Solving the Keloid Conundrum
Are cosmetic treatments too risky for patients prone to keloids?
Keloids are among the most vexing scars to treat, largely because of their unpredictable nature, high recurrence rate, and the dearth of consistently effective treatments.
The pathogenesis of keloids is poorly understood, and we don’t understand why certain patients are more susceptible than others. We also do not know why keloids are more common on certain skin sites, such as the ears, chest, and back.
If a patient forms a keloid once, he or she will very likely form another keloid subsequent times that the skin is injured. Many patients first realize that they are prone to keloids after ear piercing or trauma to the earlobe. Keloids can also occur due to acne on the chest or back or due to pseudofolliculitis on the scalp and beard area. Keloid removal is difficult, because the recurrence rates can reach 70 percent, and in some cases, the recurrences can be larger than the original keloid.
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Treating Keloid Scars
There are no FDA-approved drug treatments for keloid scars. A device that delivers superficial radiation, the Sensus SRT-100, is FDA approved for keloid removal. Other available options include excision (with or without repair), steroid injections, intralesional 5-Fluorouracil (5-FU), radiation therapy, imiquimod, silicone gel or silicone sheeting, pressure devices, botulinum toxin injections, cryotherapy, and lasers.
My keloid treatment algorithm begins with intralesional triamcinolone every four to six weeks. I inject using a small gauge needle and as few injection sites as possible.
If the keloid can be excised, I perform a shave excision followed by post-operative silicone gel and/or use of a pressure device.
Recurrent keloids are treated with radiation therapy for three days post-operatively. All excisions are followed by intralesional triamcinolone or 5-fluorouracil every four to six weeks until the scar is flat.
Counseling about the importance of follow-up is an essential part of keloid treatment. Because recurrences of keloids are unpredictable, it is important to have patients return to the clinic on a regular basis. Keloids can recur immediately or even years after treatment. It is also critical to have patients monitor the scar over time and note any symptoms, such as itching or pain.
Options for Keloid Management
Excision (with or without repair)
Silicone gel or silicone sheeting
Botulinum toxin injections
*FDA approved for keloid treatment.
When planning a procedure on a patient prone to keloids, it is important to weigh the risks of abnormal scarring against the benefits of the procedure. If a major surgery or cancer removal is necessary, then the benefits outweigh the risks. Aesthetic procedures or benign tumor removals can be particularly risky, especially when they occur on the face, ears, and neck. An honest discussion about the risks of keloid formation is warranted before proceeding with an aesthetic procedure.
Implementation of appropriate pre-operative and post-operative strategies may minimize the risk of keloid scars for our patients. We can minimize tension and trauma to the surgical site. In at-risk patients, we can use topical treatments and injections post-operatively in a prophylactic manner.
No Quick Fix
The bottom line is that there is no quick fix for keloid scars, and it can take multiple months to get a keloid flatter and more aesthetically pleasing. Research is ongoing, and we hope to have more treatments and evidence-based clinical protocols for both treatment and prevention in the near future. n
This article is based on a presentation given at Cosmetic Surgery Forum 2017. Cosmetic Surgery Forum 2018 will be held November 28 to December 1 at Cosmopolitan, Las Vegas. For information, visit cosmeticsurgeryforum.com.
Andrea Murina, MD, FAAD is an associate professor in the department of dermatology at Tulane University in New Orleans.