariably followed by even more aggressive regrowth of the scar; postoperative treatment with corticosteroid injections, pressure dressings, and silicone sheeting reduces recurrence, however.
• Silicone sheeting, worn for 12 to 24 hours daily, softens and flattens both keloids and hypertrophic scars, but data to support long-term benefit are lacking.
• Pulsed dye laser is effective for improving the appearance of up to 85% of keloids, but its greatest benefit is in scars that are relatively new; it is also more effective when combined with other therapies.
• Radiation is a last-resort treatment modality.
• There is little evidence that topical vitamin E, onion extract gels, or other commercially available herbal preparations are useful for treating established keloids or hypertrophic scars.

Preventing Keloids and Hypertrophic Scars

• Anyone with a personal or family history of keloid or hypertrophic scar formation should seek medical advice when skin injuries are sustained.
• When wounds can be anticipated (such as with surgery) properly-timed applications of silicone sheeting and pressure dressings, pulsed dye laser, and injections of corticosteroids, fluorouracil, or topical applications of imiquimod will reduce the occurrence of keloids and hypertrophic scars in susceptible individuals.
• Extensive burns should be covered with pressure stockings or dressings for six to 12 months.
• Dark-skinned individuals should avoid ear or body piercings; when such piercings are performed, pressure-type earrings or body jewelry should be employed to reduce scar formation.
• Some herbal products and over-the-counter preparations (e.g., lavender oil, Mederma gel, Contractubex gel [not available in the U.S.], Alpha Centella cream, calendula cream, etc.) may help to improve wound healing. Therefore, they might prove useful in the prevention—but not the treatment—of keloids or hypertrophic scars.
• Vitamin E oil, when used early in the wound healing process, might actually interfere with normal skin repair; it should not be employed for scar prevention.

The copyright of the article Keloids and Hypertrophic Scars in General Medicine is owned by Stephen Allen Christensen. Permission to republish Keloids and Hypertrophic Scars in print or online must be granted by the author in writing.

Facial Keloid

What do you think about this article?

---

NOTE: Because you are not a Suite101 member, your comment will be moderated before it is viewable.

post your comment

What is 0+8?

Comments

Oct 22, 2009 5:43 PM

Guest :

My daughter got a scar on her face. She picked off a scab on her face and the resulting scar was bright red. I gave it some time, but the redness did not fade readily. I understand scars can fade over time, especially on kids; but since it was on her face, I did not want to take any chances. That it only might work was good enough for me.

I've used the Dr. Max Powers Scar Serum regularly on her face for about a month and it is definitely faded, not so noticeable anymore.

I also have a deep scar that is 35 years old right smack on the bridge of my nose. It's not fading any more than it has. I decided to try it on that and also a recent burn scar on my arm. The scar on my arm is looking better. It's still there but smooth and fading. The one on the bridge of my nose is deep. I think it looks better but it will be many months before I think I'll truly know. I'll be back to update at that time.

For now, I think it does seem to help and really doesn't hurt new scar formation. I definitely recommend the Dr Max Powers Scar Serum if you have a scar on your face and are looking to fade it.

Oct 23, 2009 8:01 AM

Stephen Allen Christensen :

Even in individuals who do not form keloids or hypertrophic scars, new injuries typically leave bright pink "scars" that fade and flatten over time; it can take 6 months or more before a person knows what the ultimate appearance of a scar may be.

2 Comments