Keloids are defined as scars that heal with excess scar tissue that goes beyond the original site of the injury. They commonly arise as a result of cuts, piercings or localised infections caused by cysts, in-growing hairs or occasionally spots.
They are more common at certain sites, such as the chest over the sternum, the points of the shoulders and the ears, in particular the lobules and outer curvature.
They are also more common in some races especially afro-caribbean, middle eastern, asian and central Europeans. Caucasians are less likely to suffer from them but they do run in some families.
Keloid Scar Diagnosis
Keloids are often confused with hypertrophic or stretched scars even by Doctors and Nurses. It is important to recognise the difference if treatment is wanted, since the treatments are different.
Treatment of keloid scars
With the continued overgrowth of scar tissue within a keloid it is important to break the cycle of over-growth returning the scar tissue to conform with the norms of remodelling. This usually involves shrinking the scar down to being flat while also considering how to manage the final flat scar that may still be too big and unsightly. Treatment options include sustained pressure, (that can be difficult in some areas) and silicone sheet dressings or creams. However the main stay of treatment and usually the most effective is steroid injections directly into the scar. In resistant or stubborn cases a combination of treatments may be required and in the case of large keloids, surgical debulking (otherwise known as intra-lesional excision) will help reduce the size of the scar and speed up and improve the treatment outcome. Radiotherapy has been used with some success but this is usually difficult to access, expensive, and carries long term risks.
My preferred treatment regime
Intra-lesional steroid injection with triamcinolone using tiny doses is usually very successful as a sole treatment and can be used at any site. When skilfully injected risks are minimal but include, thinning of the surrounding skin, discolouration of the skin usually only within the scar but may occasionally affect the surrounding skin. Small thread veins can appear on the surface of the skin or pigment loss around the area can occur in darker skins, although this is usually temporary. Infection has been reported but this is extremely rare if aseptic techniques are adhered to.
Depending on the size or the aggressive nature of the keloid usually a minimum of 5-6 injections are required. The first couple can be uncomfortable but help to soften the scar. After this, pain is uncommon and the scar starts to shrink. Injections are usually spaced approximately 6 weeks apart.
In large keloids I am a proponent of intralesional excision under local anaesthetic. In this I remove as much of the central component of the scar as I can under local anaesthetic and then commence steroid injections. This shrinks the scar (including the final one) speeding up the process and improving the final outcome.
Some scars are more resistant to treatment than others and may require more injections and the addition of alternative treatments. If you are considering starting treatment then make sure you are able and prepared to see it through to the end. Some patients get half way through and stop. The keloid always comes back! And usually quickly.
Once the scar is fully under control and has gone completely flat, recurrence is rare.
Keloid Scar FAQ (Frequently asked questions)
Do the injections hurt?
The first couple might. After that the keloid is usually softer so is more easily injected causing less painful pressure and accepts more of the steroid speeding up the response.
What happens if I can’t make my appointments every 6 weeks?
Don’t worry as long as you come regularly and can average about 6 weeks between visits the treatment usually is effective. Most patient manage visits between 5-8 wks depending on other commitments and holidays.
I have a big keloid will I need more injections?
Yes, maybe but not definitely. I fill all the keloid with steroid and therefore the time response can be similar regardless of the size.
Can I just have my keloid cut out?
Sadly not. By cutting around it to remove it completely I will have enlarged on what the original scar was, since most keloids form from normal wounds it will just grow back, and bigger.
I get spots and these turn into keloids. What should I do?
First of all you should not pick. Once the inflammation has settled and the swelling and pain has started to resolve you can remove the head, but don’t squeeze. This will reduce the risk of a keloid, but if one starts an early injection usually settles it quickly.
My ingrowing hairs are turning into keloids, what should I do?
This is difficult but sometimes hairs do grow under the skin, usually after a close shave or occasionally after plucking. The keloid can form around the hairs meaning you can no longer see them. These are best injected and then the hairs removed once the scars are flat.
I am worried it is going to cost too much?
An understandable concern. Make sure you know how much each injection is going to cost and what the recommended pathway is. Be aware of the probable total cost and wait until you can afford it before you start.
Can you guarantee that my keloid will go, or how many treatments will be required?
Unfortunately not. Occasionally keloids do not respond sufficiently well to the treatments so a combination of therapies may be required. There is a small percentage of patients who need to continue treatments to control the keloid and have to accept that cure may not be possible. If untreated they would keep enlarging to an impressive size. Maintenance and control to a reasonable size is nearly always possible. Most keloids are flat with 5-6 injections.
If I have had one keloid scar, am I likely to get another?
If you have had one then yes are at a higher risk of getting another. But, keloids are still site variable even within an individual so if you have had one in a high risk location, scars in other places may well still behave normally.
In addition to this, if your keloid has formed because a traumatic abrasion or delayed healing and infection then a scar in the same site may behave normally. In the presence of these trigger factors sometimes simple excision under sterile and surgical conditions can cure the keloids. Surgical excision and scar repositioning can also be the right treatment for hypertrophic scars.
