Disease Description (Causes and Symptoms)
- Definition: A keloid is a raised, overgrown scar that extends beyond the boundaries of the original injury. It commonly occurs on the sternum (center of the chest), upper back, shoulders, and earlobes.
- Causes / pathophysiology: The exact cause is unknown, but the main mechanisms are high tissue tension at the wound site and excessive collagen production by fibroblasts. It occurs more frequently in people with a genetic predisposition (family history) and darker skin pigmentation.
- Main symptoms: A firm, smooth, irregular, erythematous elevation that spreads beyond the original wound, itching (pruritus), tenderness, and similar symptoms. Over time, it becomes brown, hard, and does not readily disappear. Recurrence is common after surgical removal alone, and it may recur in a larger form.
- Diagnosis: It is usually diagnosed based on the medical history and clinical findings; when necessary, it is differentiated through histopathological examination (biopsy).
Treatment Methods
- Treatment principles: There is no complete cure, and the recurrence rate is high. Combination therapy (two or more treatments) is often used rather than monotherapy. Individualized treatment is provided according to the location, size, and functional or cosmetic concerns.
- Conservative / topical treatment
- Compression therapy: Elastic garments, pressure earrings (for earlobes), and similar devices are used for a prolonged period (generally at least several months; the duration varies among reports) to suppress scar growth. (In clinical practice, use for 4–6 months or longer is often recommended.)
- Silicone gel sheets / gel: May help improve the scar.
- Intralesional corticosteroid injections (most common): Intralesional injections of triamcinolone and similar agents suppress collagen synthesis and reduce inflammation and volume. They are effective in relieving itching and pain but may not completely narrow the width of the lesion. Repeated injections are necessary.
- Intralesional medication injections: Intralesional injections of certain medications, such as 5-FU and bleomycin, are used (the level of evidence varies).
- Procedures / surgery and combination therapy
- Surgical excision: Considered for small lesions in areas with low skin tension. Because excision alone has a high recurrence rate, it is usually combined with adjuvant therapy (such as radiation, steroids, silicone, or compression after excision).
- Radiation therapy: May be used before or after surgery, or alone. It is effective in reducing the recurrence rate, but adverse effects (skin changes and the possibility of rare long-term malignant transformation) must be considered.
- Cryotherapy (liquid nitrogen): Used alone or in combination with steroid injections.
- Laser treatment: Includes CO2 laser and pulsed dye laser (PDL). Used in combination with other treatments or for refractory lesions.
- Medication treatment (systemic): Some reports have described cases in which low-dose methotrexate (Methotrexate) administered before and after surgery reduced the recurrence rate, but the evidence is limited, and the dosage and dosing interval vary among studies. Interferon and topical imiquimod have also been reported as treatments, but their effectiveness is inconsistent.
- Precautions: Each treatment has risks of recurrence and adverse effects (skin atrophy, worsening of the scar’s appearance, pigment abnormalities, infection, radiation-related adverse effects, etc.), so the choice should be made after discussing the advantages and disadvantages. The patient’s condition, including diabetes, infection, and pregnancy, should be considered.
Checklist Before an Outpatient Visit (Including Example Questions)
- Items / records to prepare
- Photos of the lesion (records of changes from when growth began to the present)
- Previous treatment history (injections, surgery, laser, radiation, medications, etc.) and treatment response
- List of medications being taken (including anticoagulants, antiplatelet agents, etc.)
- Medical history (diabetes, liver disease, immune disorders) and family history (whether keloids are present)
- Allergies and smoking and alcohol use history
- For women, possibility of pregnancy / breastfeeding status
- Results of previous biopsies or imaging studies (if available)
- Preparation for examinations (by treatment)
- When systemic medications (such as methotrexate) are being considered: Basic blood tests (CBC), liver function tests (LFT), and kidney function tests are needed. Pregnancy must be ruled out (contraindicated during pregnancy).
- When surgery is planned: Determine whether anticoagulants should be discontinued, record preoperative photographs, and prepare the consent form.
- When radiation therapy is being considered: Explain age-related cancer risk and check relevant history.
- Examples of information to tell the doctor in advance / questions to ask at the outpatient visit
- Whether the scar has recently grown rapidly or whether pain or itching has become severe
- Whether recurrence occurred after previous surgery and how quickly it recurred
- Medications currently being taken (especially anticoagulants, immunosuppressants, etc.)
General Examples of Questions to Ask the Doctor
- What are the common adverse effects of this treatment (for example, intralesional steroid injections)? (Skin atrophy, pigment changes, etc.)
- For my lesion, how high is the recurrence rate if it is treated with surgery alone? What adjuvant therapies can be combined to reduce recurrence?
- What is the long-term risk of radiation therapy (for example, rare malignant transformation)?
- What treatments are available during pregnancy or breastfeeding?
- What can I do myself through lifestyle management (wound care, compression therapy, scar massage, etc.)?
Examples of Condition-Specific Questions
- Is this lesion a simple hypertrophic scar (to be differentiated from a keratoid), or is a biopsy necessary for diagnosis?
- If surgery is being considered, which adjuvant therapies (radiation, steroid injections, silicone sheets, compression, etc.) would you recommend after excision? What recurrence rate should be expected?
(Note: The above summarizes recommendations commonly used in clinical practice and reported treatment options. The optimal treatment for each individual patient will be determined after examination and consultation.)