Keloids: Can we get rid of them?

This week, I want to touch on a topic all too familiar to many of us: keloids. What are they?

Keloids are raised, overgrown scars that form at the site of a skin injury such as surgery, vaccinations, ingrown hair, body piercings, tattoos or acne. Less commonly, keloids may appear in areas of the body where there has been no obvious trauma or cuts.

The initial “injury” may have been so slight that one never even noticed it. High-risk areas for keloid formation include the earlobes, the chest, the back and the lower abdomen.

It is believed that keloids affect approximately six million people in the United States, mostly within certain ethnic groups. We don’t understand why they form, but we notice that they tend to run in families. And although we can’t explain why, keloids are more common in people with darker skin: Blacks, Latinos and Asians are 15 times more likely to develop keloids than White people.

Symptoms

While keloids are benign, they can itch, burn, and cause discomfort or pain. If large enough or if they involve the skin over a joint, keloids may be disfiguring and debilitating, and they may interfere with movement. People with keloids are often very self-conscious and may suffer from social anxiety, especially when the keloids are difficult to hide.

Treatment

It is difficult to remove keloids completely. Excess scarring can be minimized if treatment is begun soon after the keloid appears. Unfortunately, there is no single treatment for keloids that is successful for everyone.

Different treatment modalities are often combined to help maximize results. Often, the selected treatments will improve the symptoms caused by the keloids, but they may not provide completely satisfying results.

• Corticosteroid injections: This widely used treatment will often be the therapy of choice for small and younger keloids. Here, a corticosteroid such as triamcinolone (Kenalog) is injected into the keloid. The injections can be repeated every four to six weeks. They may help reduce the size of the keloid and the irritation. However, many people don’t want to repeat them because they are often painful.
• Surgery, compression dressings and radiation therapy: Removal of the keloid with surgery alone is rarely successful, with recurrence in more than 45% of people. However, when combined with silicone sheets or other compression dressings, as well as radiation therapy soon after surgery, scar formation is reduced and keloids are less likely to recur.
• Laser therapy: Lasers, such as carbon-dioxide (CO₂) laser, can be used to reduce the size of keloids. If this treatment modality is chosen, it should be followed by monthly corticosteroid injections into the treated area, or in conjunction with other intralesional injections. To this day, there is no scientific evidence that lasers work better than surgery.
• Fluorouracil injections: Fluorouracil is a chemotherapy drug that can be injected into keloids. Usually, this product will be used when other methods have failed. Other emerging options for management of keloids currently under study include bleomycin, interferon, botulinum toxin A and imiquimod.

Given the imperfect treatment options available, the best advice for people prone to keloid formation is to avoid any non-necessary surgery (e.g. cosmetic surgery) or trauma to the skin (e.g. tattoos, body piercings, ingrown hairs).

If you have a keloid, first consult with a board-certified dermatologist. Before your appointment, it is helpful to think about what you expect from treatment.

Are you primarily looking to ease your symptoms like pain and itch? If you have a keloid on your earlobe, are you hoping to wear earrings again? Is flattening of the keloid important to you? It is important to discuss these elements with your dermatologist to help you set realistic expectations about what treatment can do.

In the cases where surgery is recommended, a referral to a board-certified plastic surgeon is key. If radiation therapy is considered in combination with surgery, you will also be referred to a radiation oncologist.

Dr. Valerie Lemaine, M.D., M.P.H., is a top-ranked, board-certified plastic surgeon in private practice in Bloomington, MN. She received her M.D. from University of Montreal, Canada. She also completed a reconstructive microsurgical fellowship at Memorial Sloan-Kettering Cancer Center in New York City. Dr. Lemaine then accepted a staff position at the prestigious Mayo Clinic (Rochester, MN) where she taught, practiced and published clinical research. In 2018, she transitioned to private practice and joined Plastic Surgery Consultants and Minnesota Oncology.