Keloid (Keloid)
1) Disease Description (Causes and Symptoms)
- Definition: A fibrous scar that grows excessively beyond the boundaries of a wound caused by trauma or surgery; it appears as a raised, firm, and sometimes shiny nodule.
- Causes / Pathophysiology:
- The exact cause is unknown, but the main mechanisms include tissue tension at the wound site and excessive collagen production (mainly type III and type I) by fibroblasts, along with an imbalance in collagen breakdown.
- There is a genetic predisposition (family history), and the incidence is higher in people with darker skin.
- Main symptoms:
- An irregular, raised scar that grows wider than the original wound
- Color changes from red or pink → brown, and hardening
- Itching, pain or tenderness, and cosmetic or functional discomfort
- Diagnosis:
- Diagnosis is primarily based on clinical findings and medical history. A tissue examination (biopsy) is performed when differential diagnosis is needed or malignancy is suspected.
2) Treatment Methods
- Key point of treatment: Because the likelihood of recurrence is high, combination therapy rather than a single treatment is recommended, with individualized treatment based on the site, size, and symptoms.
- Nonsurgical treatment
- Silicone gel sheets (or silicone gel): Help improve the scar and reduce its color and height. Long-term use (several months) is recommended.
- Compression therapy: Maintaining compression for a long period (usually several months) with compression garments or pressure earrings (for earlobe lesions) can help prevent recurrence.
- Intralesional injection of corticosteroids (e.g., triamcinolone): Suppresses collagen synthesis and reduces volume, itching, and pain. Usually administered at 4–6-week intervals, with multiple treatments required.
- Local injections of anticancer agents: 5-FU, bleomycin, and others may be effective when used in combination with corticosteroids or alone.
- Interferon or topical imiquimod: Used in some cases, but evidence is limited.
- Cryotherapy: Used to reduce small lesions; its effectiveness increases when combined with corticosteroids.
- Laser treatment: Pulsed dye laser (PDL) is used to relieve redness and itching, while CO2 laser is used for reduction (excision and inhibition of proliferation).
- Oral medications (limited evidence): There are some reports involving low-dose methotrexate and others. Systemic treatment should be used cautiously because of side effects.
- Surgical treatment
- Simple excision: Considered when skin tension is low and the lesion is small. Simple excision alone carries a high risk of recurrence → adjuvant therapy (pre- or postoperative corticosteroid injections, radiation, etc.) is strongly recommended.
- Postoperative adjuvant treatment: Radiation therapy immediately after excision or surgery (adjuvant radiation) is effective in reducing the recurrence rate, but side effects, age, and long-term risks must be considered.
- Radiation therapy
- Adjuvant radiation administered immediately after surgery (within 24–72 hours) lowers the recurrence rate. The possibility of radiation-related side effects in children and women of childbearing age must be considered.
- Prevention and lifestyle management
- Care for wounds properly and avoid excessive tension and irritation.
- If there is already a predisposition, avoid unnecessary piercings and surgical procedures.
- In the early stage of scar formation (after wound healing), consider silicone gel, compression therapy, and early corticosteroid injections.
- Precautions (complication risks and points to note for self-care)
- The likelihood of recurrence after simple excision alone is high — surgery without adjuvant therapy may result in a larger keloid.
- Corticosteroid injections: Risk of atrophy at the injection site, pigment changes, and infection.
- Radiation: Skin changes and a rare long-term risk of cancer development (particularly requiring caution in young patients).
- When using systemic medications (e.g., methotrexate), liver function and blood tests must be monitored; some medications are contraindicated during pregnancy or breastfeeding.
- Scar-related pain and functional limitation (near joints) may occur.
3) Checkpoints Before an Outpatient Visit (Including Sample Questions)
- Items to prepare (bringing these can help with the consultation)
- A list of all medications and supplements currently being taken, and allergy information
- Records of previous surgeries and treatments (injections, laser, radiation), and related photos if possible
- Records of when the scar developed and its symptoms (itching, pain, rate of growth)
- Family history information (keloids or abnormal scarring)
- Whether pregnancy is possible (for women)
- Photos to show the doctor during the outpatient visit: Recent photos taken from various angles and under different lighting, along with photos comparing changes over time
- Questions to prepare for the medical interview (submitting them to the doctor in advance can speed up the consultation)
- When the scar first developed and the pattern of changes in its size
- Previous treatment experience and whether there were any effects or side effects
4) Examples of General Questions to Ask the Doctor
- What treatment options do you recommend for my scar, and what are the advantages and disadvantages of each?
- How high is the recurrence rate for my scar? (Based on my lesion and treatment method)
- What are the expected treatment duration and recovery time for the recommended treatment?
- What are the common side effects and precautions associated with the medications or procedures you recommend for me?
- I am planning a pregnancy (or am breastfeeding). Will this affect treatment? Which treatments should I avoid?
5) Examples of Condition-Specific Questions
- For the location of my scar (e.g., earlobe/chest/shoulder), is surgery alone appropriate, or do you recommend surgery plus adjuvant treatment (radiation/corticosteroids, etc.)?
- My keloid has already recurred several times. Could you recommend the combination treatment with the lowest current recurrence rate (e.g., excision + radiation or excision + immediate corticosteroid injection)?
If necessary, providing current photos of the lesion, treatment history, and medication records can help you receive a more specific treatment plan and explanation of the prognosis.