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  • Based on clinical appearance of lesion
  • Keloids may present asymptomatically, pruritic, tender, or with sharp pain
  • Common areas include upper chest, back, shoulders, ears, neck, and jaw
  • Acne keloidalis nuchae: keloid formation as a result of papules and pustules on posterior neck
  • Keloid vs hypertrophic scar: the lesions appear similarly, but hypertrophic scars do not extend beyond the margins of the initial lesion

References:

Clinical Case:

1. 1. Nemeth AJ. Keloids and hypertrophic scars. J Dermatol Surg Oncol 1993; 19:738.

2. Berman B, Bieley HC. Adjunct therapies to surgical management of keloids. Dermatol Surg 1996; 22:126.

3. Goldstein, Beth. Keloids. In: UpToDate, Basow, DS (Ed), UpToDate,

Waltham, MA, 2012.

  • Our patient had her keloid excised
  • The site was then injected with triamcinolone
  • Instructions were given to avoid intentional trauma to the skin in the future, as patient is prone to keloids

Radiation Therapy

  • Reduces recurrence rate of keloids, especially following surgical excision
  • Use is limited due to potential to cause malignancy, especially in young patients
  • May be an appropriate option for keloids that are unresponsive to other treatments including excision
  • Less favorable characteristics for RT tx include larger size, location on the chest, and keloid as the result of a burn

Diagnosis of Keloids

Clinical Case:

Surgical Excision

Treatment Options

A 14 year old Asian American female with no significant PMHx presents with a firm, flesh-colored, fibrous nodule on her upper back. She reports that her father tried to pop a closed comedone in that area several months ago. The nodule is not painful or pruritic, but the patient finds it cosmetically problematic and wants it "totally gone". She is not taking any medications and denies allergies.

  • Consider use if corticosteroids alone will be insufficient
  • Always refer to a dermatologist or plastic surgeon for excision, as a high rate of recurrence exists
  • Treat excision pre, intra, or postoperatively with triamcinolone or interferon injection to reduce likelihood of recurrence
  • Prevention!!!
  • Intralesional corticosteriods
  • Excision
  • Radiation Therapy
  • Laser therapy
  • Interferon Alpha
  • Imiquimod
  • Cryosurgery
  • Pressure earrings
  • Silicone gel sheeting
  • Intralesional fluorouracil
  • Intralesional verapamil

*Combinations of these therapies may be employed

*Earlier treatment generally produces better results

Keloids: Overview

Keloids: Pathogenesis, Diagnosis, and Treatment Options

Intralesional Corticosteroids

  • Keloid: "tumorlike" in Greek
  • Benign, fibrous growths caused by altered wound healing
  • Results from overproduction of extracellular matrix
  • More common in individuals of African and Asian descent
  • Genes influence susceptibility to keloid formation
  • Usually first-line therapy
  • Up to 70% of patients respond, with a 50% recurrence rate at 5 years
  • Triamcinolone, 5-40mg/mL is injected into the keloid
  • Injections are made under pressure (wear goggles!)
  • Repeat injections every 4-6 weeks until lesion is softer and flatter
  • If there is no response after several injections, move to surgical excision
  • Watch for atrophy of the skin and hypopigmentation

Pathogenesis of Keloids

Chana-Rivka Foster, MSIII

8 February 2012

  • True pathogenesis is unknown
  • Caused by any trauma to the dermis in predisposed individuals (trauma, piercing, tattoos, etc.)
  • Due to increased fibroblast proliferation and collagen synthesis
  • Overexpression of CTGF, VEGF, and TGF-beta
  • Altered apoptosis of fibroblasts
  • Overactivation of signals for ILGF-I
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