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Keloids are found at the site of tissue injury. They are easily identified but not easily remedied. In this case study, the author presents two patients with keloids: one whose keloids involved her ear lobes, the other with acne keloidalis. Both patients underwent several months of treatment, with slow improvement. Keloids are often recalcitrant to treatment and are prone to recurrence. Several new therapeutic treatment strategies are being studied and developed. I hope that through continued research, new techniques will be discovered to prevent and treat these benign but potentially cosmetically devastating growths.
Dermatology healthcare professionals see many scars, which are a proliferation of fibrous tissue that replaces prior normal collagen after a wound or injury. Early on, they are deeper pink or red. Keloids, however, form within scar tissue with mainly Type I and some Type III collagen, which results in an overgrowth of tissue at the site of a healed skin injury, sometimes producing a lesion many times larger than that of the original scar. Keloids are benign and noncontagious. Although they usually occur at the site of an injury, keloids can also arise spontaneously. They can occur at the site of a piercing and even from something as simple as a pimple or scratch. Keloids also have the capability to hurt with a needle-like pain or to itch without warning, although the degree of sensation varies from patient to patient and can in severe cases affect movement of skin.
This is a 17-year-old African girl who recently immigrated to the United States from Uganda with her family. She had pierced both ear lobes about 6 months before moving to the United States, and about 3 months after the procedure, she developed keloids. The keloids were treated with an injection in Uganda 1 month before presenting to my office, which she said had not helped. There was no family history of keloids.
On initial presentation, on the bilateral anterior and posterior ear lobes, she had firm, skin-colored to slightly hyperpigmented nontender nodules. The keloids on the anterior and posterior right ear lobe each measured 1.5 cm in diameter; the keloids on the left ear lobe both measured 1 cm. There was no home treatment and the patient reported that all of the keloids were slowly enlarging.
The patient's past medical history was significant for exposure to tuberculosis. She had been treated with isoniazid for an unknown length of time, prior to moving to the United States. She reported a nonkeloidal scar on her chest, present for about 5 years.
No treatment was provided at her first visit. Two weeks later, she underwent excision of the keloids; all areas were allowed to heal by second intention. The pathology was consistent with keloid. Immediately following excision, intralesional (IL) Kenalog (triamcinolone) 40 mg/ml was injected into each ear lobe, with 0.25 ml total to the keloids on anterior and posterior aspects of each ear lobe. The day of the surgery, pressure dressings were applied. The patient was instructed to begin using compression (pressure) earrings immediately and to wear the earrings for as much of the time as possible, only to remove the earrings for at most 3-4 hours per day.
Compression earrings are spring-loaded pressure clips that patients apply over keloids on the ears. Continuous pressure helps to prevent keloid growth. These may be purchased online and in some jewelry stores.
One month later, the patient returned, with compression earrings in place, stating that her ear lobes "looked good." IL Kenalog 40 mg/ml, 0.5 ml was injected into each ear lobe. She returned twice in the next 3 months for treatment, at each visit receiving IL Kenalog 40 mg/ml. Unfortunately, the keloids regrew.
Because the enlarging keloids now measured an anterior-posterior width of 7 mm, the compression earrings could not be closed over the earlobes, and the patient was not able to wear them. She received a fifth injection of IL Kenalog 40 mg/ml and was scheduled for keloid re-excision.
Re-excision of the keloids was performed, and again, pathology was consistent with keloids. This time, the patient did not receive IL Kenalog at the time of the surgery. Since this second surgery, she has received five injections of IL Kenalog 40 mg/ml, spaced 1 month apart. She continues to wear the compression earrings at all times. At the time this article was written, 8 months after the last re-excision and 2 months since the last injection, the patient showed no signs or symptoms of recurrence.
This is a 44-year-old African American gentleman, Fitzpatrick Skin Phototype 5, who reported a 1-year history of itchy "ingrown hairs" on his left cheek. The problem began when the patient was sunburned on the left side of his face while driving a car during a summer in Italy. He had not treated the rash with anything. He shaves his beard daily with a straight razor blade, using "sensitive skin" shaving cream.
At presentation, he had one 8-mm hyperpigmented firm dome-shaped nodule on the upper left cheek and several 4-mm skin-colored nodules with central erosion and hemorrhagic crust, grouped on the left cheek. On bilateral cheeks and on the anterior neck, he had multiple 1- and 2-mm firm, skin-colored follicular papules. He was diagnosed with acne keloidalis on the left cheek and pseudofolliculitis barbae (PFB) on the cheeks and anterior neck.
He was initially given clindamycin 1% gel to be applied twice daily for the PFB and Retin-A Microgel 0.1% to be applied at bedtime for the acne keloidalis. At his first visit, he received an injection of 1 ml of IL Kenalog 2.5 mg/ml into the largest keloid on the left cheek.
Three weeks later, he returned, stating that the largest keloid was smaller but not totally gone. He complained that Retin-A was irritating his skin, but clindamycin was helping the PFB. He also complained of two itchy scars on his right shoulder, which had never been treated, that had been present for 1 year.
On the right shoulder, he had two linear, hypertrophic, hyperpigmented, nontender firm plaques, measuring 3-cm x 5-mm. On his face, he still had multiple firm 4-mm keloids. The patient received IL Kenalog 5 mg/ml into the two keloids on his right shoulder and the largest lesion on the left cheek. He was started on doxycycline 100 mg by mouth twice daily. His topical regimen was changed to include imiquimod 5% cream every night for 1 week, alternating with tretinoin 0.1% cream every night for 1 week. Treatment of keloids with imiquimod 5% cream is off-label.
Two months later, he returned, but he had misunderstood the instructions and had taken doxycycline for 1 week only. The treatment plan was re-explained. No Kenalog was injected.
After 2 months of topical and oral treatment as described earlier, the affected area on the left cheek was smaller in diameter and less raised. He tolerated the treatments without complaint. A total of 0.5 ml of IL Kenalog 5 mg/ml was injected into three keloids on the left cheek. Topical and oral treatments remained the same.
Six weeks later, he stopped taking doxycycline for 10 days and immediately noticed recurrence of keloids on the left cheek. He reported significant irritation from the imiquimod and had stopped using it. He continued to apply Retin-A Microgel 0.1% at bedtime and clindamycin 1% lotion twice daily. At this visit, five keloids on the left cheek were treated with IL Kenalog 5 mg/ml.
At this point, he had received five treatments with IL Kenalog over the course of 7 months. He received another six IL Kenalog treatments over the next 10 months. Both patient and provider were frustrated with the lack of improvement. His keloids were not enlarging, but at each visit, he required another injection. Other treatment options, including laser therapy, were discussed. Because of his phototype, the provider was hesitant to recommend laser therapy. A 3-mm punch biopsy was taken from the left cheek to confirm the diagnosis of keloid. The pathology showed "dermal scarring with multinucleated giant cell reaction to hair shafts," which is consistent with keloids.
The patient was referred to Massachusetts General Hospital Laser Center for consultation and possible laser hair removal or experimental laser treatment. Since February 2009, he has received two treatments, spaced 6 weeks apart, with the Lyra laser, with a 1,064-nm, 100-ms pulse duration and with a fluence of 24 J/cm2, to the left cheek only. He states that his face "has never looked this clear." He is no longer taking doxycycline. He uses clindamycin 1% lotion as needed. He will probably require six to eight laser treatments. He has not experienced any hyperpigmentation or hypopigmentation secondary to the laser treatment.
Keloids occur because of an overgrowth of dense fibrous tissue, usually following skin injury (Berman, 2009). This fibrous tissue grows beyond the initial wound margin, without regression. The exact pathogenesis of keloid formation is unclear. Darker skin types are affected more frequently than lighter skin types, suggesting a genetic component. Dominant and recessive models of inheritance have been described. Keloids are more likely to form when there is foreign material, infection, or high skin tension present at the site of tissue injury in patients who are susceptible to keloids. Keloids most commonly occur between the ages of 10 and 30 years and are rarely seen in infants or older persons (Bolognia, 2003; Nouri, 2008).
Keloids are typically asymptomatic but can be painful or itchy. Most patients seek treatment because of cosmetic concerns. Dermatology nurses and staff are key players in identifying and preventing keloids. Diagnosing keloids is often not challenging; however, treating them can be challenging.
Occlusive dressings, IL corticosteroids, cryosurgery, excision, radiation, laser, interferon therapy, 5-fluorouracil, bleomycin, retinoic acid, imiquimod, tacrolimus, and botulinum toxin have been used to treat keloids (Berman & Kaufman, 2002; Kontochristopoulos, Stefanaki, Panagiotopoulos, Stefanaki, Argyrakos, Petridis et al., 2005). The use of many of these treatments is off-label and has not been studied in randomized clinical trials. Some recent studies have demonstrated benefit from imiquimod 5% cream and 5-fluorouracil. Other therapies aimed at decreasing collagen synthesis include vascular endothelial growth factor inhibitors, photodynamic therapy, transforming growth factor-beta 3, tumor necrosis factor-alpha inhibitors, and recombinant human interleukin, all currently being studied for use in treating keloids.
Treatment of keloids with laser has been well studied in recent years. The laser treatment that Patient 2 received was with the Lyra laser, which is a nonablatic long-pulsed yttrium-aluminum-garnet (YAG) 1,064-nm laser. It is known by the brand names Lyra, Gemini, and Cynergy. It is also used to treat spider veins, broken capillaries, rosacea, facial flushing, fine wrinkles, acne scars, and sometimes for hair removal in patients with dark skin. Its long wavelength allows it to penetrate to the lower dermis. The long wavelength makes it less effective for hair removal than does lasers with shorter wavelengths but safer for dark-skinned individuals because it is not absorbed in the epidermis, making it less likely to cause pigmentation changes (Kelly, 2006).
Scars and keloids are both frequently seen by dermatology healthcare professionals. Scars are benign and may not cause significant problems. As seen by these two case studies, keloids can be very complicated. These two patients have achieved cosmetic improvement but only after multiple office visits, medications, injections, and surgeries. Not only is the process of treating keloids slow, but the cost can be prohibitive. In addition to copayments and the cost of medications, many patients must pay for treatment themselves because a keloid is considered a benign "cosmetic" diagnosis by most insurance companies. This frequently means that patients cannot afford treatment. Sometimes dermatology office staff can be involved to help find ways to pay for treatments.
The key to managing keloids is prevention. Patients who have a history of keloids or are of skin types more prone to their development should avoid elective surgery, avoid incision over the central chest or over joint spaces, and have all wounds closed with minimal skin tension and be instructed in bandaging which minimizes tension to a site. Dermatology nurses and staff can serve a critical role in providing education on the prevention of keloids and in identifying those patients at increased risk.
Berman, B. (2009). Keloid and hypertrophic scar. Retrieved April 18, 2009, from http://emedicine.medscape.com/article/1057599-overview[Context Link]
Berman, B., & Kaufman, J. (2002). Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids. Journal of the American Academy of Dermatology, 47(4 Suppl.), S209-S211. [Context Link]
Bolognia, J. L. (Ed.). (2003). Dermatology (6th ed.). New York: Mosby. [Context Link]
Kelly, A. P. (2006). Acne keloidalis nuchae. Retrieved March 3, 2009, from http://emedicine.medscape.comarticle/1072149[Context Link]
Kontochristopoulos, G., Stefanaki, C., Panagiotopoulos, A., Stefanaki, K., Argyrakos, T., Petridis, A., et al. (2005). Intralesional 5-fluorouracil in the treatment of keloids: An open clinical and histopathologic study. Journal of the American Academy of Dermatology, 52(3 Pt. 1), 474-479. [Context Link]
Nouri, K. (2008). Laser revision of scars. Retrieved April 18, 2009, from http://emedicine.medscape.com/article/1120673-overview[Context Link]
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