Poornima* was 12 when she fell on a manhole cover in school and grazed her knee badly. In the first aid room, a small wad of dry cotton with some medication was placed over the wound. By the time she got home and taken to her family doctor the cotton had dried up in the wound. The wound healed but formed a thick scar called a keloid. Years later Poornima had to have a skin biopsy to diagnose a skin allergy. Although the dermatologist took utmost precaution and removed a very small piece of skin, a second keloid formed.
Pankaj*, a 60 year old male of fair complexion, underwent a mitral valve replacement. The procedure and post-operative recovery were uncomplicated. But, during the next six months he developed itching and thickening over the incision site. On consulting the dermatologist he was informed that he had developed a keloid and would require treatment to relieve the itching and flatten it.
When 15-year-old Deepika* visited her dermatologist she had a plum-sized pedunculated growth on the ear lobe, which became evident six months after an ear piercing. The diagnosis: a keloid.
Describing a keloid, Dr. Mukta Sachdev, Consultant Dermatologist, Manipal Hospital, Bengaluru, says “A keloid — sometimes referred to as a keloid scar — is a tough scar that rises on certain areas of the skin. It usually has a smooth top and a pink or purple colour. Keloids also have an irregular shape and enlarge progressively. Compared to regular scars, keloids by and large do not subside over time.”
Adds Dr. Murlidhar Rajagopalan, Senior Consultant Dermatologist, Chennai, “Keloids are pathologic scars that continue to grow and extend beyond the confines of the original wound. However not all keloids follow a wound. Some appear spontaneously; the initiating event may even be an insignificant hair root or acne infection, which heals into a keloid.”
Distinctive features
While nature's healing process ensures that most wounds heal without a problem, sometimes the complex mechanisms involved get messed up. Explains Dr. Murlidhar, “Excessive matrix accumulation and cell proliferation are distinctive features of keloid lesions. This results in a scar with excess packed fibre and can be attributed to an abnormal wound healing process that lacks the control mechanisms, which regulate tissue repair .”
The location of the keloids also provides some insights. As Dr. Mukta points out, “Keloids are commonly seen over the sternal region or the midline of the chest where there is little or no fat besides the back, shoulders and earlobes. They are also found at the site of acne lesions (a specific condition called acne keloidalis) surgery scar sites and sites of trauma or injury. Finally they can be seen over body piercing sites and tattoo sites.”
Today, when every other disease can be traced back to a faulty gene, there is no such clinching evidence for keloids. However, as Dr. Murlidhar Rajagopalan observes, “There does appear to be a familial tendency in a small percentage of patients .People who already have one keloid are prone to developing other keloids at other sites of injury or even spontaneously.”
And if you want a profile of keloid patients Dr. Mukta provides some links. Certain races like Asians, Indians and African Americans and Negroid races — basically people with darker skin types — are more prone to keloids, although they can occur in people of all skin types. Keloids are less common in children and elderly people. They are equally common in men and women although seen more frequently in women due to increased earlobe and body piercing.”
Recurrence possible
Modes of treatment vary from steroid injections to external creams and laser therapy. The point to note is that surgery does not seem to be a viable option as the keloids can recur. Dr. Narendra Pandya, Mumbai-based plastic surgeon, says “Surgery is extremely unhelpful. Sometimes with a small keloid one can excise it, put a small graft and administer radiotherapy. That might slow down the activity of new cells and prevent recurrence. Injections can be given in case of keloids getting bigger. My dictum is not to touch a patient with a keloid.”
While leaving them alone seems a good thing to do, do untreated keloids cause any harm? Putting things in perspective, Dr. Mukta states “Keloids are more a cosmetic nuisance and will not cause any harm locally or systemically. There may be local symptoms like itching or pain.”
“One has to be cautious when the keloids become infected. The infection is likely to recur and tends to worsen the keloids. It is important to treat such a keloid early and fast,” says Dr. Murlidhar Rajagopalan.
Finally, the familial tendency not withstanding, can keloids be prevented? Concludes Dr. Mukta, “The best way is not to get one .A person who has had a keloid should not undergo elective skin surgeries or procedures such as piercing. When it comes to keloids, prevention is crucial because current treatments are often not completely successful and may not work.”
Treatment options
Cortisone injections: Safe and not very painful. Injections are given once a month for 3 to 6 sessions usually until the maximum benefit is obtained. They usually help flatten keloids and are sometimes combined with other treatments like cryotherapy. The keloid may look better after treatment but there may still be a scar and it is hard to achieve complete resolution of the lesion.
Lasers: Certain lasers have been tried to reduce the redness. However treatment may be painful and generally expensive. Multiple sessions may be necessary. Silicone sheets: This involves wearing a sheet of silicone gel on the affected area for several hours a day for weeks or months. Results are variable. Several different compression dressings are now available.
Cryotherapy: Freezing keloids with liquid nitrogen may flatten them and is effective. This treatment is often combined with intra-lesional cortico-steroid injections.
Interferon: Interferons are proteins produced by the body's immune systems that help fight viruses, bacteria and other challenges. In recent studies, injections of interferon have shown promise in reducing the size of keloids though it is not yet certain whether the effect will be lasting .Current research is underway using a variant of this method applying topical imiquimod that stimulates the body to produce interferon but these are not standard modalities as of now.
Fluorouracil: Injections of this chemotherapy agent alone or together with steroids have been used.
Radiation: Some doctors have reported safe and effective use of radiation to treat keloids.
* Names changed to protect privacy
